1. Cerebrovascular Disease
(simple introduction)
Lecture class
Pratap Sagar Tiwari, MD, Lecturer,
NGMC

2. Cerebrovascular disease ?
Stroke

3. Definition of Stroke
• A stroke or Cerebrovascular accidents is defined by abrupt
onset of a neurological deficit that is attributable to a focal
vascular cause.
• Stroke is the third most common cause of death in the
developed world after cancer and ischaemic heart disease,
and is the most common cause of severe physical disability.
References : Harrison 18th ed

5. Stroke types
• Stroke is classified into two major types:
1. Ischemic stroke: Brain ischemia due to thrombosis,
embolism, or systemic hypoperfusion
2. Hemorrhagic stroke: Brain hemorrhage due to
intracerebral hemorrhage or subarachnoid hemorrhage.
• Approximately 80 % of strokes are due to ischemic cerebral
infarction and 20 % to brain hemorrhage.

6. Stroke types ?

7. BRAIN ISCHEMIA 1
• Thrombosis generally refers to local in situ obstruction of an artery.
• Embolism refers to particles of debris originating elsewhere that block
arterial access to a particular brain region .
• Systemic hypoperfusion is a more general circulatory problem,
manifesting itself in the brain and perhaps other organs.
• References 1: Caplan LR. Basic pathology, anatomy, and pathophysiology of stroke. In: Caplan's Stroke:
A Clinical Approach, 4th ed, Saunders Elsevier, Philadelphia 2009. p.22.

8. Hemorrhagic stroke

9. Hemorrhagic stroke: types
1. Intracerebral hemorrhage refers to bleeding directly into
the brain parenchyma
2. Subarachnoid hemorrhage refers to bleeding into the
cerebrospinal fluid within the subarachnoid space that
surrounds the brain
• Note: Hemorrhage is characterized by too much blood
within the closed cranial cavity, while ischemia is
characterized by too little blood to supply an adequate
amount of oxygen and nutrients to a part of the brain.1
•
Reference 1: Caplan LR. Intracranial branch atheromatous disease: a neglected, understudied, and
underused concept. Neurology 1989; 39:1246.

11. Diagnosis ?
• Clinical
• Investigation

12. Clinical ?
• Is there any neurological deficit ?
• Is there any risk factor for vascular disease ?

13. STROKE RISK FACTORS
•
•
•
•
•
Age
Gender (male > female)
Race (Afro-Caribbean > Asian > European)
Heredity
Previous vascular event, e.g. MI, stroke or
peripheral embolism
• High fibrinogen

14. STROKE RISK FACTORS
• High blood pressure
• Heart disease (atrial fibrillation, HF,
endocarditis)
• Diabetes mellitus
• Hyperlipidaemia
• Smoking, Excess alcohol consumption
• Polycythaemia
• Oral contraceptives

15. • Cerebral infarction is mostly due to
thromboembolic disease secondary to
atherosclerosis in the major extracranial
arteries (carotid artery and aortic arch).
• About 20% of infarctions are due to embolism
from the heart, and a further 20% are due to
intrinsic disease of small perforating vessels
(lenticulostriate arteries), producing so-called
'lacunar' infarctions.

16. Hemorrhagic stroke : Risk Factor

17. Cincinnati Prehospital Stroke Scale
1. Facial droop: Have the person smile or show his or her teeth.
•Normal: Both sides of face move equally
•Abnormal: One side of face does not move as well as the other (or at all)
2. Arm drift:
•Normal: Both arms move equally or not at all
•Abnormal: One arm does not move, or one arm drifts down compared with the
other side
3. Speech:
•Normal: Patient uses correct words with no slurring
•Abnormal: Slurred or inappropriate words or mute
Patients with 1 of these 3 findings as a new event have a 72% probability of an
ischemic stroke. If all 3 findings are present the probability of an acute stroke is
more than 85%
Hurwitz AS, Brice JH, Overby BA, Evenson KR (2005). "Directed use of the Cincinnati Prehospital Stroke Scale by laypersons". Prehosp Emerg Care 9 (3): 292–6

18. Investigations ?
• Imaging

19. 7 questions ?
1. Is this a vascular lesion ?
CT/MRI

20. CT HEAD
• Imaging

21. 7 questions ?
2. Is it ischaemic or haemorrhagic?
CT/MRI

22. 7 questions ?
3. Is it a subarachnoid haemorrhage?
CT/MRI

23. SubArachnoid Hemorrhage

24. 7 questions ?
4. Is there any cardiac source of embolism?
ECG/ECHO

25. ECG: Afib

26. 7 questions ?
5. What is the underlying vascular disease?
•
• Duplex ultrasound of carotids
Magnetic resonance angiography(MRA)
• CT angiography (CTA)
• Contrast angiography

27. 7 questions ?
6. What are the risk factors?
Full blood count
Cholesterol
Blood glucose

28. 7 questions ?
7. Is there an unusual cause?
Rule out Bleeding Disorders/
ESR

29. References
•
•
•
•
Harrison’s 18th edition
Davidsons 20th ed
Uptodate 20.3
Emedicine.com