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Cerebrovascular Disease

Cerebrovascular Disease. Section 1 General consideration. Cerebrovascular disease: any abnormality of the brain resulting from a pathologic process of the blood vessels.

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Cerebrovascular Disease

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  1. Cerebrovascular Disease

  2. Section 1 General consideration • Cerebrovascular disease: any abnormality of the brain resulting from a pathologic process of the blood vessels. • Cerebrovascular accident orstroke may be defined as a sudden interruption of blood supply or hemorrhage into apart of the brain. • the third commonest cause of death

  3. Classification • Ischemic transient ischemic attack (TIA) cerebral thrombosis cerebral embolism cerebral infarction lacunar infarct • Hemorrhagic cerebral hemorrhage subarachnoid hemorrhage (SAH)

  4. 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

  5. Supply eyes and anterior 3/5 of the brain: frontal, parietal, part of temporal lobe, basal ganglia.

  6. 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

  7. supply cerebellum, brain stem, posterior 2/5 of brain (occipital, part of tempral lobe)

  8. Blood supply of brain • 3. Circle of Willis

  9. 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 arteriesanterior communicating artery two posterior cerebral arteries two posterior communicating arteries

  10. Risk factors of CVD • Age, family history, race • Hypertension • Heart disease • Diabetes • Hyperlipemia • Smoking, excessive drinking • Obesity, diet, contraceptive drugs

  11. 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.

  12. Etiology • Micro embolism • Spasm of cerebral blood vessel • Hemodynamic change • Compression of vertebral artery, steal syndrome

  13. Clinical feature 1. 50-70, M>F characteristics: • Abrupt onset • Transient • Complete recovery • Repetitive

  14. 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

  15. 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

  16. Clinical feature (3) Symptoms may present: • Dysphagia, dysarthria • Ataxia • Disturbance of consciousness • diplopia

  17. Diagnosis • clinical features • No signs between attack

  18. Differential diagnosis • Partial epilepsy • Meniere disease

  19. Treatment 1. Etiologic therapy • Blood pressure, sugar, lipid • Carotid endarterectomy, anastomosis of extra-intra cranial vessels 2. Prophylactic treatment • Anti-platelet aggregation drugs: Aspirin 50-300mg Qd Po Ticlopidine 250mg Qd Po

  20. 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

  21. Prognosis • 1/3 → repetitive attack • 1/3 → remission • 1/3 → cerebral infarction

  22. 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.

  23. Etiology • atherosclerosis • Arteritis: such as leptospirosis, rheumatic fever • rare cause: congenital vascular malformation, polycythemia blood hypercoagulability

  24. Pathology • Vessel: carotid > middle > posterior > anterior > vertebral-basilar • Super-early stage: 1-6 hour • Necrosis→ cyst • White infarct • Red infarct: hemorrhagic infarct

  25. Pathophysiology • Neurons are sensitive to ischemia • Central necrosis • Ischemic penumbra • Super early stage: < 6 hours

  26. 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

  27. Clinical type • Complete stroke • Progressive stroke • Reversible ischemic neurological deficit, RIND)

  28. 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.

  29. Clinical syndrome 2. Middle cerebral artery • contralateral hemiplegia, hemianesthesia, hemianopia • aphasia (if the dominant hemisphere is affected) • Disturbance of body image (non-dominant hemisphere)

  30. 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

  31. Clinical syndrome 4. Posterior cerebral artery • contralateral hemianopia or quadrantanopia • thalamic syndrome: contralateral hemianesthesia, thalamic pain, ataxia, tremor, athetosis

  32. 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

  33. 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

  34. 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

  35. Investigation 1. CT Low density focus after 24-48 hours

  36. Investigation A right carotid artery occlusion, low signal of T1, and high signal of T2 weighted image. • 2. MRI

  37. Investigation 3. Lumbar puncture • Normal. • Large infarct: pressure ↑ • Hemorrhagic infarction: RBC 4. DSA 5. TCD

  38. Diagnosis • after middle or old age. • rapid onset focal cerebral symptoms • premonitory symptoms • occurs in rest or sleep • CT/MRI find cerebral infarction focus

  39. Differential diagnosis • Cerebral hemorrhage • Cerebral embolism • Intracranial tumor

  40. 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

  41. Treatment 5. Fibrinogen degradation • Defibrase, Batroxobin 6. Anti platelet aggregation • Aspirin, Ticlopidine 7. Others • ? Vessel dilator • ? Metabolic activator

  42. Treatment 8. Surgical treatment • Reduce intracranial pressure 9. General management • Reduce intracranial pressure: mannitol 10. Stroke unit 11. Rehabilitation 12. Prophylactic treatment • Aspirin, Ticlopidine

  43. Lacunar infarct

  44. Pathology • 3-4mm, <15-20mm • Small liquid cavity • Basal ganglia, thalamus, brain stem • Small artery: 100-200μm • Atherosclerosis

  45. 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

  46. Cerebral embolism Occlusion of a major cerebral artery by an embolus, with resultant infarction of part of the brain.

  47. 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

  48. 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

  49. Treatment • Cerebrovasodilators • Anticoagulant therapy • Treatment of primary disease

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