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CEREBROVASCULAR ACCIDENT. CLASSIFICATION Complete stroke T.I.A R.I.N.D Stroke in evolution. Acute neurological injury which occurs as a result of ; 1—Embolism 2---Thrombosis 3---Haemorrhage 4---Demyelation 5---SOL { Space occupying lesion}. RISK FACTORS Age—advanced age

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slide3
CLASSIFICATION
  • Complete stroke
  • T.I.A
  • R.I.N.D
  • Stroke in evolution
slide5
Acute neurological injury which occursas a result of ;
  • 1—Embolism
  • 2---Thrombosis
  • 3---Haemorrhage
  • 4---Demyelation
  • 5---SOL { Space occupying lesion}
slide6
RISK FACTORS
  • Age—advanced age
  • Sex—males more than females
  • Hypertension
  • DM
  • Hyperlipidemia
  • Smoking
  • Excess alcohol consumption
  • Polycythemia
slide7
O.C. pills
  • Vasculitis
  • Thrombophillia
  • Anticardiolipin antibody
  • Homocysteinurea
management
MANAGEMENT

HISTORY

May be helpful

Headache + vomiting ---favour the Dx of IC hge or SAH

Abrupt onset of impaired cerebral function without focal symptoms suggest SAH

slide9
EXAMINATION
  • BP
  • Breathing
  • Fever----meningitis

subdural haematoma

brain abcess

infective endocarditis

  • Neck---for bruits
  • Pulses----in neck and arms
slide10
CVS---valvular heart disease ,AF
  • Skin---signs of cholesterol embolism+IE
  • Fundus
slide11
INVESTIGATIONS
  • CBC , ESR
  • U+E, RBS
  • LFT, PT, PTT
  • CT scan brain or MRI
  • Doppler U.S of carotids
  • Echo
  • Hypercoagguable screen
  • Screen for connective tissue disease
  • Toxicology screen
slide12
D/D

--Migraine

--Head trauma

--Brain tumour

--Systemic infections

--Toxic metabolic disturbance

hypoglycemia

acute renal+ hepatic failure

drug intoxication

Todd,s paralysis

slide13
HAEMORRHAGE

Intracranial hge can be caused by—

  • Intracerebral hge {ICH}

also called parenchymal hge which involves bleeding directly into brain tissue.

  • SAH

involves bleeding into the CSF that surrounds the brain and the spinal cord

  • Trauma

causing subdural or extradural haematomas

slide17
COMMONCAUSES
  • Hypertension
  • Trauma
  • Bleeding diathesis
  • Amyloid angiopathy
  • Illicit drug abuse {amphetamine , cocaine}
  • Vascular malformation
  • Rupture of aneurysm
  • Vasculitis
slide18
SUBARACHANOID HAEMORRHAGE

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

2—2nd commonest causes

A/V malformation

bleeding diathesis

drugs

amyloid angiopathy

slide19
COMPLICATION OF SAH DUE TOANEURYSM
  • Rebleeding within 10 days
  • Vasospasm
  • Systemic complications

--hyponatremia

--MI

--CNS disturbance

slide20
TREATMENT
  • Identify cause
  • Prevent rebleeding
  • Prevent brain damage due to delayed ischaemia related to vasoconstrictionof IC arteries

--surgical removal

--Calcium channel blocker -Nimodipine

slide21
PROGNOSIS
  • SAH from intra cranial aneurysm has a mortality of 50%
  • Prognosis is closely related to pts neurological condition on hospital arrival
  • Pts who are alert and have no major focal defecit have a 70-80% chances of survival
  • Those who are comatosed have 90%mortality
slide22
INTRACERBRAL HAOMORRHAGE

Strongly associated with hypertension

Hypertension leads to fibrinoid necrosis of arterioles

+

Long standing hypertension leads to hyaline changes in the muscular and elastic arterial layer-----leads to microaneurysim-----liable to rupture

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

Majority of ICH occur in the region of the internal capsule

slide23
FIVE COMMON AREAS OF HAEMORRHAGE
  • Putamen
  • White matter or lobe
  • Thalamous
  • Pons
  • Cerebellum
slide24
ICH usually presents abruptly when the pt. is awake
  • Severe headache
  • ½ of pts. Present with LOC and fits
  • Since internal capsule is involved so there is hemiplegia
  • Massive bleeding---increase intracranial pressure---papilloedema----deep coma
slide25
GENERAL RULE
  • If the bleeding is greater than 80 mls as estimated by CT scan, and is associated with deep coma------chances of survival are very poor
  • ICH of moderate size >1.5 cm in diameter, surgical evacuation may be life saving
slide26
Bleeding forms localized haematoma

---spreads along the white matter

---haematoma enlarges and continues to grow

---pressure surrounding it increases to limit its spread

OR

Decompresses itself into the ventricular system CSF

slide27
Any patient with sudden onset of severe headache should be considered to have SAH.
  • Headache with global impairement of conciousness is typical
  • Focal neurological signs are rare
  • Diplopia + cranial nerve lesion may occur
  • Neck stiffness
  • Subhyloid hge
slide28
PUTAMEN
  • Majority of hgic strokes occur in this area
  • Hemiparesis or hemiplegia
  • Sensory loss
  • Aphasia if on dominant side
  • Surgery of questionable value
slide29
PONS
  • Rapid loss of conciousness
  • Pin point pupils
  • Periodic respiration
  • Quadriparesis

Surgery of no value

slide30
WHITE MATTER OR LOBE
  • Same as putamin hge signs
  • Distinguished only by neuroimaging
  • Surgical evacuation, if suitable
slide31
EMBOLIC STROKE
  • Usually occur abruptly
  • Occasionally present with stuttering fluctuating symptoms
  • Either the anterior (carotid) or posterior (vertibobasilar ) circulationmay be involved
slide32
CLASSIFCATION ACCORDING TOLOBES

FRONTAL LOBE

Personality and emotional disorders

Expressive dysphasia

Contralateral hemiparesis

Primitive reflexes

slide33
PARITAL LOBE

-Spatial disorientation

-Apraxia +acalculia +agraphia +alexia

-Sensory inattention,neglect of non dominant side

-Contralateral hemisensory loss

-Lower quadrantonopia

slide34
TEMPORAL LOBE

-Receptive dysphasia

-De ja vu phenomena

-Hallucination of taste and smell

-Excessive lip smacking

-Micropsia

-Upper quandrantonopia

slide35
OCCIPITAL LOBE

-Homonymous hemianopia with sparing of the macula

-Thalamic syndrome

slide36
LOCALIZING FEATURES OF MOTORLESIONS

CEREBRAL CORTEX

  • Flaccid weakness---flexors+extensors equally affected (globalweakness)
slide37
INTERNAL CAPSULE
  • Spastic weakness
  • Extensors more than flexors
  • Distal muscles affected more than proximal
  • Patient looks away from the lesion (paralysis of head and eye movement )
slide39
BRAIN STEM

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

limb palsy

ROOT AND PERIPHERAL LESION

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

slide40
l

LOCALIZING ACCORDING TO BLOOD SUPPly

MIDDLE CEREBRAL ARTERY

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

  • Contralateral spastic weakness
  • Hemianopia
  • May have signs of frontal , temporal or parietal lobes
slide41
ANTRIOR CEREBRAL ARTERY

(Supplies the frontal lobe , superior portion of cerebral cortex and anterior portion of internal capsule)

--Motor dysphasia

--Cortical flaccid weakness of the opposite leg

--Cortical sensory loss in opposite leg

--Frontal lobe signs

slide42
POSTERIOR CEREBRAL ARTERY

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

--homonomous hemianopia with sparing of the macula

--thalamic syndrome

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

slide44
CNS LOCALIZATION
  • HEMIPLEGIA
  • CORTICAL

speech disturbances

UMNL 7th N palsy

SUBCORTICAL

multiple cranial nerve

palsy

slide45
SPINAL CORD
  • Bilateral pyramidal signs
  • Higher function intact
  • No cranial nerve palsy apart from occasional 11th nerve palsy
slide46
WEAKNESS OF LOWER LIMBS
  • With pyramidal signs

cord lesion

MND

  • Without pyramidal signs

neuropathy either sensory or

motor

muscle disease

slide47
CRANIAL NERVES
  • Single

DM or Bell,s palsy

  • Multiple

brain stem , with or without

long tract signs----SOL

----vascular

slide48
EXTRAPYRAMIDAL
  • With pyramidal signs

vascular like atherosclerosis

  • Without pyramidal signs

degenarative group

slide49
CEREBELLAR
  • Wings

look for pes cavus

  • Tract signs

SOL (acoustic neuroma)

PICA

MUSCLES

Dystrophies

slide50
CEREBELLUM
  • Headache
  • Vertigo
  • Atxia
  • Lethargy
  • No focal weakness

Surgical evacuation for all except small

haemorrhages

slide51
CLASSIFICATION

Within the cavernous sinus (infraclinoid)

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

----dilated pupil

----facial pain

----variable loss of facial sensation

slide52
Above the cavernous sinus (supraclinoid)
  • Most frequently compress the occulomotor nerve , optic tracts and chiasm
  • May extend into the frontal lobe