Cerebrovascular diseases

Written by Dr.Md.Redwanul Huq (Masum)
Sunday, 15 January 2012 16:17

Cerebrovascular diseases (CVD):

Following disorders are included in cerebrovascular diseases (CVD)-

1. Stroke
2. Subarachnoid hemorrhage
3. Cerebral venous disease

Stroke

Definition:

Stroke is defined as rapidly developed clinical signs of focal or global disturbance ofCerebral function lasting more than 24 hours (if symptoms are not interrupted by asurgical intervention) or leading to death, with no apparent cause other than a vascular origin.

Classification of stroke:

1. Clinical classification of stroke

Clinically stroke is classified as-

a) Transient ischemic attack (TIA)- here symptoms resolve within 24 hours
b) Progressing stroke or stroke in evolution- here the focal neurological deficit worsens progressively
c) Completed stroke- here the focal deficit is persistent and does not increase progressively

2. Etiological classification of stroke

Etiologically stroke is classified as-

a) Ischemic stroke (or stroke due to cerebral infarction)
b) Hemorrhagic stroke.

Risk factors for stroke:

Non-modifiable risk factors for stroke-

a) Age- more in elderly
b) Sex- more in male
c) Positive family history
d) Previous history of (H/O) Myocardial infarction(MI), CVD,Peripheral vascular diseases(PVD) etc.

Modifiable risk factors for stroke-

a) Hypertension
b) Diabetes Mellitus
c) Hyperlipidaemia
d) Heart disease (e.g. atrial fibrillation, endocarditis, carotid stenosis, heart failure)
e) OCP (Oral contraceptive pill)
f) Smoking
g) Alcohol intake
h) Polycythaemia
i) Blood dyscrasia
j) Anticoagulant therapy
k) Thrombolytic therapy
l) AVM(Arteriovenous malformation).

Clinical manifestations of Stroke:

History:

a) Positive family history
b) Previous history of (H/O) Myocardial infarction(MI), CVD, Peripheral vascular diseases (PVD) etc.

Symptoms of stroke:

Symptoms of stroke are-

  • Sudden or progressive onset of following symptoms-
  • Weakness or paralysis of one side of the body
  • Difficulty in speech
  • Deterioration of level of consciousness up to unconsciousness
  • Headache
  • Vomiting
  • Convulsion
  • Difficulty in swallowing
  • Restlessness
  • Sensory deficit
  • Neck rigidity.

Differences between history and symptoms of Haemorrhagic and Ischemic stroke:

Haemorrhagic stroke Ischemic stroke
Age – common in relative young patients Common in relative elderly patients
Onset – during excitement or work During rest and sleep
HTN – on irregular treatment Usually on regular treatment
Headache, vomiting more common Less common
Level of consciousness- usually impaired Usually maintained

Signs of stroke:

General examination findings-

  • Assessment of level of consciousness(GCS)
  • Pulse- may be normal or irregularly irregular due to atrial fibrillation
  • Blood pressure – may have hypertension or hypotension
  • Jugular venous pressure- may be raised if heart failure is present
  • Temperature- normal or may be increased
  • Respiratory rate- may be normal or increased.

Systemic examination findings-

Examination of nervous system-

1) Higher psychic function:

May have disorders in appearance, behavior, concentration, communication, perception, thought, intelligence, insight, mood, memory, speech & language, orientation about time, place and person.

2) Cranial nerves:

May have signs of definite cranial nerve lesion according to the level of the lesion (usually in opposite side of the lesion).

3)Motor:

Findings are present usually in opposite side of the lesion.

a) Inspection:

i) Wasting may be present- in late cases
ii) Fasciculation may be present

b) Others:

i) Palpation of muscle groups.
ii) If wasting is present, measurement of circumference of muscle – establishes wasting
iii) Tone of the muscles:

  • Palpation of muscles- shows spasticity (in early stage) or flaccidity(in late stage)
  • Passive movements of joints- also shows spasticity (in early stage) or flaccidity(in late stage)

iv) Power of muscles:

a) Grading of power of muscles:

  • Grade O: Complete paralysis (no muscle contraction is seen)
  • Grade 1: A flicker of contraction only, but no movement of joint.
  • Grade 2: Joint movement when effect of gravity eliminated.
  • Grade 3: The limb can be held against gravity, but not against the examiner’s resistance.
  • Grade 4: Limb can be held against gravity plus added pressure, but weakly.
  • Grade 5: Normal power is present.

b) Power of individual muscle group – decreased.

V) Reflexes:

  • Superficial reflexes are lost and deep reflexes are exaggerated
  • Plantar reflex- extensor.
  • Ankle clonus and knee clonus- may be present.

4) Sensory:

Sensory deficits are present usually in opposite side of the lesion.

5) Signs of co-ordination:

Usually remains intact if cerebellum is not involved..

6) Gait:

Hemiplegic gait: Hand flexed, hemi-circle of foot.

Examination of CVS-

  • Peripheral pulses and bruits- are examined to exclude generalised arteriopathy
  • Murmurs – may be present.

Examination of Respiratory system-

May have evidences of pulmonary infection or edema.

Examination of Skin-

May have-rashes, xanthelasma.

Examination of Urinary system-

May have urinary retention.

Examination of Eyes-

May show evidences of hypertensive or diabetic retinopathy.

Investigations for stroke:

1. To find out the type of stroke and level of lesion:

a) CT scan or MRI of brain
b) Cerebral angiography
c) Doppler USG of carotid arteries

2. To identify the risk factors:

a) Blood sugar
b) Fasting lipid profile
c) BT, CT, PT, APTT
d) ECG
e) Echo (if needed)

3. Other tests:

a) CBC with ESR
b) Urine R/M/E
c) Chest X-ray
d) S. Creatinine
e) S. electrolytes.

Treatment of stroke:

1. General measurements:

a) Maintenance of airway, breathing and circulation
b) Ensuring adequate nutrition- orally, if not possible -by NG tube feeding along with intravenous nutrition (if necessary).
c) Posture should be changed 2 hourly
d) Catheterization – if needed
e) Antibiotic eye drop should be used in unconscious patients to prevent exposure keratitis
f) Oral antifungal agents should be used to prevent oral thrush
g) Bed pan can be used to prevent soiling of the cloth in cerebrovascular diseases.

2. Specific treatment of stroke:

i) Treatment of Haemorrhagic stroke

* Tab. Nimodipine 30 mg-2 Tab 6 hourly for 2-3 weeks which should be started within 3-7 days of stroke
* Surgical removal of intracranial hemorrhagic mass is done in appropriate cases of haemorrhagic stroke.

ii) Treatment of Ischemic stroke
* Antiplatelet Drugs-
Tab. Aspirin (75 mg)
1tab-once daily (AM, usually after launch) —————– contd.
Or,
Tab.Clopidogrel (75 mg)
1tab-once daily ( AM, usually after launch) —————– contd.
Or,
Tab.Aspirin & Tab.Clopidogrel (75/75 mg) combination
1tab-once daily ( AM, usually after launch) —————– contd.

* rt- PA can be given within 3 hours of onset of an acute ischemic stroke
* Secondary prevention of ischaemic stroke can be done by treating with simvastatin 40 mg daily.

3. Physiotherapy in stroke

Physiotherapy is a significant part of treatment of stroke.

  • In case of Hemorrhagic stroke- in late period
  • In case of Ischemic stroke– from early period.

4. Treatment of significant risk factors

a) Treatment of Hyperlipidemia:
I. If Serum Cholesterol level is high-
Tab. Atorvastatin (10 /20/40 mg)
Or,
Tab. Rosuvastatin Calcium(5/10mg)
1 tab-once daily( +M) ———————–contd.

II. If serum Triglyceride level is high-
Cap. Fenofibrate (200 mg)
1 cap-once daily (AM)————————2 /3 M or contd.
Or,
Cap. Gemfibrozil(300mg)
1 Cap- once daily/bid ( ½ HBM) ———————2 /3 M or contd.

III. Tab.Trimetazidine (35mg)
1tab-once daily (AM) ————————2 /3 M or contd.

b) Treatment of Diabetes Mellitus:

c) Treatment of Hypertension:

5. Lifestyle modification:

  •  Don’t smoke
  • Avoid extra salt
  • Stop taking alcohol
  • Control your body weight.

6. Diet for stroke (specially for Ischemic stroke):

  • Decrease intake of saturated fat, polyunsaturated fat and transfatty acids and therefore decrease intake of butter, fatty meats, margarine, dairy products made from 2% or whole milk.
  • Use oils containing monounsaturated fatty acids and n-3 fatty acids (eg, canola and olive oil).
  • Eat monounsaturated-rich nuts in moderation.
  • Eat at least five to seven servings of vegetables and fruits daily.
  • Eat soy products and legumes daily.
  • Eat garlic regularly.
  • Increase intake of soluble fiber ( Present in Apples, Barley, Citrus fruits, Strawberries, Carrots, Guar, Legumes).

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