CEREBROVASCULAR CEREBROVASCULAR ACCIDENTACCIDENT

CLASSIFICATIONCLASSIFICATION

Complete strokeComplete stroke T.I.AT.I.A R.I.N.DR.I.N.D Stroke in evolutionStroke in evolution

Acute neurological injury which occursAcute neurological injury which occurs as a as a result of ;result of ;

1—Embolism1—Embolism 2---Thrombosis2---Thrombosis 3---Haemorrhage3---Haemorrhage 4---Demyelation4---Demyelation 5---SOL { Space occupying lesion}5---SOL { Space occupying lesion}

RISK FACTORSRISK FACTORS

Age—advanced ageAge—advanced age Sex—males more than femalesSex—males more than females HypertensionHypertension DMDM HyperlipidemiaHyperlipidemia SmokingSmoking Excess alcohol consumptionExcess alcohol consumption PolycythemiaPolycythemia

O.C. pillsO.C. pills VasculitisVasculitis ThrombophilliaThrombophillia Anticardiolipin antibodyAnticardiolipin antibody HomocysteinureaHomocysteinurea

MANAGEMENTMANAGEMENT

HISTORYHISTORY

May be helpfulMay be helpfulHeadache + vomiting ---favour the Dx of IC hge Headache + vomiting ---favour the Dx of IC hge

or SAH or SAH

Abrupt onset of impaired cerebral function Abrupt onset of impaired cerebral function without focal symptoms suggest SAHwithout focal symptoms suggest SAH

EXAMINATIONEXAMINATION BPBP BreathingBreathing Fever----meningitisFever----meningitis subdural haematomasubdural haematoma brain abcessbrain abcess infective endocarditisinfective endocarditis Neck---for bruitsNeck---for bruits Pulses----in neck and armsPulses----in neck and arms

CVS---valvular heart disease ,AFCVS---valvular heart disease ,AF Skin---signs of cholesterol Skin---signs of cholesterol

embolism+IEembolism+IE FundusFundus

INVESTIGATIONSINVESTIGATIONS

CBC , ESRCBC , ESR U+E, RBSU+E, RBS LFT, PT, PTTLFT, PT, PTT CT scan brain or MRICT scan brain or MRI Doppler U.S of carotidsDoppler U.S of carotids EchoEcho Hypercoagguable screenHypercoagguable screen Screen for connective tissue diseaseScreen for connective tissue disease Toxicology screenToxicology screen

D/DD/D--Migraine--Migraine--Head trauma--Head trauma--Brain tumour--Brain tumour--Systemic infections--Systemic infections--Toxic metabolic disturbance--Toxic metabolic disturbance hypoglycemiahypoglycemia acute renal+ hepatic failureacute renal+ hepatic failure drug intoxicationdrug intoxicationTodd,s paralysisTodd,s paralysis

HAEMORRHAGEHAEMORRHAGEIntracranial hge can be caused by—Intracranial hge can be caused by— Intracerebral hge {ICHIntracerebral hge {ICH} } also called parenchymal hge which also called parenchymal hge which

involves bleeding directly into brain tissue.involves bleeding directly into brain tissue. SAHSAH involves bleeding into the CSF that involves bleeding into the CSF that

surrounds the brain and the spinal cordsurrounds the brain and the spinal cord TraumaTrauma causing subdural or extradural causing subdural or extradural

haematomashaematomas

COMMONCOMMON CAUSESCAUSES HypertensionHypertension TraumaTrauma Bleeding diathesis Bleeding diathesis Amyloid angiopathyAmyloid angiopathy Illicit drug abuse {amphetamine , Illicit drug abuse {amphetamine ,

cocaine}cocaine} Vascular malformationVascular malformation Rupture of aneurysm Rupture of aneurysm VasculitisVasculitis

SUBARACHANOID HAEMORRHAGESUBARACHANOID HAEMORRHAGE

1--Bleeding from aneurysm typically located 1--Bleeding from aneurysm typically located in the anterior half of circle of willis at in the anterior half of circle of willis at the base of the brain.the base of the brain.

2—22—2ndnd commonest causes commonest causes

A/V malformationA/V malformation

bleeding diathesisbleeding diathesis

drugsdrugs

amyloid angiopathyamyloid angiopathy

COMPLICATION OF SAH DUE TOCOMPLICATION OF SAH DUE TO ANEURYSMANEURYSM

Rebleeding within 10 daysRebleeding within 10 days VasospasmVasospasm Systemic complicationsSystemic complications --hyponatremia--hyponatremia --MI--MI --CNS disturbance--CNS disturbance

TREATMENTTREATMENT Identify causeIdentify cause Prevent rebleedingPrevent rebleeding Prevent brain damage due to Prevent brain damage due to

delayed ischaemia related to delayed ischaemia related to vasoconstrictionof IC arteriesvasoconstrictionof IC arteries

--surgical removal--surgical removal --Calcium channel blocker ---Calcium channel blocker -

NimodipineNimodipine

PROGNOSISPROGNOSIS SAH from intra cranial aneurysm has a SAH from intra cranial aneurysm has a

mortality of 50%mortality of 50% Prognosis is closely related to pts Prognosis is closely related to pts

neurological condition on hospital arrivalneurological condition on hospital arrival Pts who are alert and have no major focal Pts who are alert and have no major focal

defecit have a 70-80% chances of survivaldefecit have a 70-80% chances of survival Those who are comatosed have Those who are comatosed have

90%mortality90%mortality

PROGNOSISPROGNOSIS SAH from intra cranial aneurysm has a SAH from intra cranial aneurysm has a

mortality of 50%mortality of 50% Prognosis is closely related to pts Prognosis is closely related to pts

neurological condition on hospital arrivalneurological condition on hospital arrival Pts who are alert and have no major focal Pts who are alert and have no major focal

defecit have a 70-80% chances of survivaldefecit have a 70-80% chances of survival Those who are comatosed have Those who are comatosed have

90%mortality90%mortality

INTRACERBRAL HAOMORRHAGEINTRACERBRAL HAOMORRHAGEStrongly associated with hypertensionStrongly associated with hypertensionHypertension leads to fibrinoid necrosis of arterioles Hypertension leads to fibrinoid necrosis of arterioles ++Long standing hypertension leads to hyaline changes Long standing hypertension leads to hyaline changes

in the muscular and elastic arterial layer-----leads in the muscular and elastic arterial layer-----leads to microaneurysim-----liable to ruptureto microaneurysim-----liable to rupture

Middle cerbral artery and the lenticular branches are Middle cerbral artery and the lenticular branches are prone to develop these aneurysmsprone to develop these aneurysms

Majority of ICH occur in the region of the internal Majority of ICH occur in the region of the internal capsulecapsule

FIVE COMMON AREAS OF FIVE COMMON AREAS OF HAEMORRHAGEHAEMORRHAGE

PutamenPutamen White matter or lobeWhite matter or lobe ThalamousThalamous PonsPons CerebellumCerebellum

ICH usually presents abruptly when ICH usually presents abruptly when the pt. is awakethe pt. is awake

Severe headacheSevere headache ½ of pts. Present with LOC and fits½ of pts. Present with LOC and fits Since internal capsule is involved so Since internal capsule is involved so

there is hemiplegiathere is hemiplegia Massive bleeding---increase Massive bleeding---increase

intracranial pressure---intracranial pressure---papilloedema----deep comapapilloedema----deep coma

GENERAL RULEGENERAL RULE If the bleeding is greater than 80 mls If the bleeding is greater than 80 mls

as estimated by CT scan, and is as estimated by CT scan, and is associated with deep coma------associated with deep coma------chances of survival are very poorchances of survival are very poor

ICH of moderate size >1.5 cm in ICH of moderate size >1.5 cm in diameter, surgical evacuation may diameter, surgical evacuation may be life savingbe life saving

Bleeding forms localized haematomaBleeding forms localized haematoma---spreads along the white matter---spreads along the white matter---haematoma enlarges and continues ---haematoma enlarges and continues

to growto grow---pressure surrounding it increases to ---pressure surrounding it increases to

limit its spreadlimit its spread ORORDecompresses itself into the Decompresses itself into the

ventricular system CSFventricular system CSF

Any patient with sudden onset of severe Any patient with sudden onset of severe headache should be considered to have headache should be considered to have SAH.SAH.

Headache with global impairement of Headache with global impairement of conciousness is typicalconciousness is typical

Focal neurological signs are rareFocal neurological signs are rare Diplopia + cranial nerve lesion may occurDiplopia + cranial nerve lesion may occur Neck stiffnessNeck stiffness Subhyloid hgeSubhyloid hge

PUTAMENPUTAMEN Majority of hgic strokes occur in this Majority of hgic strokes occur in this

areaarea Hemiparesis or hemiplegiaHemiparesis or hemiplegia Sensory lossSensory loss Aphasia if on dominant sideAphasia if on dominant side Surgery of questionable valueSurgery of questionable value

PONSPONS Rapid loss of conciousnessRapid loss of conciousness Pin point pupilsPin point pupils Periodic respirationPeriodic respiration QuadriparesisQuadriparesis

Surgery of no valueSurgery of no value

WHITE MATTER OR LOBEWHITE MATTER OR LOBE

Same as putamin hge signsSame as putamin hge signs Distinguished only by neuroimaging Distinguished only by neuroimaging

Surgical evacuation, if suitableSurgical evacuation, if suitable

EMBOLIC STROKEEMBOLIC STROKE

Usually occur abruptlyUsually occur abruptly Occasionally present with Occasionally present with

stuttering fluctuating symptomsstuttering fluctuating symptoms Either the anterior (carotid) or Either the anterior (carotid) or

posterior (vertibobasilar ) posterior (vertibobasilar ) circulationcirculation maymay be involved be involved

CLASSIFCATION ACCORDING TOCLASSIFCATION ACCORDING TO LOBESLOBES

FRONTAL LOBEFRONTAL LOBEPersonality and emotional disordersPersonality and emotional disordersExpressive dysphasiaExpressive dysphasiaContralateral hemiparesisContralateral hemiparesisPrimitive reflexesPrimitive reflexes

PARITAL LOBEPARITAL LOBE

-Spatial disorientation-Spatial disorientation

-Apraxia +acalculia +agraphia +alexia-Apraxia +acalculia +agraphia +alexia

-Sensory inattention,neglect of non -Sensory inattention,neglect of non dominant side dominant side

-Contralateral hemisensory loss-Contralateral hemisensory loss

-Lower quadrantonopia-Lower quadrantonopia

TEMPORAL LOBETEMPORAL LOBE

-Receptive dysphasia-Receptive dysphasia-De ja vu phenomena-De ja vu phenomena-Hallucination of taste and smell-Hallucination of taste and smell-Excessive lip smacking-Excessive lip smacking-Micropsia-Micropsia-Upper quandrantonopia-Upper quandrantonopia

OCCIPITAL LOBEOCCIPITAL LOBE

-Homonymous hemianopia with -Homonymous hemianopia with sparing of the maculasparing of the macula

-Thalamic syndrome-Thalamic syndrome

LOCALIZING FEATURES OF LOCALIZING FEATURES OF MOTORMOTOR LESIONSLESIONS

CEREBRAL CORTEXCEREBRAL CORTEX

Flaccid weakness---Flaccid weakness---flexors+extensors equally flexors+extensors equally affected (globalaffected (global weakness)weakness)

INTERNAL CAPSULEINTERNAL CAPSULE Spastic weaknessSpastic weakness Extensors more than flexorsExtensors more than flexors Distal muscles affected more than Distal muscles affected more than

proximalproximal Patient looks away from the lesion Patient looks away from the lesion

(paralysis of head and eye (paralysis of head and eye movement )movement )

BRAIN STEMBRAIN STEM

--crossed hemiplegia i.e ipsilateral cranial --crossed hemiplegia i.e ipsilateral cranial nerve palsy with contralateralnerve palsy with contralateral

limb palsylimb palsy

ROOT AND PERIPHERAL LESIONROOT AND PERIPHERAL LESION

--peripheral nerve lesions usually affect both --peripheral nerve lesions usually affect both motor and sensory function in muscles and motor and sensory function in muscles and skin supplied by the nerveskin supplied by the nerve

ll

LOCALIZING ACCORDING TO BLOOD SUPPlyLOCALIZING ACCORDING TO BLOOD SUPPly

MIDDLE CEREBRAL ARTERYMIDDLE CEREBRAL ARTERY

Supplies majority of the internal capsule, Supplies majority of the internal capsule, larger part of frontal , parietal and larger part of frontal , parietal and temporal lobe)temporal lobe)

Contralateral spastic weaknessContralateral spastic weakness HemianopiaHemianopia May have signs of frontal , temporal or May have signs of frontal , temporal or

parietal lobesparietal lobes

ANTRIOR CEREBRAL ARTERYANTRIOR CEREBRAL ARTERY(Supplies the frontal lobe , superior (Supplies the frontal lobe , superior

portion of cerebral cortex and portion of cerebral cortex and anterior portion of internal capsule)anterior portion of internal capsule)

--Motor dysphasia--Motor dysphasia--Cortical flaccid weakness of the --Cortical flaccid weakness of the

opposite legopposite leg--Cortical sensory loss in opposite leg--Cortical sensory loss in opposite leg--Frontal lobe signs--Frontal lobe signs

POSTERIOR CEREBRAL ARTERYPOSTERIOR CEREBRAL ARTERY

(supplies occipital lobe, branch to thalamous (supplies occipital lobe, branch to thalamous and mid brain)and mid brain)

--homonomous hemianopia with sparing of --homonomous hemianopia with sparing of the maculathe macula

--thalamic syndrome--thalamic syndrome

--if both cerebral arteries are occluded—--if both cerebral arteries are occluded—cortical blindness (pt is blind but all the cortical blindness (pt is blind but all the pupillary reflexes are intactpupillary reflexes are intact

CNS LOCALIZATIONCNS LOCALIZATION HEMIPLEGIAHEMIPLEGIA CORTICALCORTICAL speech disturbancesspeech disturbances UMNL 7UMNL 7thth N palsy N palsySUBCORTICALSUBCORTICAL multiple cranial nerve multiple cranial nerve palsypalsy

SPINAL CORDSPINAL CORD Bilateral pyramidal signsBilateral pyramidal signs Higher function intactHigher function intact No cranial nerve palsy apart from No cranial nerve palsy apart from

occasional 11occasional 11thth nerve palsy nerve palsy

WEAKNESS OF LOWER LIMBSWEAKNESS OF LOWER LIMBS With pyramidal signsWith pyramidal signs cord lesion cord lesion MNDMND Without pyramidal signsWithout pyramidal signs neuropathy either sensory or neuropathy either sensory or motormotor muscle diseasemuscle disease

CRANIAL NERVESCRANIAL NERVES Single Single

DM or Bell,s palsyDM or Bell,s palsy Multiple Multiple

brain stem , with or without brain stem , with or without

long tract signs----SOLlong tract signs----SOL

----vascular----vascular

EXTRAPYRAMIDALEXTRAPYRAMIDAL

With pyramidal signsWith pyramidal signs

vascular like atherosclerosisvascular like atherosclerosis Without pyramidal signsWithout pyramidal signs

degenarative groupdegenarative group

CEREBELLARCEREBELLAR WingsWings look for pes cavuslook for pes cavus Tract signsTract signs SOL (acoustic neuroma) SOL (acoustic neuroma) PICAPICAMUSCLESMUSCLES DystrophiesDystrophies

CEREBELLUMCEREBELLUM HeadacheHeadache VertigoVertigo AtxiaAtxia LethargyLethargy No focal weaknessNo focal weaknessSurgical evacuation for all except smallSurgical evacuation for all except smallhaemorrhageshaemorrhages

CLASSIFICATIONCLASSIFICATION

Within the cavernous sinus Within the cavernous sinus (infraclinoid)(infraclinoid)

It may compress structures like 3,4,5 It may compress structures like 3,4,5 and 6and 6thth nerve palsy nerve palsy

----dilated pupil----dilated pupil

----facial pain----facial pain

----variable loss of facial sensation----variable loss of facial sensation

Above the cavernous sinusAbove the cavernous sinus ((supraclinoid)supraclinoid)

Most frequently compress the Most frequently compress the occulomotor nerve , optic tracts and occulomotor nerve , optic tracts and chiasmchiasm

May extend into the frontal lobeMay extend into the frontal lobe

6th year