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Cerebrovascular Disease
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Section 1 General consideration
Cerebrovascular disease: any abnormality of the brain resulting from a pathologic process of the blood vessels. Cerebrovascular accident or stroke may be defined as a sudden interruption of blood supply or hemorrhage into apart of the brain. the third commonest cause of death
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Classification Ischemic transient ischemic attack (TIA)
cerebral thrombosis cerebral embolism cerebral infarction lacunar infarct Hemorrhagic cerebral hemorrhage subarachnoid hemorrhage (SAH)
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Blood supply of brain 1. Internal carotid system
Branchiocephalic trunk→right common carotid artery left common carotid artery →internal carotid artery → carotid foramen → Ophthalmic artery Anterior choroidal artery Posterior communicating artery Anterior cerebral artery Middle cerebral artery
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Supply eyes and anterior 3/5 of the brain: frontal, parietal, part of temporal lobe, basal ganglia.
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Blood supply of brain 2. Vertebral-basilar system
Subclavian artery → vertebral artery → C6-C1 transverse foramen → great occipital foramen → basilar artery posterior spinal arteries, anterior spinal artery posterior inferior cerebellar artery auditory artery posterior cerebral arteries
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supply cerebellum, brain stem, posterior 2/5 of brain (occipital, part of tempral lobe)
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Blood supply of brain 3. Circle of Willis
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Blood supply of brain This forms a unique anastomotic system at the base of the brain between the internal carotid and vertebral-basilar systems. internal carotid arteries two anterior cerebral arteries anterior communicating artery two posterior cerebral arteries two posterior communicating arteries
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Risk factors of CVD Age, family history, race Hypertension
Heart disease Diabetes Hyperlipemia Smoking, excessive drinking Obesity, diet, contraceptive drugs
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Section 2 TIA A transient ischemic attack is a focal disturbance of the cerebral circulation, frequently repetitive, resulting in a period of impaired function lasting for a short period (anything from a few minutes to twenty-four hours). Attacks can occur in the carotid and/or vertebral artery territories.
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Etiology Micro embolism Spasm of cerebral blood vessel
Hemodynamic change Compression of vertebral artery, steal syndrome
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Clinical feature 1. 50-70, M>F characteristics: Abrupt onset
Transient Complete recovery Repetitive
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Clinical feature 2. Transient carotid ischemic attacks
(1)Common symptoms: Weakness of the contralateral arm and/or leg. (2) Characteristic symptoms: Transient loss of vision in the eye contralateral to the paresis (amaurosis fugax). Horner sign (3) Symptoms may present: Dysphasia Paraesthesia or numbness in the contralateral limbs. hemianopia
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Clinical feature 3. Transient vertebral –basilar ischemic attack
(1) Common symptoms Vertigo, nausea, vomiting (2) Characteristic symptoms: Drop attack Transient global amnesia, TGA Cortical blindness Crossed paralysis or sensory disturbance
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Clinical feature (3) Symptoms may present: Dysphagia, dysarthria
Ataxia Disturbance of consciousness diplopia
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Diagnosis clinical features No signs between attack
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Differential diagnosis
Partial epilepsy Meniere disease
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Treatment 1. Etiologic therapy Blood pressure, sugar, lipid
Carotid endarterectomy, anastomosis of extra-intra cranial vessels 2. Prophylactic treatment Anti-platelet aggregation drugs: Aspirin mg Qd Po Ticlopidine 250mg Qd Po
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Treatment 2. Prophylactic treatment Anticoagulants: heparin
Chinese herbs Chuanxiong rhizome, Red sage root, Saf flower Others: vessodilator, volume expensor (Dextran-40) 3. Brain protective agents Calcium antagonist: nimodipine 20-40mg tid po flunarizine (Sibelium) 5mg Qn po
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Prognosis 1/3 → repetitive attack 1/3 → remission
1/3 → cerebral infarction
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Section 3 Cerebral Thrombosis
infarction of an area of the brain secondary to arterial occlusion by thrombosis of a major vessel with insufficient collateral circulation.
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Etiology atherosclerosis
Arteritis: such as leptospirosis, rheumatic fever rare cause: congenital vascular malformation, polycythemia blood hypercoagulability
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Pathology Vessel: carotid > middle > posterior > anterior > vertebral-basilar Super-early stage: 1-6 hour Necrosis → cyst White infarct Red infarct: hemorrhagic infarct
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Pathophysiology Neurons are sensitive to ischemia Central necrosis
Ischemic penumbra Super early stage: < 6 hours
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Clinical feature onset is rapid usually occur in the rest and sleep
premonitory symptoms such as weakness of a limb, transient ischemic attack The headache, vomit, and loss of consciousness may be absent or slight. Focal signs develop in several days
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Clinical type Complete stroke Progressive stroke
Reversible ischemic neurological deficit, RIND)
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Clinical syndrome 1. Internal carotid artery
May have no signs (if the collateral supply, from the other side, is good ) amaurosis fugax, uniocular blindness Horner's syndrome may present in the side of the occlusion. contralateral hemiplegia and hemianesthesia.
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Clinical syndrome 2. Middle cerebral artery
contralateral hemiplegia, hemianesthesia, hemianopia aphasia (if the dominant hemisphere is affected) Disturbance of body image (non-dominant hemisphere)
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Clinical syndrome 3. Anterior cerebral artery
contralateral hemiplegia, the leg frequently being more affected than the arm. paracentral lobule: regulation of sphincter function, retention or incontinence mental symptoms: apathy, euphoria
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Clinical syndrome 4. Posterior cerebral artery
contralateral hemianopia or quadrantanopia thalamic syndrome: contralateral hemianesthesia, thalamic pain, ataxia, tremor, athetosis
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Clinical syndrome 5. Vertebro-basilar artery (1) Main trunk
nausea, vomiting, tetraplegia, coma, death (2) Weber syndrome Unilateral lesion of midbrain Ipsilateral oculomotor nerve paralysis, contra lateral hemiplegia
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Clinical syndrome (3) locked-in syndrome
Bilateral infarction in the basis pontis Tetraplegia, can not speak, can not swallow Conscious Can only respond by vertical gaze and blinking
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Clinical syndrome 6. posterior inferior cerebellar artery
Wallenberg's syndrome, Lateral medullary syndrome Vertigo, vomiting, nystagmus Crossed sensory disturbance Ipsilateral Horner sign Dysphagia, dysarthria Ipsilateral ataxia
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Investigation 1. CT Low density focus after hours
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Investigation 2. MRI A right carotid artery occlusion, low signal of T1, and high signal of T2 weighted image.
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Investigation 3. Lumbar puncture Normal. Large infarct: pressure ↑
Hemorrhagic infarction: RBC 4. DSA 5. TCD
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Diagnosis after middle or old age. rapid onset focal cerebral symptoms
premonitory symptoms occurs in rest or sleep CT/MRI find cerebral infarction focus
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Differential diagnosis
Cerebral hemorrhage Cerebral embolism Intracranial tumor
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Treatment 1. Principle 2. Fibrinolytic therapy of super-early stage
Within 6 hours Urokinase, rt-PA 3. Anticoagulant Heparin, low molecular heparin 4. Brain protect Calcium antagonist: nimodipine, flunarizine Mannitol Hypothermia
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Treatment 5. Fibrinogen degradation Defibrase, Batroxobin
6. Anti platelet aggregation Aspirin, Ticlopidine 7. Others ? Vessel dilator ? Metabolic activator
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Treatment 8. Surgical treatment Reduce intracranial pressure
9. General management Reduce intracranial pressure: mannitol 10. Stroke unit 11. Rehabilitation 12. Prophylactic treatment Aspirin, Ticlopidine
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Lacunar infarct
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Pathology 3-4mm, <15-20mm Small liquid cavity
Basal ganglia, thalamus, brain stem Small artery: μm Atherosclerosis
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Clinical feature 40-60 years of age Always combined with hypertension
Lacunar syndrome: 1. Pure motor hemiparesis 2. Pure sensory stroke 3. Ataxic-hemiparesis 4. Dysarthric-clumsy hand syndrome 5. Sensorimotor stroke 6. Lacunar state
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Cerebral embolism Occlusion of a major cerebral artery by an embolus, with resultant infarction of part of the brain.
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Etiology Cardiac cause:
Atrial fibrillation, rheumatic valve disease, endocarditis, atrial myxoma, myocardial infarction Non-cardiac: Atherosclerosis plaque, pus embolus, fat embolus, tumor embolus Embolus of unknown origin
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Clinical feature Left middle cerebral artery
abrupt onset, maximum disability occurring at once In some cases, there is rapid improvement The primary disease, such as rheumatic heart disease
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Treatment Cerebrovasodilators Anticoagulant therapy
Treatment of primary disease
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