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CVD: STROKE Septemius A. Pansacola RN,MD. ANATOMY OF THE BRAIN. ANATOMIC DIVISION. Two cerebral hemispheres Brain stem Midbrain Pons Medulla cerebellum. Lobes of the cerebral hemisphere. Frontal lobe Planning and sequencing of movement Voluntary eye movement Emotional affect

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CVD: STROKE Septemius A. Pansacola RN,MD

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Cvd stroke septemius a pansacola rn md



Septemius A. Pansacola RN,MD

Cvd stroke septemius a pansacola rn md



Anatomic division


  • Two cerebral hemispheres

  • Brain stem

    • Midbrain

    • Pons

    • Medulla

  • cerebellum

Lobes of the cerebral hemisphere

Lobes of the cerebral hemisphere

  • Frontal lobe

    • Planning and sequencing of movement

    • Voluntary eye movement

    • Emotional affect

    • Broca’s area

  • Parietal lobe

    • Subserve motor control and cortical sensation

    • Dominant: governs motor program

    • Nondominant: governs spatial orientation

Lobes of the cerebral hemisphere1

Lobes of the cerebral hemisphere

  • Temporal lobe

    • Subserve olfaction

    • Memory

    • Certain components of auditory and visual perception

    • Wernicke’s area

  • Occipital lobe

    • Visual perception and involuntary eye movement

Vessels supplying blood to the brain

Vessels supplying blood to the brain

  • Anterior Circulation

    • Anterior Cerebral Artery

    • Middle Cerebral Artery

  • Posterior Circulation

    • Posterior Cerebral Artery

Anterior circulation

anterior cerebral artery

extends upward and forward from the internal carotid artery

supplies the frontal lobes, the parts of the brain that control logical thought, personality, and voluntary movement,

Stroke in the anterior cerebral artery results in opposite leg weakness. 

Anterior Circulation

Anterior circulation1

Middle Cerebral Artery

largest branch of the internal carotid.

supplies a portion:

frontal lobe

lateral surface of the temporal and parietal lobes

includes the primary motor and sensory areas of the face, throat, hand and arm and in the dominant hemisphere, the areas for speech.

artery most often occluded in stroke

Anterior Circulation

Lenticulostriate arteries

Small, deep penetrating arteries which branch from the middle cerebral artery

lacunar strokes

lenticulostriate arteries

Posterior circulation

Posterior cerebral artery

Originates in the

basilar artery

ipsilateral internal carotid artery

supply the temporal and occipital lobes


usually secondary to embolism

vertebral basilar system or heart.

The most common finding is occipital lobe infarction leading to an opposite visual field defect

Posterior Circulation

Circle of willis

Arterial anastomosis of vessels that enables the entire brain to reliably vascularized

Circle of Willis

World health organization

World Health Organization

  • neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours'



  • blood supply to a part of your brain is interrupted or severely reduced:

    • oxygen and nutrients.

  • caused by

    • thrombosis, embolism, or hemorrhage

  • Stroke is a medical emergency.

    • Early treatment can also minimize damage to your brain and potential disability.



  • It is the third leading cause of death and the leading cause of adult disability in the United States and industrialized European nations.

Risk factors

Risk factors

  • advanced age

  • Hypertension

  • previous stroke or TIA (transient ischaemic attack)

  • diabetes mellitus

  • high cholesterol

  • cigarette smoking

  • atrial fibrillation

  • Migraine with aura

  • thrombophilia

Stroke warning signs

Stroke Warning Signs

  • Sudden weakness, paralysis, or numbness of the face, arm and the leg on one or both sides of the body

  • Loss of speech, or difficulty speaking or understanding speech

  • Dimness or loss of vision, particularly in only one eye

  • Unexplained dizziness (especially when associated with other neurologic symptoms), unsteadiness, or sudden falls

  • Sudden severe headache and/or loss of consciousness

    • The warning signs of stroke depend upon the vascular territory involved.

Types of stroke

Types of Stroke

  • Strokes may be classified into two general types:

    • ischemic

    • hemorrhagic

Types of stroke1

Types of Stroke

Ischemic stroke

Ischemic Stroke

  • 80% of strokes are ischemic

    • 50%: cerebral thrombosis

      • 30% of strokes: Large-vessel thrombosis

        • (e.g., carotid, middle cerebral, or basilar arteries)

      • 20% involve small, deeply penetrating arteries

        • (e.g., lenticulostriate, basilar penetrating, medullary): lacunar stroke.

    • 30%: cerebral embolism

      • most frequently: heart or from the cervical portion of the carotid artery

      • more common in  younger patients

      • develop rapidly

      • maximum deficit usually present within seconds to minutes.

Hemorrhagic stroke

20% of all strokes

intracerebral hemorrhage

also called a parenchymal hemorrhage

The major risk factor: hypertension

Minute dilations at small artery bifurcation

Occurs: basal ganglia and thalamus

Most signs and symptoms

compression of brain structures and blood vessels.

Hemorrhagic stroke

Berry aneurysm

subarachnoid hemorrhage

usually follows the rupture of an aneurysm or an arteriovenous malformation

Berry Aneurysm

Systemic hypoperfusion

Systemic hypoperfusion

  • reduction of blood flow to all parts of the body.

    • all parts of the brain may be affected

  • most commonly due

    • cardiac pump failure/ low cardiac output

      • Cardiac arrest

      • Arrhythmias

      • pulmonary embolism

      • pericardial effusion or bleeding

Signs and symptoms

Signs and symptoms

  • brainstem: 12 cranial nerves

    • altered smell, taste, hearing, or vision (total or partial)

    • drooping of eyelid (ptosis) and weakness of ocular muscles

    • decreased reflexes: gag, swallow, pupil reactivity to light

    • decreased sensation and muscle weakness of the face

    • balance problems and nystagmus

    • altered breathing and heart rate

    • weakness in sternocleidomastoid muscle (SCM) with inability to turn head to one side

    • weakness in tongue (inability to protrude and/or move from side to side)

Signs and symptoms1

Signs and symptoms

  • cerebral cortex

    • aphasia

      • Brocas area

      • Wernicke's area

    • apraxia (altered voluntary movements)

    • visual field defect

    • memory deficits

    • Hemineglect

    • disorganized thinking, confusion, hypersexual gestures

  • cerebellum

    • trouble walking

    • altered movement coordination

    • vertigo and or disequilibrium



  • neurological examination

  • blood tests

  • CT scans

  • MRI scans

  • Doppler ultrasound

  • arteriography

Ct vs mri

CT vs. MRI

For diagnosing ischemic stroke in the emergency setting

  • CT scans (without contrast enhancements)

    • sensitivity= 16%

    • specificity= 96%

  • MRI scan

    • sensitivity= 83%

    • specificity= 98%

      For diagnosing hemorrhagic stroke in the emergency setting

  • CT scans (without contrast enhancements)

    • sensitivity= 89%

    • specificity= 100%

  • MRI scan

    • sensitivity= 81%

    • specificity= 100%

Doppler ultrasound

Doppler ultrasound

Internal Carotid stenosis

Carotid endarterectomy

Carotid endarterectomy





  • Ischemic Stroke

    • antiplatelet medication

      • aspirin

      • Clopidogrel

      • Dipyridamole

      • anticoagulant medication warfarin

    • Thrombolysis

      • Tissue plasminogen activator

      • first 3 hours

    • Mechanical Thrombectomy

    • Hemorrhagic stroke must be ruled out with medical imaging

Mechanical thrombectomy

Mechanical Thrombectomy



  • Hemorrhagic stroke

    • Neurosurgical evaluation

      • detect and treat the cause of the bleeding.

    • Patients are monitored and their blood pressure, blood sugar, and oxygenation are kept at optimum levels.

Care and rehabilitation

Care and rehabilitation

  • help the survivor:

    • adapt to difficulties

    • prevent secondary complications

    • educate family members to play a supporting role.

  • rehabilitation team

    • nursing staff, physiotherapy, occupational therapy, speech and language therapy, and usually a physician trained in rehabilitation medicine

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