stroke =
abrupt onset of focal or global neurological impairment...
of 24+ hours...
caused by ischemia or hemorrhage
of 24+ hours...
caused by ischemia or hemorrhage
4 possible outcomes of brain ischemia
no effect (anastomoses compensate)
transient physiological disturbance (TIA)
selective neuronal necrosis (incomplete infarct)
just affects neurons; glia are intact
pan-necrosis of neurons & glia (complete infarct)
transient physiological disturbance (TIA)
selective neuronal necrosis (incomplete infarct)
just affects neurons; glia are intact
pan-necrosis of neurons & glia (complete infarct)
histopathologic identification of stroke
red neuron is a dead neuron
24h: neutrophils
48h: macrophages
wks: debris removed => space
24h: neutrophils
48h: macrophages
wks: debris removed => space
2 types of ischemic stroke
global
due to cardiac arrest, systemic hypotension, increased ICP
widespread, multifocal ischemic necrosis
especially pronounced in border zones / watershed areas
symmetric
focal
emboli
occlusion of blood vessel
infarction
due to cardiac arrest, systemic hypotension, increased ICP
widespread, multifocal ischemic necrosis
especially pronounced in border zones / watershed areas
symmetric
focal
emboli
occlusion of blood vessel
infarction
lacunar infarction
occlusion of lenticulostriate / penetrating artery...
...due to small vessel arteriosclerosis
...due to small vessel arteriosclerosis
usual causes of brain hemorrhage
hypertensive small vessel disease
cerebral amyloid angiopathy
ruptured vascular malformation
drugs (cocaine, amphthemine)
neoplasm
ruptured Berry aneurysm
bleeding diathesis
trauma
cerebral amyloid angiopathy
ruptured vascular malformation
drugs (cocaine, amphthemine)
neoplasm
ruptured Berry aneurysm
bleeding diathesis
trauma
consequence of hypertensive small vessel disease
rupture of arteriosclerotic small penetrating artery
parenchymal brain hemorrhage
parenchymal brain hemorrhage
berry aneurysm
arise at forks of arteries in CoW
85% in anterior circulation
15% in posterior circulation
5% prevalence
most do not rupture
annual risk of <1%
85% in anterior circulation
15% in posterior circulation
5% prevalence
most do not rupture
annual risk of <1%
complications of aneurysmal subarachnoid hemorrhage
elevated ICP
rebleeding
vasospasm
hydrocephalus
rebleeding
vasospasm
hydrocephalus
AV malformation
congenital
tangle of abnormal arteries & veins with no intervening capillary bed
wedge-shaped
involve brain & meninges
can rupture into subarachnoid space or brain
annual risk: 3%
feeder vessels can develop berry aneurysms
tangle of abnormal arteries & veins with no intervening capillary bed
wedge-shaped
involve brain & meninges
can rupture into subarachnoid space or brain
annual risk: 3%
feeder vessels can develop berry aneurysms
cavernoma
= cavernous angioma
small, tightly-packed group of thin-walled blood vessels
annual risk of rupture: <1%
can cause seizures
can be familial
can be multiple
small, tightly-packed group of thin-walled blood vessels
annual risk of rupture: <1%
can cause seizures
can be familial
can be multiple
stroke flow chart
stroke
ischemic
atherosclerotic
large artery atherothrombosis (extracranial, intracranial)
small artery atherothrombosis (lacunar infarction)
embolus
intra-artery
cardiogenic
paradoxical (R=>L heart via patent foramen ovale)
systemic hypotension / cardiac arrest
hemorrhagic
brain hemorrhage
due to hypertension, cerebral amyloid angiopathy
subarachnoid hemorrhage
due to ruptured berry aneursym
ischemic
atherosclerotic
large artery atherothrombosis (extracranial, intracranial)
small artery atherothrombosis (lacunar infarction)
embolus
intra-artery
cardiogenic
paradoxical (R=>L heart via patent foramen ovale)
systemic hypotension / cardiac arrest
hemorrhagic
brain hemorrhage
due to hypertension, cerebral amyloid angiopathy
subarachnoid hemorrhage
due to ruptured berry aneursym
TIA
transient episode of focal neurological dysfunction resulting from ischemia...
...not associated with permanent cerebral infarction
...always <24hrs
...not associated with permanent cerebral infarction
...always <24hrs
risk factors for stroke
| non-modifiable | modifiable |
| HTN | age |
| diabetes | gender |
| cardiac disease | race |
| atrial fib | heredity |
| TIA / prior stroke | |
| dyslipidemia | |
| smoking | |
| EtOH abuse | |
| obesity | |
| physical inactivity | |
| carotid stenosis |
clinical management of stroke
history
neurological exam
localization
CT to evaluate for blood
thrombolysis
supportive management
diagnosis of pathophysiology
secondary prevention
rehabilitation
neurological exam
localization
CT to evaluate for blood
thrombolysis
supportive management
diagnosis of pathophysiology
secondary prevention
rehabilitation
secondary prevention of stroke
ischemic stroke
identify & remove cause
antiplatelet drugs:
aspirin, clopidogrel
risk factor modification
BP, cholesterol, smoking, diabetes
anticoagulation in atrial fibrillation
carotid endarterectomy in carotid stenosis
hemorrhagic stroke
identify and remove cause of bleeding
BP management
identify & remove cause
antiplatelet drugs:
aspirin, clopidogrel
risk factor modification
BP, cholesterol, smoking, diabetes
anticoagulation in atrial fibrillation
carotid endarterectomy in carotid stenosis
hemorrhagic stroke
identify and remove cause of bleeding
BP management
Kartensatzinfo:
Autor: bstokes25
Oberthema: Stroke Management
Thema: Stroke
Veröffentlicht: 27.03.2010
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