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

ØAmaurosis Fugax

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