CEREBRAL CIRCULATION

The Circle of Willis is

the joining area of
several arteries at the
bottom (inferior) side of
the brain. At the Circle
of Willis, the internal
carotid arteries branch
into smaller arteries that
supply oxygenated
blood over 80% of the
cerebrum.

CEREBRAL CIRCULATION

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CEREBRAL CIRCULATION

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 CEREBRAL CIRCULATION

CEREBRAL CIRCULATION
The brain receives its blood
supply from four main
arteries: the two
internal carotid arteries
and the two vertebral
arteries. The clinical
consequences of vascular
disease in the cerebral
circulation is depend upon
which vessels or
combinations of vessels are
involved.

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 CEREBRAL CIRCULATION
Principal types of stroke:
Thrombotic: Stroke due to the blockage of an artery leading
to or in the brain by a blood clot.
Haemorrhagic: Stroke due to bleeding from a ruptured blood
vessel, usually a consequence of hypertension.
Embolic: Stroke due to the formation of a blood clot in a
vessel away from the brain. The clot is carried in the
bloodstream until it lodges in an artery leading to or in the
brain.
The thrombotic and haemorrhagic forms are common,

CEREBRAL CIRCULATION

Dementia: This may result from repeated episodes of

small strokes which produce progressive damage to the
brain over a period of time.
The main clinical feature of dementia is a gradual loss of
memory and intellectual capacity.
Loss of motor function in the limbs and incontinence can
also occur.

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CEREBRAL CIRCULATION

CEREBRAL CIRCULATION

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CEREBRAL CIRCULATION

CEREBRAL CIRCULATION

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Cerebrovascular Accident/Stroke
Definition and Types of CVA
 death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired
by blockage or rupture of an artery to the brain
 CVA is also known as stroke

Types of Cerebrovascular Accident

 There are two types of cerebral cardiovascular accidents/ stroke
o Ischemic
o Haemorrhagic
Ischemic Stroke/CVA
 Ischemic stroke is the most common type of stroke (~ 80%) usually due to a blocked artery
often by a blood clot
 Usually this type of stroke results from clogged arteries, a condition called atherosclerosis
 Fat, cholesterol, and other substances collect on the wall of the arteries forming a sticky
substance called plaque. Over time the plaque builds up
 This often makes it hard for blood to flow properly which can cause the blood to clot There
are two types of clots
o A clot that stays in place in the brain is called a cerebral thrombus
o A clot that breaks loose and moves through the blood to the brain is called a cerebral
embolism
 Transient ischemic attacks (TIAs) are often an early warning sign of an impending ischaemic
stroke
 They are caused by a brief interruption of the blood supply to part of the brain
 Because the blood supply is restored quickly, brain tissue may not die, as it does in a stroke.

Hemorrhagic Stroke
 Rupture of an artery to the brain causing blood to leak into the brain

Causes and Risk Factors for CVA

Risk Factors
 Atherosclerosis (narrowing or blockage of arteries by patchy deposits of fatty material in the
walls of arteries)

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 High blood cholesterol levels
 High blood pressure
 Diabetes
 Smoking
 Family history of stroke
 Old age
 Too much alcohol
 Cocaine or amphetamines consumption
 Abnormal heart rhythm (atria fibrillation)
 Inflamed blood vessels (vasculitis)

Causes
 An artery to the brain may be blocked by a clot (thrombosis) which typically occurs in a
blood vessel that has previously been narrowed due to atherosclerosis
 A blood clot can form in a chamber of the heart when the heart beats irregularly, as in atria
fibrillation

 A cerebral hemorrhage (bleeding in the brain), as from an aneurysm.

Clinical Features
 Strokes usually damage only one side of the brain

 Because nerves in the brain cross over to the other side of the body sign appear on the side of

the body opposite the

damaged side of the brain
 Signs and symptoms depend on the area of the brain affected
o Change in alertness (consciousness)
o Coma
o Lethargy
o Drowsiness
o Stupor
 Difficulty speaking or understanding others
 Difficulty swallowing
 Difficulty writing or reading
 Headache
o Starts suddenly
o Occurs when lying flat

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 o Gets worse when changing positions or when bending, strain, or cough
With vomiting frequently and loss of body balance check for

ROMBERG SIGN
 Loss of coordination
 Loss of balance
 Movement changes usually on only one side of the body
o Difficulty moving any body part
o Loss of fine motor skills
 Nausea or vomiting
 Seizures
 Sensation changes usually on only one side of the body
o Decreased sensation
o Numbness or tingling
 Sudden onset of confusion
 Vision changes
o Decreased vision
o Loss of all or part of vision
 Weakness or paralysis of one side of the body

Management of CVA
 Patients clinically suspected of having CVA (history and examination) must be referred to
hospital for investigation and treatment.
 Take blood pressure to rule out hypertension although sometimes blood pressure tends to
normalize after stroke.
 At primary health care facilities, pre-referral management must be done before patients are
referred (i.e. ensuring airway is open, patient is breathing and circulation is proper)

Investigations
 Diagnosis is based on medical history and symptoms but imaging and blood tests are also
done

 The blood sugar level is measured

immediately because a low blood sugar
level (hypoglycemia) can cause symptoms similar to those of stroke
 Other tests at higher centers

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o Computed tomography (CT scan) or Magnetic Resonance Imaging (MRI) of the
brain

o Complete blood count (CBC)

o Electrocardiogram (ECG) to diagnose underlying heart disorders

o Echocardiogram if the stroke may have been caused by a blood clot from the heart

o SERUM
CHOLESTEROL : IS
i. TRIGLYCERIDES
ii. TOTAL
CHOLESTROL
iii. LOW DENSITY
LIPOPROTEIN
iv. VERY LOW DENSITY
LIPOPROTEIN
v. HIGH DENSITY
LIPOPROTEIN
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Treatment
 Definitive management of patients with CVA must be done in the hospital and therefore
referral is a must.
 Treatments designed to reverse or lessen the amount of tissue infarction fall within the
following categories
o Medical support

o Thrombolysis
o Anticoagulation (e.g. low molecular
heparin)
o CLOT CONTROL
o _ ANTIPLATELET ASA 162 325 mg PO chew _1
o dose, then 75 162 mg PO daily (for medically
o treated unstable angina/NSTEMI), or 162 325 mg
o
o STEMI, clopidogrel 300 600 mg _1 dose
then
o 75 mg PO daily. Combination ASA plus clopidogrel
o for minimum of 1 month (ideally 1 year) post PCI
o with bare metal stent, or minimum 12 months
o (possibly indefinitely) for drug eluting stents. If
o post PCI, pain unresponsive to nitroglycerin

(SUB LINGUAL) UNDER THE

TONGUE
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o _

o ANTICOAGULATION options include

LMWH low (enox =

molecular weight heparin

o aparin 30 mg IV bolus, then 1 mg/kg SC BID for
o (unfractionated heparin 70 U/kg [up to 4000U] IV
o
o _
o

o Streptokinase 1.5million units IV over

30 60 min
o )
o

IV
o RATE CONTROL

metoprolol is mostly contra

o indicated. Start with metoprolol 25 mg PO BID and
o titrate slowly. Alternatively, atenolol 25 mg PO daily
o and titrate to 100 mg PO daily. The goal heart rate is
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o 50 55 with normal activity. If b blocker contraindi
o cated, consider non dihydropyridine calcium chan
o nel blockers diltiazem 30 120 mg PO QID or verapa
o mil 80 120 mg PO TID (contraindicated if LV
o dysfunction)
o

simvastatin 40
o LIPID CONTROL

mg PO daily or
o atorvastatin 80 mg PO

daily
o
o BLOOD PRESSURE SUPPORT for patients with
o cardiogenic shock, consider IV fluids, inotropes
o (dobutamine/dopamine), balloon pump, and early
o revascularization
o OVERALL APPROACH

o Antiplatelet agents (e.g. Aspirin)

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Ischemic Stroke
 When cerebral infarction occurs the immediate goal is to optimize cerebral perfusion in the
surrounding ischemic area.
 Attention is also directed toward preventing the common complications of bedridden patients
o Infections
 Pneumonia
 Urinary tract
 Skin
o Deep venous thrombosis (DVT)
o Pulmonary embolism
 If treatment can be started within 3 hours of the first symptom then thrombolytic therapy
(‘clot breaking drug’) may be considered as an option
 Low doses of intravenous heparin is sometimes an option
 Supportive measures may be considered as an option
 Blood pressure is cautiously controlled. Lowering blood pressure too much may cause
another stroke to occur

Hemorrhagic Stroke
 Supportive measures only
 All blood thinning medications will make a stroke worse and therefore need to be avoided
 Correct any bleeding problems
 Blood pressure is controlled very cautiously
 Treatment of blood pressure that is too high or too low may be necessary
o Lowering elevated blood pressure into the normal range is no longer recommended
during the first few days following a stroke (current recommendation is to have BP
between 140-160 systolic in setting of acute stroke)
o If the blood pressure is low, raising it is advisable using intravenous fluids
 Pain killers may be given to control severe headache but avoid respiratory depression
 The blood sugar (glucose) in diabetics is often quite high after a stroke
 Controlling the glucose level may minimize the size of a stroke
 Oxygen is given as needed

Rehabilitation
 The goal of long-term treatment is to help the patient recover as much function as possible
and prevent future strokes
 Depending on the symptoms rehabilitation may include
o Occupational therapy

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 o Physical therapy
o Speech therapy

Prevention of CVA
General Principles
 A number of medical and surgical interventions as well as life-style modifications are
available for preventing stroke.
 Some of these can be widely applied because of their low cost and minimal risk.
 Others are expensive and carry substantial risk but may be valuable for selected high-risk
patients.
 One of the most important interventions to prevent stroke is to identify HTN early and
initiate proper treatment.
 If the patient has atrial fibrillation, warfarin is recommended, secondary option aspirin.
 Cholesterol levels should be brought to normal level.
 Diabetes mellitus should be controlled.
 Alcohol consumption should be limited.
 Exercising regularly and if overweight, losing weight helps people control high blood
pressure, diabetes, and high cholesterol levels.
 Having regular checkups enables a doctor to identify risk factors for stroke so that they can
be managed quickly.
 Stop smoking - this is probably the second most important intervention after HTN control
 Low dose aspirin 75 mg daily should be instituted in those at high risk for stroke with risk
factors (e.g. persons with previous stroke or TIA, diabetics, those with known cardiac
disease, or atherosclerosis). Do not use if contraindications for aspirin exist.

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