CVA Pathology and Medical Management

What is a stroke?

A sudden onset of a focal neurologic deficit resulting from cerebrovascular disease
• AKA cerebrovascular accident (CVA)

stats about strokes

• 5th leading cause of death in adults
• Leading cause of permanent disability
• Healthcare costs ~$40 billion/year
• Accounts for >50 of all neurologic hospitalizations
• Are preventable and treatable!

epidemiology of strokes

• 800000 people in the US have a stroke
  • ~25% are recurrent
  • 9.4 million people in the US living with stroke (2020)

• Prevalence increases with age in both males and females

stroke classification

• transient Ischemic Attack
  • Full resolution within 24 hours

• Ischemic stroke (87%)
  • Blockage of blood flow (thrombic/embolic)

• Hemorrhagic stroke
  • Intracerebral hemorrhage (~10%)
  • Subarachnoid hemorrhage (~3%)

ischemic stroke

• thrombus

• embolus

stroke mortality

• Ischemic CVA
  • 8-12% within the 1 st month

• Hemorrhagic CVA
  • 37-38% within the 1 st month

Racial and Geographic Disparities in the US

• Stroke risk in the US is nearly twice as high for non-Hispanic Black adults than for white adults
• Mortality risk in the US is highest is non-Hispanic Black adults and in Pacific Islander adults
• Geographic pattern of mortality

death rates after stroke

Overall death rate ~50%
• 48.1% white males
• 74.9% black males
• 47.2% white females
• 65.5% black females

risk factors of Ischemic strokes

• Hypertension
• Diabetes
• High cholesterol
• Smoking
• Irregular heart rhythm or other heart disease
• Drug use
• Alcohol abuse
• Obesity
• Lack of exercise

risk factors for Hemorrhagic strokes

• Hypertension
• Increasing age
• Black ethnicity
• Lower cholesterol with low LDL
• Lower triglycerides

evidence of stroke

• Face droops

• Arm weakness

• Speech difficulty

• Time is critical

Acute Stroke Examination

• Last known normal (LKN)

• Brief, pertinent history
  • PMH
  • Meds – specifically anticoagulants
  • Recent surgery/medical procedures/trauma

• Data
  • Vital signs
  • Blood glucose
  • Head CT scan

• ABC workup: Artery, Blood, Cardiac

• Complete the National Institutes of Health Stroke Scale (NIHSS)

Head CT

• is blood present

• signs of stroke

  • nearly all can be seen in 24 hours

    • 60% at 3-6 hours

  • early infarct signs

Ischemic Stroke Management

• Thrombolytics
• Intra-arterial thrombectomy
• Other factors

Thrombolytics

• Standard of care is administration of tissue plasminogen activator (tPA)

  • Used within 4.5 hours of symptom onset
    • Danger of conversion to hemorrhagic stroke

  • Shown to improve functional outcomes

Intra-arterial Thrombectomy (IAT)

• Manual removal of arterial blockage

• Patient-selection is critical

  • 6-6-6 rule
    • < 6 hours onset
    • NIHSS >6
    • ASPECTS >6

other factors of

• Maintain/increase cerebral perfusion
  • Head of bed flat
  • IV fluids
  • Permissive hypertension

• Stabilize metabolic demands
  • Normothermia/normoglycemia

• Evaluate stroke etiology

Hemorrhagic Stroke Presentation

• Symptoms often progressive over 48-72 hours

• Headache

• Nausea/vomiting

• Seizure (4-29% of patients)

• Focal neurologic deficits

• Herniation syndromes
  • Range from stupor to coma

Acute ICH Management

• Blood pressure control
• Reverse coagulopathy
• Intracranial pressure management
• Surgical management

Surgical Management of Ischemic CVA

Posterior fossa decompression
• Performed in the case of a potentially fatal brainstem compression - can be life saving!

prognosis of stroke

Hemorrhagic stroke has higher morbidity and mortality than ischemic
• 30-50% mortality
• Only 20% independent at 6 months post

neurological findings of ischemic stroke impacted by

• Size of lesion
• Location of lesion
• Amount of collateral blood blow

unilateral deficits of ischemic stroke

arotid vascular system

bilateral deficits of ischemic stroke

ascular supply to the basilar system

Acute Stroke Symptoms Include

• Weakness

• Numbness

• Difficulty with speech

  • Aphasia vs dysarthria

• “Confusion”

  • Aphasia

  • Neglect

  • Somnolence

• Altered vision

  • Loss

    • One or both eyes

    • Whole or partial

• Impaired gait/balance

• Ataxia

• Vertigo

• Dysphagia

• Headache

how can you tell the symptoms of acute stroke

Will vary depending on the location of the pathology

how are ischemic strokes named

Ischemic strokes are named for the artery involved

Stroke Location/Syndrome

• Middle cerebral artery*
• Anterior cerebral artery
• Internal carotid artery
• Posterior cerebral
• Vertebral
• Basilar

Left MCA

• R hemiparesis

• R sensory loss

• Aphasia

• R visual field cut

  • R homonymous hemianopsia

• Left gaze preference

Right MCA

• L hemiparesis

• L sensory loss

• Neglect/anosognosia

• L visual field cut
  • L homonymous hemianopsia

• Right gaze preference

visual field defects

1. peripheral loss (glaucoma)

2. central scotomata

3. monocular loss (right)

4. bitemporal loss (optic chiasm) pituitary mass

5. homonomous hemianopia (right)

6. quadrantanopia (right parietal)

7. quadrantanopia (right temporal)

ACA Syndrome

• Contralateral weakness (LE>UE>face)
• Contralateral sensory loss (LE>UE>face)
• Abulia (Left)
• Gaze preference
• Incontinence

Central PCA Syndrome

• Visual field cut

• Thalamic involvement

  • Weakness (contralateral hemiparesis)

  • Sensory changes
    • Anesthesia
    • Thalamic pain syndrome

  • Hemiballismus

Peripheral PCA Syndrome

• Amnesia
  • Hippocampus involvement

• Alexia without agraphia

• Visual deficits
  • Cortical blindness
  • Visual field cuts

Basilar Artery Syndrome

• Supplies pons, midbrain, cerebellum & more

• Altered mental status/sedation

• Brainstem findings
  • Cranial nerve deficits, weakness, anesthesia

• Can be catastrophic due to (B) pons damage
  • Tetraplegia
  • Coma
  • Locked-in syndrome

Stroke of the Cerebellum

Supplied by basilar and vertebral arteries
• Nystagmus
• Dizziness
• Nausea/vomiting
• Ipsilateral ataxia

Ischemic strokes are described by

• their depth

• their location

depth of strokes

• Intracerebral
• Subarachnoid
• Subdural
• Epidura

possible locations of stroke

• Basal ganglia/thalamus
• Cerebral white matter
• Brainstem
• Cerebellum

Intracranial Hemorrhage (ICH)

• Bleeding from an arterial source into the brain parenchyma
• Most fatal of all CVA subtypes

Subarachnoid Hemorrhage (SAH)

• Bleeding into the subarachnoid space between the arachnoid and the pia mater
• Aneurysms and vascular malformations are the most common non-traumatic causes

SAH

• 90% of SAHs are due to saccular or berry aneurysm,
  • Typically occur at bifurcations

• Stimulus is usually a transient rise in BP when physically straining such as orgasm or Valsalve

most common sites of SAH

• Anterior communicating artery
• Posterior communicating artery
• Middle Cerebral artery

Dangers of SAH

• Spewing of blood, under high pressure, into brain tissue
• Susceptibility to re-rupture
• Obstruction of the SA space which can lead to hydrocephalus due to CSF blockage

Hemorrhagic CVA Syndromes

Tend to be less focal than ischemic due to more generalized area of tissue involvement

• Putaminal Hemorrhage

• Thalamic Hemorrhage

• Cerebellar Hemorrhage

• Pontine Hemorrhage

Putaminal Hemorrhage

Similar to MCA CVA, but with greater alteration of consciousness

Thalamic Hemorrhage

Results in contralateral hemiplegia with disproportionately greater sensory loss

Cerebellar Hemorrhage

Results in ataxia and vestibulopathy

Pontine Hemorrhage

• Offers the poorest prognosis
• Tetraplegia and coma

Lacunar CVA

Characteristics of ischemic & hemorrhagic

• Syndromes include
  • Pure motor
  • Pure sensory
  • Ataxic hemiparesis
  • Clumsy hand dysarthria
  • Mixed sensory and motor

Other Common Signs/Symptoms of hemmorrahagic stroke

• Fatigue
• Cognitive dysfunction
• Depression
• Anxiety
• PTSD

stages of recovery from stroke

• Acute/Early
• Late
• Chronic
All must consider adaptation to personal environment

Initial Improvements

• Reduction of cerebral edema
• Absorption of damaged tissue
• Improved local vascular flow
• Damaged areas of the brain are circumvented

Recovery

• Previously believed to be complete following 3-6 months
• Current research tells us that it may continue for months or years

Stroke Outcomes

From the Framingham Heart Study
• Good chance of functional recovery
• Rehab is effective
• Age not factor in outcome