Cerebrovascular diseases

Dr. Mehzabin Ahmed

 Cerebrovascular
disorders

Transient
ischemic Stroke
attacks

Ischemic Hemorrhagic

Thrombosis Embolism
• The term cerebrovascular diseases denote any

abnormality of the brain caused by a

pathologic process of blood vessels, and

includes thrombosis, embolism and

hemorrhage.
Forms of Clinical Presentation
• Transient ischemic attack: Defined as episodes of
non-traumatic focal loss of cerebral or visual function
lasting for not more than 24 hours. It is a major risk
factor for stroke.
• Stroke is the common manifestation of
cerebrovascular diseases, characterized by sudden or
rapid onset of non-traumatic neurological deficit due
to a vascular disease.
• The causes of stroke are divided into two
groups
1.     Ischemic stroke (85%) due to cerebral
infarction

2.     Hemorrhagic stroke (15%), due to

intracerebral and subarachanoid hemorrhage.
 Ischemic stroke
Mechanisms:
• Hypoxic and ischemic damage to the brain
results in failure of energy sources.
• This results in death of neurons because they
are more vulnerable to hypoxia than the other
cells.
• Neurons depend on oxidative metabolism of
glucose for energy.
This situation is seen in:

1)    Failure of blood oxygenation (severe

respiratory diseases, asphyxiation, CO poisoning);

2)    Failure of the blood flow, which can be focal

(occlusion of the cerebral artery) or generalized
(cardiac arrest, shock)

The most vulnerable neurons to hypoxia, are the

large cells in the hippocampus and those in the
cerebral cortex (purkinje fibers).
 FOCAL ISCHEMIA: CEREBRAL INFARCTS
• Stroke, the sudden onset of a permanent, localized neurologic
deficit, may result either from infarction(75%) or hemorrhage
• Infarction: may be due to
– Thrombosis
• On atherosclerotic plaques- common sites being
– the carotid bifurcations and
– the vertebrobasilar system
– Embolism
• Intracardiac thrombi
– fibrillating atria,
– mural thrombi over old infarcts
• Less often, atheroemboli, paradoxical emboli, and other
materials
– Vasculitis
• Syphilis, tuberculosis, PAN
• Infectious – in immunocompromised patients-
Toxoplasmosis, aspergillosis & CMV
Ischemic stroke is of 4
main types:
1. Large vessel disease:
Regional infarction
Thrombosis in the internal
results due to carotid artery
thrombosis or
embolism of the
cerebral arteries.

Hemorrhagic infarction due to

emboli
 Cerebral infarction –
liquefactive necrosis- on
resolution leaves a cavity
 

Cerebral infarction
on resolution
formed a cystic
space
2. Small vessel disease:
causes micro infarcts
known as ‘lacunar
infarcts’.
These are due to
Large hemorrhage
arteriosclerosis due to Hypertension
predisposed by
hypertension and
diabetes.
The main sites are pons
and basal ganglia.
3. Venous infarction: causes hemorrhagic necrosis due to

thrombosis in venous sinuses.

It is associated with

– polycythemia,

– local sepsis,

– dehydration, and

– disorders that cause hypercoagulability of the

blood (oral contraceptives and pregnancy)

4. Global ischemia; causes widespread

neuronal necrosis and lead to laminar

cortical necrosis.

Seen in generalized failure of blood flow

or oxygenation, for example, following

• cardiac arrest,

• severe hypoglycemia and

• CO poisoning.

Infarction is seen at arterial boundary Laminar cortical necrosis-

thin rim like cortex
zones, termed as ‘watershed infarcts’.
 GLOBAL CEREBRAL ISCHEMIA
• Ischemic / Hypoxic encephalopathy is said to be present when the whole brain
has suffered the effects of poor perfusion.

• Outcome of global cerebral ischemia:

– Mild- transient post-ischemic confusional state

– Irreversible damage of selective neurons (selective vulnerability)

– Severe cases - widespread brain infarction resulting in death or in a

vegetative state (deeply comatose and neurologically impaired)
– Brain death- evidence of diffuse cortical injury (flat EEG), brainstem
damage (absent reflexes and respiratory drive) and absent cerebral perfusion-
maintained on mechanical ventilation
 Anterior
cerebral Primary motor cortex
artery (M1)

Middle
cerebral
artery

Posterior
cerebral
artery
 Common causes of stroke in
younger patients
Ischemic stroke Hemorrhagic stroke
• Vascular occlusion • Hypertension
– by emboli, atherosclerosis • Berry aneurysms
and vasculitis
• AV malformations
• Vascular spasm
– due to migraine or drugs • Cocaine and heroin
abuse.
• Increase thrombotic tendency
– oral contraceptives,
pregnancy &
antiphospholipid
antibodies.
 Intracerebral hemorrhage
• Spontaneous intracerebral hemorrhage accounts for 15%
of cerebral stroke and is caused by intracerebral
hematoma and subarachnoid hemorrhage.
• The most common cause of cerebral hemorrhage is
hypertensive vascular damage. Prolonged hypertension
results in arteriosclerosis and development of small micro
aneurysms (Charcot-Bouchards aneurysms), which
predispose to vessel rupture resulting in a hematoma.
Common sites are basal ganglia, internal capsule,
thalamus, cerebellum and pons)
• Bleeding into the subarachnoid space is a cause of
stroke in about 5% of cases.
• The common cause of such hemorrhage is the
rupture of a Berry aneurysm (are small micro
aneurysms formed because of developmental
defects in the internal elastic lamina of the vessels.)
or because of the rupture of AV malformations (are
developmental abnormalities in the blood vessels,
in which vessels are usually fragile and clinically
the patient can develop epilepsy and they can
bleed resulting in life threatening intracranial
hemorrhage).
 INTRACEREBRAL HEMORRHAGE

Spontaneous intraparenchymal hemorrhage

• Middle to late adult age
• Causes:
– Hypertension
– Bleeding disorders
– Hemorrhage into brain tumors
– Amyloid angiopathy
– Vascular malformations (angiomas)
– Vasculitis
– Aneurysms
 Ruptured Berry
Aneurysm

Subarachnoid
hemorrhage due to a
ruptured aneurysm
 HYPERTENSIVE CEREBROVASCULAR DISEASE (contd..)

LACUNAR INFARCTS

“Lacunae" are little infarcts, a few mm across

• In the deep structures of the brain (the basal ganglia and
nearby structures are typical sites).
• Hypertensive hyaline arteriolar sclerosis occludes the vessels
causing micro –infarcts
 HYPERTENSIVE CEREBROVASCULAR DISEASE (contd..)

• HYPERTENSIVE ENCEPHALOPATHY
– Sudden or extreme rises in blood pressure produce brain
dysfunction.
– Patients complain of confusion, drowsiness, headache, and
nausea. Seizures are also common
– Rapid intervention is required to reduce the ↑ ICP
– vascular (multi- infarct) dementia syndrome- dementia, gait
abnormalities, psuedobulbar signs, and focal neurological
deficits- seen in multiple bilateral gray and white matter
infarcts.
 Clinical features
Cerebral infarction is • Intracerebral hemorrhages
characterized by are characterized by
• sudden loss of – abrupt onset of headache,
neurological function dense neurological deficit
corresponding to the area and loss of consciousness.
involved. – Patient may have problems
• The onset may be acute with movement, such as
• weakness,
and the neurological • clumsiness or
deficit progress over • paralysis.
several hours to days – He can also develop
• impaired speech,
• emotional liabilities,
• visual impairment, and
• difficulty in swallowing
and difficulty in breathing
• ataxia,
• coma