1. Cerebrovascular diseases Cerebrovascular diseases

2. Definitions: -Stroke :it is acute onset of neurological deficit that persist for at least 24h. -Stroke :it is acute onset of neurological deficit that persist for at least 24h. -Minor stroke : it is deficits that last for longer than 24h but resolve completely. -Minor stroke : it is deficits that last for longer than 24h but resolve completely. -stroke in evolution: actively progressing as a direct consequence of the underlying vascular disorder. -TIA :neurological deficit that resolve completely within 24h. Stroke either due to ischemia 85% or hemorrhage 15%. Stroke either due to ischemia 85% or hemorrhage 15%.

3. Pathophysiology : acute occlusion of an intracranial vessel causes reduction in blood flow, fall in CBF to zero lead to death of tissue within 4-10 min. tissue surrounding the core region of infarction is ischemic but reversibly dysfunction and referred to ischemic penumbra. Saving the ischemic penumbra is the goal of thrombolytic therapy. acute occlusion of an intracranial vessel causes reduction in blood flow, fall in CBF to zero lead to death of tissue within 4-10 min. tissue surrounding the core region of infarction is ischemic but reversibly dysfunction and referred to ischemic penumbra. Saving the ischemic penumbra is the goal of thrombolytic therapy.

4. Risk factors : -nonmodifiable: modifiable -Age -Hypertension -Sex -D.M -Race ethnicity -Smoking -Hereditary -Alcohol Intake -Obesity -Obesity -Drugs abuse -Drugs abuse -Food intake -Food intake

5. Causes : -common causes: -Thrombosis : lacunars stroke -large vessel stroke -dehydration - Embolic occlusion: -artery to artery like carotid bifurcation and aortic arch. Cardioembolic : AF, mural thrombus, MI, dilated cardiomyopathy,

6. Uncommon causes: -hypercoagulable diseases. -venous sinus thrombosis. -fibromuscular dysplagia. -vasculitis.-Cardiogenic-drugs. -moya-moya disease. -eclampsia.

7. Clinical manifestations : -1-Middle cerebral art. Stroke: it is the commonest art. Involved by imbolic rather than thrombosis. -A- superior division stroke: - contralateral hemiparesis. -contralateral hemisensory loss. -no homonymous hemianopia. -expressive aphasia if dominant. -B-inferior division stroke: -contralateral homonymous hemianopia. -agraphesthasia &asteriognosis. -anosognosia. -neglect contralateral space &limb. -wernicke aphasia if dominant. -acute confusion. -C- stem of MCA: -contralateral hemiplegia & sensory loss affecting face, arm &leg. -global aphasia.

8. -2- ACA stroke: - contralateral paralysis & sensory loss affecting the leg. -impaired maturation center. -contralateral grasp reflex & sucking R. -abulia. - 3-internal carotid art. Stroke: - one fifth of ischemic stroke. -may be asymptomatic. -symptomatic similar to that of MCA stroke. -4-PCA syndrome: - homonymous hemianopia with or without macular sparing. -anomic aphasia. -alexia without agraphia. -Visual agnosia. -Cortical blindness. -memory impairment. -prosognosia.

9. -5- Basilar art. Syndrome : -brief anatomy. -hemiplegia or quadriplegia. -coma is common. -unilateral or bilateral 6 th N. palsy. -locked in syndrome. -unilateral or bilateral 3th N.palsy. - Paralysis upward or downward gaze. -6-PICA syndrome : -epsilateral cerebellar ataxia. -horner syndrome. -facial sensory loss. -nausea & vomiting. -nystagmus -vertigo. -contralateral loss pain &tempru. -dysphasia & dysartheria -excessive salivation. -7- Associated symptome : -seizures.-headache.

10. Small vessel stroke: -lipohyalinotic or atherothrobotic occlusion of small art. -Hypertention & age. -20% of all stroke. -1-pure motor hemiparesis: -2-pure sensory stroke: -3-ataxic hemiparesis: -4-dysarthria-clumsy hand syndrome: -5-pure motor hemiparesis & brocas aphasia:

11. Investigative studies : -A- blood tests : 1-blood count. 2-ESR. 3-serology for syphilis. 4-RBS. 5-serum lipids. - B-ECG. -C-echo study. -D-CT or MRI: -E-carotid Doppler. -F-LP.-G-Angiography.-H-EEG.

12. DDx: 1-vascular disorders: -ICH-SAH -subdural or epidural hematoma. -saggital sius thrombosis. 2-structural brain lesion: - tumors. -abscess.3-metabolic: - hypoglycemia. -hyperosmolar nonketotic hyperglycemia.

13. Treatment: 1-medical support: the immediate goal is to optimize cerebral perfusion in the surrounding ischemic penumbra. 1-Blood pressure: when 240/140 mmhg ?? 2-Glucose: <11.1mml/L (200mg/dl). 3-Fever. 4-Prevent complicaion: 5-Antiedema drugs: 2-Thrombolysis: - rTPA. -Indications:-C/I:3-Anticoagulation:

14. 4-Antiplatelets:-aspirin. -ticlopidine &clopidogrel. -compination. 5-surgical therapy: - A-symptomatic carotid stenosis. -B-asymptomatic carorid stenosis. 6-Rehabilitation: 1-early physical therapy. 2-speech therapy. 3-education of pat. &family. 4-prevente complication of immobility.

15. Intracranial hemorrhage: -it is classified by their location & the underlying vascular pathology. -it is incidence 15% of CVA. Causes: 1-head trauma. 2-hypertensive H. 3-transformation of prior stroke. 4-metastatic brain tumor. 5-coagulopathy.6-drugs.7-AVM.8-aneurysm. 9-amyliod angiopathy. 10-vasculitis.11-vasculopathy. 12-cavernous angioma.

16. Risk factors: -age. higher in young subjects. -male gender. -hypertension.-DM.-smoking. -high alcohol intake. -very low cholesterol <160mg/dl.

17. Pathophysiology: ICH has 3 main phases. - arterial rupture & hematoma formation. -haematoma enlargement. -peri-hematoma oedema. -ICH result from rupture of small penetrating art. -early oedema is due to the vasogenic oedema. peak 4-5 days. -delayed oedema is both vasogenic &cytotoxic. Last 2-4weeks.

18. Diagnosis : 1-Imaging noncontrast CT. 2-Routine investigation. -CBP & ESR. - B. urea. & creatinine. -Electrolyte. -S. cholesterol. -PT & PTT. -ECG. -U/S. 3-If young patients. Send to the following. -ANA & antidouble strand DNA. -Antiphospholipid ABS. -VDRL. 4- EEG.

19. Treatment: 1-admition to stroke unit. 2-reducing ICH. -Mannitol. -Steriod. 3-hdrocephalus. 4-cerebellar hematoma. >3cm. 5-large lobar hematoma. 6-hypertension. BP >180/105mmhg. 7-seizures. 8-prevention of aspiration. Nasogastic tube. 9-prevention of complication. 10-hematoma growth.

20. Hypertensive hemorrhage: -brief pathophysiolgy. -common sites in order. Putamen, thalamus, deep ceebellum & pons. -almost occurs when the patients are awake &stressed. -develop over 30-90min. -abrupt onset of focal neurological deficits. Thalamic hemorrhage : -contralateral hemipligia &hemisensory loss. -horner syndrome. -homonymous field defect. -Paralysis of vertical gaze. -absent of light R. -absence of convergence.

21. Pontine hemorrhage: -occurs over min. -deep coma. -quadriplegia. -pin-piont pupils. -hyperpyrexia. -severe hypertension. -hyperpnea & hyperhydrosis. -impiarment of dolls maneuver. Cerebellar hemorrhage: - usually develop over h. -occipital headache &vomiting. -dizziness &vertigo. - ataxia of giat. Impaired of gaze. -dysartheria & dysphagia.

22. SAH: - excluding head trauma the most common cause of SAH is rupture of aneurysm. -saccular aneurysm occurs in 2% of adults. -the most common location are terminal ICA, MCA bifurcation, & top of basilar art. -mycotic aneurysm. Clinical manifestations: -most unruptured aneurysm are completely asymptomatic. -the hallmark feutures. -sudden onset loss of coniousness. -neck stiffness &vomiting. -cranial N. palsy. -subhyliod hemorrhage. -hemiparesis, aphasia &abulia.

23. Delayed neurological deficits: 1-Rerupture: 1-Rerupture: 2-Hydrocephalus: 2-Hydrocephalus: 3-Vasospasm: 3-Vasospasm: 4-Hyponatremia: 4-Hyponatremia: Laboratory evaluation & Imaging: - the hallmark is blood in the CSF. -noncontrast CT of brain. -if CT fail, LP done. -what are the finding of CSF. -four vessel angiography. -ECG finding. -monitoring of electrolytes.

24. Tretment: -Early aneurysm repair prevent rerupture. -Early aneurysm repair prevent rerupture. -protecting the airway. -protecting the airway. -managing BP. -managing BP. -treat vasospasm. -treat vasospasm. -decrease raised ICP. -decrease raised ICP. -bed rest in quiet room & given stool softeners. -bed rest in quiet room & given stool softeners. -treat seizures. -treat seizures. -managing hyponatremia. -managing hyponatremia. -prevent of complication. -prevent of complication. -neurosurgical consultation. -neurosurgical consultation.