Stroke Neuro

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Stroke

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a sudden onset of neurological deficit that persist longer than 24 hours and may recover to a varying degree

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Nonmodifiable risk factors

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Age
Ethnicity
Gender
Family History
Genetics

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Modifiable Risk Factors

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hypertension
history of stroke
cerebrovascular disease
obesity

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Complete interruption of cerebral blood flow causes progressive functional loss with time:

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1. Suppression/ reduction of brain electrical activity within 12-15sec
2. Inhibition of synaptic excitability of cortical neurons after 2-4min
3. inhibition of electrical after 4-6 min

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penumbra

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cellular dysfunction..but can recover to a certain extent

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when blood flow decreases to 18 ml/100g/min

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cells do not function but have potential for recovery
-penumbra

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At 8 ml/100g/min

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the threshold of membrane failure is reached and cell death may occur

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the two categories of strokes

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1. Occlusive (most common)
2. Hemorrhagic

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Extraparenchymal Hemorhage

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subarachnoid , intraventricular (outside tissue)

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Intraparenchymal Hemorhage

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within tissue

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what is the most common form of occlusive stroke

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embolism

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the typical material that typically gets lodged in the artery in a cerebral embolism

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thrombus

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In the anterior circulation (ICA) what branch is most commonly occluded

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Middle Cerebral Artery

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In the posterior circulation (vertebrobasilar) the most common branch to get occluded

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a cerebellar artery or PCA

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the progession of damage within an embolus is described as

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Ishemia--> infarction

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ishchemia

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lacking oxygen but not necessarly dead

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Infarction

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vascular infficiency resulting in necrosis of the area supplied by the artery

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what is the major direct and indirect souce of emboli?

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Atherosclerosis

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other major source of emoli results from

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cardiomyopathies or arrhythmias

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Minorsources of emoli

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air emboli
fat emboli- from broken bone
amniotic fluid
tumor emboli

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intracranial hemorrhage technically associated with stroke

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Subarachnoid hemorrhage
Intraventricular Hemorrhage
Parenchymatous, Cerebral hemorrhage

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Hemorrhage associated stroke can arise from vessel rupture via?

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-defect arteriovenous malformation
-aneurysms
-trauma
-Disease

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Cerebral Hemorrhage is usually due to the rupture of small vessels such as the

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Lenticulostriate Arteries

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Most common hemorrhage with a hemorrhagic stroke

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sub arachnoid hemorrhage
(usually from blood leakage from a small aneurysm)

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Major risk factors for cerebral hemorrhage

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1. Hypertension
2. Diabetes
3. Atherosclerotic disease

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Carotid aneurysms in the canernous sinus can result in compression of

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CN III, IV, VI
and opthalmic and maxillary branches of CN V

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compressing on CN III, IV, VI and V from a carotid aneurysm in teh cavernous sinus can produce what symptoms?

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partial or complete paralydid of eye movement, loss of the corneal reflex and paresthesias or pain wthin the distributions of CN V

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what are abnormal communications between cerebral arteries and veins which cna cause bleeding into CSF spaces or braintissue. And normally superficial

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Arteriovenous malformations

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An ateriovenous malformation of the great cerebral vein of Galen (usually seen in newborns) produces what symptoms?

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-bulging fontanelles
-progressive hydrocephalus
(compression and occulsion of hte cerebral aqueduct)
-dilated veins of the face and scalp

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ICA occlusion may cause infarction of the entire hemisphere except

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-the thalamus
-inferior portion of the temporal lobe
-medial portion of occipital lobe

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Signs and Symptoms of ICA occlusion usually associated with

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MCA occlusion
(because of more direct anterior communicating artery location to anterior circulation)

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neurological deficits occur but recover before 24 hours but usually before 10min

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TIAs

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Amaurosis Fugax

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transient blindness on the affected side from TIA in ophthalmic artery

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What distinguishes MCA syndrome from CA syndrome

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Ophthalmic involvement

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Symptoms of TIAs in carotid (Anterior) Circulation

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1. Ipsilateral amaurosis fugax
2. Contralateral sensory or motor dysfunction liminted to one side of the body
3. Language deficits may occur

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Symptoms of TIAs in vertebrobasilar (Posterior) Circulation

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1. Bilateral or shifting motor or senosry dysfunction
2. Bilateral visual disturbances
3. Bifacial numbness
4. Vertigo
5. Diplopia
6. Ataxia

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TIA's are often associated with

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vascular stenosis from emboli or narrowing of arteries from various causes

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Watershed regions

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the border zones between the areas supplied by the anterior, middle and posterior cerebral arteries

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watershed strokes occur along

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the borders between arterial territories

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Watershed strokes are usually from?

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Reduced cerebral blood flow from severe arterial hypotension or hypoxemia or severe carotid artery disease

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Anterior Watershed Infarcts can produce

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ACA/MCA
produce person in a barrel syndrome
-proximal body motor and or sensory deficits
-expressive language deficits and behavior changes

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Posterior Watershed infarcts can produce

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MCA/PCA
-complex visual and sensory loss and a variety of lanuage problems depending upin the extent of damage to the dominant hemisphere

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lacunar strokes occur in

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penetrating arteries to deep tissue of the brain or brainstem (not cortex)

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Lacunar syndromes include

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-1.pure motor strokes

-2.pure sensory strokes

-3.ataxic hemiparesis
- clumsy hand syndrome with other deficits that do not represent a large artery distribution

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Multiple Lacunar Strokes are assoiciated with

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multi infarct dementia (MID)

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Pure Motor syndrome involves

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descending motor fibers (corticospinal tract) fibers

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PMS possible areas of involvement

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posterior limb of the internal capsule, ventral pons, corona radiata or crus cerebri

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Treatment for TIAs

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chronic antiplatelet therapy
anticoagulants
carotid endarterectomy
angioplasty and stents

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Stroke in evolution is managed with

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anticoagulants

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Completed stroke is treated with

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- IV or IA thrombolytic therapy
-Antiplatelet/ anticoagulation/ antihypertensive/ antiedma
-surgery