Cerebro vascular Accident (C V A)
Definition
Ø Sudden loss of blood supply to an area of the brain
Ø Corresponding loss of neurologic function
Ø TIA vs. CVA
Risk Factors
Ø Age
Ø Hypertension**
Ø Prior TIA/CVA
Ø DM
Ø Hypercholesterolemia
Ø Smoking!
Ø Atrial fibrillation
Causes
Ø Ischemic
Ø Thrombotic
ØVirchow’s Triad
Ø Embolic
Ø Hypoperfusion
Ø Hemorrhagic
Ø Primary
Ø Hemorrhagic transformation
Virchow’s Triad
Ø Venous Stasis
Ø Phenomena of interrupted blood flow
Ø Endothelial Injury
Ø phenomena associated with irritation of vessel and its vicinity
Ø Hypercoaguability
Ø phenomena of blood coagulation
Hypercoaguability
Ø Congenital
Ø Antithrombin III deficiency
Ø Protein C & S deficiency
Ø Factor V Leiden
Ø Prothrombin mutation
Ø MTHFR mutation (homocysteine)
Ø Sickle Cell Disease
Ø Acquired
Ø Antiphospholipid antibodies
ØAnti-cardiolipin Ab/lupus anticoagulant
Ø HIT
Ø Paroxysmal Nocturnal Hemoglobinuria
Ø Nephrotic syndrome
Ø OCP’s
Ø SMOKING!!!
Ø Malignancy
Presentation
Ø Face weakness/asymmetry
Ø Extremity drift or weakness
Ø Abnormal speech +/- Aphasia
Ø Unilateral
Ø Ataxia +/- Vertigo
Ø Anosognosia
Ø Loss of Conciousness
Major Cerebral Arteries
Internal Carotid Artery
Ø Terminal branch of Common Carotid
Ø Cervical (C1), Petrous (C2), Lacerum (C3), Cavernous (C4), Clinoid (C5), Ophthalmic (C6), Communicating (C7) segments
Ophthalmic Artery Occlusion
Ø Ocular Ischemic Syndrome
Ø Usu. Age 50-80
Ø M:F 2:1
Ø Dull radiating ache of eye/brow
Ø Intractable pain (ocular angina)
Ø Blot retinal hemorrhage/beaded retinal veins
Ø Transient blurred vision
Ø Retinal artery occlusion
Anterior Cerebral Occlusion
Ø Frontal lobe, anterior basal ganglia and internal capsule function
Ø Disinhibition
Ø Primitive reflex production
Ø Altered mental status
Ø L side CVA ® aphasia
Ø Contralateral weakness (legs>arms)
Ø Contralateral sensory deficits
Ø Gait apraxia
Ø Urinary incontinence
Middle Cerebral Occlusion
Ø Majority lateral aspect of frontal, parietal lobes, inferior temporal lobe
Ø Contralateral hemiparesis
Ø Contralateral sensory deficits
Ø Ipsilateral/homonymous hemianopsia
Ø Gaze preference
Ø Agnosia
Ø R CVA ® Contralateral Neglect
Ø Extremity weakness (upper>lower)
Posterior Cerebral Occlusion
Ø Occipital lobe
Ø Contralateral homonymous hemianopsia with macular sparing
Ø Cortical blindness
Ø “Medial Midbrain Syndrome”
Ø Altered mental status
Ø Impaired memory
Ø “Prosopagnosia” -visual agnosia
Ø Ipsilateral deficits CN V, VIII, IX, X & XI
Lacunar Occlusion
Ø Small perforating arteries of deep subcortical areas of the brain
Ø Lesions occur in deep nuclei of the brain
Ø Putamen (37%)
Ø Thalamus (14%)
Ø Pons (16%)
Ø Caudate (10%)
Ø Internal capsule - posterior limb (10%)
Ø Deep cerebral white matter, anterior limb internal capsule and cerebellum less common)
Lacunar Syndromes
Ø Pure Motor (30-35%)
Ø Infarction posterior limb internal capsule
Ø Hemiparesis/hemiplegia
Ø Dysarthria
Ø Dysphagia
Ø Transient sensory symptoms
Ø Pure Ataxic
Ø Infarction of posterior limb internal capsule, basis pontis & corona radiata
Ø Cerebellar and Motor symptoms
ØIpsilateral weakness
ØClumsiness
Ø Usually affects leg > arm (homolateral ataxia)
Ø Dysarthria/Clumsy Hand
Ø Variant of ataxic hemiparesis
Ø Infarction in the pons
Ø Dysarthria
Ø Clumsiness of the hand
ØMost prominent when the patient is writing
Ø Pure Sensory
Ø Infarction in contralateral thalamus
Ø Persistent/transient
ØNumbness
ØTingling
ØPain
ØBurning
ØUnilateral “unpleasant sensation”
Ø Mixed Sensorimotor
Ø Infarction in thalamus & adjacent posterior limb internal capsule
Ø Hemiparesis or hemiplegia
Ø Ipsilateral sensory impairment
Treatment
Ø ABC’s!!
Ø BP control is SBP >220, DBP >120
Ø Not rapidly!
Ø SBP >185, DBP >110 is contraindication for TPA
Ø Clinically (aim SBP 160-180)
ØWhy?
Ø TPA
Ø Must present within 3 hours of onset of Sx with severe neurologic deficit
Ø Excluded
ØSx suggestive of SAH
ØPrevious Hx intracranial hemorrhage
ØRecent CVA or MI (within 3 mo)
ØRecent head injury (within 3 mo)
ØRecent major surgery (within 14 days)
ØHeparin/anticoagulants (within 48 hours)
ØThrombocytopenia (<100 x9)
ØHypo/hyperglycemia (<50, >400)
Ø Radiology
Ø CT Head
Ø With or without contrast?
Ø r/o intracranial hemorrhage
Ø Neurology Consult
Ø Repeat CT 48hrs (r/o hemorrhagic conversion)
Ø MRI / EEG / Carotid Dopplers / 2D Echo
Ø Antiplatelets vs. Aggrenox
Ø Cardiology Consult
Ø Arrythmia contributer?
Ø Speech Evaluation
