STROKELA TORRE, KRYSTLE MAE G.

Medical Student, Department of Anatomy

New Era University

LEARNING OBJECTIVES• To identify Cardiovascular Accident• To identify blood supply of the brain• To be able to define stroke and its types• To enumerate the risk factors • To discuss the latest stroke treatment strategies

CASE STUDIES: To be able to analyze clinical situations, localize the stroke lesion.

ABSTRACT

• A 48 year old Attorney was hypertensive. He had several episodes of blurred vision involving his left eye. Several weeks later, he complained to his wife a left-sided headache and slumped in a chair half hour later, apparently confused and paralyzed on the right side.

ABSTRACT

• Neurologic examination revealed total paralysis of the right arm and severe weakness of the right face. The leg was only mildly affected. The patient was globally aphasic.

ABSTRACT

• A computer Tomography Scan revealed an infarct in the territory of middle cerebral artery of the left side. Angiography revealed occlusion of the internal carotid artery (left side) The patient is given a tPa (Tissue Plasminogen Activator) through an IV in the arm and recovered only minimally.

CLINICAL FINDINGSHistory of Present Illness•4 days history of several episodes of blurred vision (left eye) attacks lasted less than an hour. Amaurosis Fugax•He complained of a left-sided headache several weeks later•Total paralysis of the right arm and severe weakness of the right face•Leg was only mildly affected•Globally aphasic

Physical Examination Findings•BP: 160/90 mmHg

DIAGNOSTICS

• Angiography revealed occlusion of the internal carotid artery on the left.

Cerebral angiogram showing the left and right carotid artery, the arrow points to occlusion on the left side.

DIAGNOSTICS

•Computer Tomography Scan revealed an infarct in the territory of middle cerebral artery of the left side.

CT scan image of a horizontal section of the head showing an infarct caused by middle cerebral artery occlusion

MANAGEMENT

• The patient is given a tPa (Tissue Plasminogen Activator) through an IV in the arm by dissolving the clot and improving blood flow to the part of the brain being deprived of blood flow and administered within 3-4.5 hours.

• The patient recover minimally.

Normal pathway of blood circulation in the brain artery

1. Blood from right and left vertebral artery will join together in basilar artery2. This will branch laterally to right and left posterior cerebral artery3. Ascend to create the right and left communicating artery4. Then pass through the right and left middle cerebral artery5. Meet again in the anterior communicating artery which complete the circle of Willis

BLOOD SUPPLY OF THE BRAIN

BLOOD SUPPLY OF THE BRAIN

BLOOD SUPPLY OF THE BRAIN

ATHEROSCLEROSIS

• Atherosclerosis causes arteries to narrow, weaken and be less flexible. It's the process of fatty buildup in the inner lining of an artery reduces the amount of blood and oxygen that is delivered to vital organs.

BROCA’S AREA

• Expressive speech area.• Integration with other

language areas.

WERNICKE’S AREA

• Receptive speech area.• Integration with other

language areas

MOTOR CORTEX

• Movement of right head, neck, trunk and arm.

SENSORY CORTEX

• Sensation from right head, neck, trunk and arm.

OVERVIEW(AFFECTED AREAS OF BRAIN)

OVERVIEW(AFFECTED AREAS OF BRAIN)

STRUCTURES OF BRAIN (HEMISPHERES)

CEREBROVASCULAR ACCIDENT (CVA)

• Other terms: “stroke”, “brain attack”• Occurs when blood supply to part of the brain is

disrupted, causing brain cells to die when blood flow top the brain is impaired, oxygen and glucose cannot be delivered to the brain.

• A neurological deficit of cerebrovascular cause that persists beyond 24 hours.”-WHO

How Serious Is Stroke in the US?

• Third leading cause of death• About 700,000 strokes occur each year. • A leading cause of serious long-term

disability in adults.

Major Causes of Death in the United States, 1995

Death Rates for Stroke per 100,000 Population

US Death Rates for Stroke per 100,000 PopulationGroups Defined by Race, Age, and Gender: 1993

Types of Stroke

• Ischemic, 80%• Hemorrhagic, 20%

ISCHEMIC STROKE

• occurs when a clot or a mass clogs a blood vessel, cutting off the blood flow to brain cells. The underlying condition for this type of obstruction is the development of fatty deposits lining the vessel walls.

THROMBOTIC STROKE

occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to your brain. A clot may be caused by fatty deposits (plaque) that build up in arteries and cause reduced blood flow (atherosclerosis) or other artery conditions.

THROMBOTIC STROKE

EMBOLIC STROKE

• occurs when a blood clot that forms elsewhere in the body (embolus) breaks loose and travels to the brain via the bloodstream. Eventually, the clot lodges in a blood vessel and blocks the flow of blood, causing a stroke.

EMBOLIC STROKE

TRANSIENT ISCHEMIC STROKE (TIA)

• a "mini stroke" that occurs when a blood clot blocks an artery for a short time.

TRANSIENT ISCHEMIC STROKE (TIA)

HEMORRHAGIC STROKE

• results from a weakened vessel that ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue.

HEMORRHAGIC STROKE

The two types:•Subarachnoid hemorrhage (SAH) occurs when a blood vessel on the surface of the brain ruptures and bleeds into the space between the brain and the skull. •Intracerebral hemorrhage (ICH) occurs when a blood vessel bleeds into the tissue deep within the brain.

Risk Factors for Stroke (unchanged)

• Increased age • Being male • Race (e.g., African-Americans) • Diabetes mellitus • Prior stroke/transient ischemic attacks • Family history of stroke

Risk Factor For Stroke (treatable)

• Hypertension • Heart disease, esp. atrial fibrillation • Cigarette smoking • Transient ischemic attacks• Physical inactivity• Obesity

STROKE MANAGEMENT

Stroke Prevention

• Anticoagulants (Heparin, Warfarin)• Antiplatelets (aspirin, clopidogrel)• Antihypertensives (metropolol, losartan)• Statin• Carotid endarterectomy • tPa (Tissue Plasminogen Activator)

Other Neuroimaging Techniques & Ancillary Tests

• Computer Tomography (CT) Scan • Magnetic Resonance Imaging

(MRI)• Magnetic Resonance Angiography

(MRA)• Ultrasound (Carotid Duplex,

Transcranial Doppler, 2-D echo)