Cerebrovascular Diseases

Dr. K. D. Pathirana
Consultant Neurologist
Senior Lecturer in Medicine
Galle
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 Contents
• Transient Ischaemic Attacks

• Stroke

• Subarachnoid Haemorrhage

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 Definitions

• TIA -acute loss of focal cerebral or

monoccular function with
symptoms lasting less than 24
hours and of embolic or thrombotic
origin

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 Epidaemiology
• Prevalence 5/1000 population
• Incidence of TIA 0.5/1000/yr
• Risk increases with Blood Pressure
• No difference in incidence in two sexes

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 Pathophysiology
• 80%- cerebral Infarct
• 10%- intracerebral Haemorrhage (ICH)
• 10% Subarachnoid Haemorrhage
(SAH)

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 Risk Factors
• Hypertension
• Diabetes Mellitus
• IHD and other heart diseases
• Atrial fibrillation
• Smoking
• Cholesterol
• HISTORY OF/O TIA
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• PVD
• Increased fibrinogen levels
• contraceptive pills
• heavy alcohol consumption
• vertebral or carotid bruits

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 Carotid territory TIA
• Face, arm leg
• Weakness or numbness
• Isolated or in combinations
• Aphasia
• Amaurosis fugax (transient blindness)
• Dysarthria only due to facial

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 Vertebro-basilar TIA
• Vertigo
• Dizziness
• unsteadiness
• dysarthria
• diplopia

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 Definitions

• Stroke: Rapidly developing focal or

global loss of cerebral function with
symptoms lasting more than 24 hours
or leading to death with no apparent
cause other than that of vascular
origin

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 Carotid arteries
Normal US & stenotic DSA

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 TIA
• Investigations~ Similar to stroke
• Risk of stroke 12 % ist yr, 7%
afterwards
• Risk of vascular death 10 %
• Risk of MCI- 7%

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 TIA Management
• Control BP
• control diabetes
• control lipids-
– diet
– drugs
• Aspirin/ Ticlopidine/ clopidogrel
• Anticoagulation
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 TIA Management
• Anticoagualtion in
– Atrial Fibrillatio
– after myocradial Infarction
– Cardiac source of emboli known
– “Poor response to aspirin”

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 TIA Management- Surgery
Carotid Endarterectomy

• If stenosis is >70%
• In a centre with less than 5% mortality
and morbidity

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 Stroke
• Clinical Features
– Depending on the site affected
• Depends on the artery affected

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 Examination

• CNS- for disability / site/ artery

• Neck stiffness, Kernig’s for H’ge
• Plycythemia, rash.. vasculitis
• CVS: BP BP BP , heart etc….
• Abdomen

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 Investigation
• Relatively old

• Relatively young

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 In Young Patient
C T S c a n m a n d a to ry

H a m o rrh a g e I n fa r c t

G e n e r a lis e d Local

H y p e r t e n s io n V a s c u lit is B le e d in g D is o r d e r s AVM A n e u r is m

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 Table 1 Some familial causes
of stroke
• Vascular anomalies
• Vascular malformation
• Saccular aneurysm
• Hereditary haemorrhagic telangiectasia

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 Connective tissue anomalies
• Ehlers &Danlos syndrome
• Pseudoxanthoma elasticum
• Marfan's syndrome
• Polycystic kidney disease
• Mitral leaflet prolapse

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 Haematological diseases
• Haemophilia and other coagulation
factor deficiencies
• Sickle-cell disease
• Antithrombin III deficiency
• Protein C deficiencyProtein S

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Other familial causes of stroke
• Familial hypercholesterolaemia
• Cerebral amyloid angiopathy (Icelandic
form)
• Neurofibromatosis
• Tuberous sclerosis
• Homocystinaemia
• Fabry's
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Other familial causes of stroke
• Migraine
• Cardiac myxoma
• Von Hippel& Lindau syndrome
• Mitochondrial cytopathy

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 Relatively old patient

• CT if needed
• FBS
• Hb% PCV
• ECG
• Lipids
• Blood urea and electrolytes
• CXR
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 Relatively young patient

• CT is a must
• Differentiate H’ge from Infarct

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 AVM

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 Management- Evidenced
based
• Early aspirin therapy -160 -300mg/day
– oral/NG/ per rectal- within 48 hrs
– reduces the risk of death and disability
– NNT -77
• Heparin did not improve outcome but may
be indicated in prevention ofembolism
– DVT
– morbid obesity
 Management ctd.
• Heparin-therapeutic in
– carotid or vertebral dissection
– embolic or recurrent TIAs

• Always exclude haemorrhage or

haemorrhagic infarct before
anticoagulation

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Current status of thrombolysis
• Different outcome in different studies
– Beneficial within 3 hours- NNT 7 (NINDS
trial)
– No benefit (ECASSII trial)
– Hamorrhagic complications are common
• Still only in randomised trials

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 Neuroprotection
• Calcium chanel blokers Nimodipine - no
benefit may be harmful)
• Glutamate antagonists- NMDA receptor
blokers to stop excitatory cytotoxicity
• Anti oxidants
• GABA agonists
• No agent is still proven to be useful

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 Stroke units
• Proven to improve prognosis
• Cost effective
• Shorten the hospital stay

• One unit in Colombo

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 Secondary prevention
• Aspirin 150 - 300 mg/day
– if haemorrhage excluded
– if possibility of hamorrhage is remote*
• Aspirin + dipyridamole
– one study showing additive effect ( if 25mg
of aspirin + 400mg of dypiridamole given)
• criticism on study design

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 If aspirin is contraindicated
• Ticlopidine
• Clopedogrel

• Expensive
• Side effect profile worse

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 Secondary prevention-
anticoagulation
• In patients with cardiac source of emboli

• In patients with AF, dialated

cardiomayopathy, mitral stenosis,
prosthetic valves

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 Secondary prevention-
cholesterol lowering

• In carotid atheromatous strokes

• in patients < 70

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Secondary prevention- carotid
endarterectomy
• Symptomatic carotid obstruction > 70%

• In a centre with morbidity and mortality

<5%

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 Primary prevention
• In patients with atrial fibrillation

• High risk of embolism

– dialated cardiomyopathy,
– prosthetic valves

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 Primary prevention
• Control hyoertension

• Control diabetes mellitus

• Stop smoking

• Control lipids
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 Supportive care and
rehabilitation
• swallowing
• prevent aspiration
• prevent bed sores
• physiotherapy
• speech therapy
• visual rehabilitation
• cognitive rehabilitation
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 Swallowing
• Asses with gag reflex
• “formal assessment”

• If either is positive- NG feeds

• On recovery - semi solids etc

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 Physiotherapy
• as early as possible

• train the carer at home

• For upper limb

– extension at each joint and rotation at shoulder
joint
• For lower limb
– flexion at each joints
 Speech therapy
• Aphasia - by family members
• teach as for a small baby
• Dysarthria-
• exercise to facial muscles, blowing
baloons, candles etc

• refer to speech therapist if

possible!
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 Prevent bed sores
• Frequent turning
• special mattresses
• Water mattresses

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 Emotional rehabilitation

• prevent being on the bed all the time

• encourage independence
• encourage to go out
• wheel chair till recovery

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 • Surplus of resources
will never be found in
the real world.

• Our aim should be to

give the best care
possible from available
resources while
fighting for better
facilities
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Subarachnoid haemorrhage
and aneurism

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 Presentation
• Sudden severe occipito-frontal
haedaahe
• Neckstiffness Kernigs
• Ix- CT
• If CT is normal CSF xanthochromia

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 Management
• Bed rest
• Control Ht
• Pain control
• Nimodipine
• Confirm
• If GCS > 5 surgery
• If <5 conservative mgt---> surgery
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