LEC-8 CVA.pptx cardiovascular diseases hh

Cardio disease

1. CEREBRO VASCULAR DISORDER (CEREBRO VASCULAR ACCIDENT)

2. DEFINITION A stroke is characterized by sudden neurologic deficit resulting from ischemia (88% of cases) or hemorrhage (12% of cases) Cerebrovascular accident (CVA), occurs when blood supply to part of the brain is disrupted, causing brain cells to die.

3. INCIDE N CE AGE : The percentage is higher for people age 65 and older. Of those who survive, 50% to 70% will be functioning independent and 15% to 30% will live with permanent disability. SEX : Stroke is more common in men than in women.

4. 4 RISK FACTORS Nonmodifiable risk factors : Age : more than 65 yr Gender : More in men than women Race : African American Family history : Heredity Modifiable risk factors : Hypertension Heart disease Smoking Excessive alcohol consumption Obesity Poor diet Drug abuse Oral contraceptive

5. C AUSES Vessel wall embolus Carotid artery most often the source Related to thrombus formation distal to stenosis Cardiac source Mitral valve stenosis Mitral valve prolapsed Calcified mitral annulus Ventricular aneurysm Atrial or ventricular clot Valvular vegetation Atrial septal defect

6. 6 Vascular sources Intracranial artery thrombus (esp. African- Americans) Aortic arch atherosclerotic Plaque Transient hypotension with Carotid Stenosis

7. TYPES OF STROKE Strokes are classified as ischemic or hemorrhagic based on the underlying pathophysiologic findings. 7

8. 8 1. Ischemic stroke An ischemic stroke result from inadequate blood flow to the brain from partial or complete occlusion of an artery. Ischemic stroke are further divided into thrombotic and embolic . The most significant risk factor for acute ischemic stroke is systemic HYPERTENSION

9. Risk factors: Cigarette smoking Hyperlipidemia Diabetes mellitus Excessive alcohol consumption Increased serum homocysteine concentrations.

10. 10 a. Thrombotic stroke A thrombotic stroke occurs from injury to a blood vessels wall and formation of a blood clot. The lumen of the blood vessel becomes narrowed and if it becomes occluded, infarction occur. Thrombosis develops readily where atherosclerotic plaques have already narrowed blood vessels. Thrombotic stroke, is the most common cause of stroke. Two third of thrombotic strokes are associated with hypertension or diabetes mellitus

11. 11 b. Embolic stroke Another type of stroke may occur when a blood clot or a piece of atherosclerotic plaque loose, breaks , travels through the bloodstream and lodges in an artery in the brain. When blood flow stops, brain cells do not receive the oxygen and glucose they require to function and a stroke occurs. This type of stroke is referred to as an embolic stroke.

12. 12 CLINICAL MANIFESTATIONS Visual Field Deficits : Homonymous hemianopsia (loss of half of the visual field ) Unaware of persons or objects on side of visual los s Neglect of one side of the body Difficulty judging distances Loss of peripheral visio n Difficulty seeing at night Unaware of objects or the borders of objects Diplopia Double vision Sensory defect Paresthesia (occurs on the side opposite the lesion) Numbness and tingling of Extremity

13. 13 Motor Deficits Hemiparesis : Weakness of the face, arm, and leg on the opp side (due to a lesion in the opposite hemisphere) Hemiplegia : Paralysis of the face, arm, and leg on the opp side (due to a lesion in the opposite hemisphere) Ataxia : Defective muscular co-ordination, unsteady gait Unable to keep feet together; needs a broad base to stand Dysarthria : Difficulty in forming words Dysphagia : Difficulty in swallowing

14. 14 Verbal Deficits Expressive aphasia : Unable to form words that are understandable; may be able to speak in single-word responses Receptive aphasia : Unable to comprehend the spoken word; can speak but may not make sense Global (mixed) aphasia : Combination of both receptive and expressive aphasia

15. 15 Cognitive Deficits Short- and long-term memory loss Decreased attention span Impaired ability to concentrate Poor abstract reasoning Altered judgment Emotional Deficits Loss of self-control Emotional lability Decreased tolerance to stressful situations Depression Withdrawal Fear , hostility, and anger Feelings of isolation

16. 16 ASSESSMENT AND DIAGNOSTIC FINDING HEALTH HISTORY : Past health history : Hypertension, previous stroke, aneurysm, cardiac disease (including recent myocardial infraction), dysrhythmias, heart failure, valvular disease, infective endocarditis, hyperlipidemia, polycythemia, diabetes Family history : Hypertension, diabetes, stroke, coronary artery disease. Medications : Use of oral contraceptives, use of antihypertensive and anticoagulant therapy Nutritional history : Anorexia, nausea, vomiting,dysphagia, altered sensation of taste and smell Cognitive perceptual history : Numbness, tingling of one side of body, loss of memory, altered in speech, pain, headache, visual disturbance

17. 17 PHYSICAL ASSESSMENT Glasgow coma scale NIH stroke scale COGNITIVE FUNCTION :- Orientation : Speech .

18. NIH stroke scale

19. 20 Speech :-aphasia & other problems Fluent aphasia (motor/ Borka’s ) – inability to express self Non-fluent aphasia ( sensory / wernicke’s ) – inability to understand the spoken language. Global aphasia – inability to speak or understand spoken language. Other aphasia syndromes – amnesia. MOTOR FUNCTION : Voluntary movement Reflexive movement : B ice p s , T r i ce p s , P a t el l a r , Achilles, Planter

20. 21 DIAGNOSTIC EVALUATION Diagnosis of stroke, including extent of involvement CT, CTA (computer tomographic angiography) MRI, MRA (magnetic resonance angiography) SPECT (single photon emission computed tomography) PET ( Positron emission tomography ) MRS (magnetic resonance spectroscopy) Xenon CT Electroencephalogram Cerebral angiography Cerebrospinal fluid analysis

21. CT SCAN 3 /0 4 /2 15 www.drjayeshpatidar.blogspot.com 22

22. 23 Cerebral blood flow measures Cerebral angiography Digital subtraction angiography Doppler ultrasonography Transcranial Doppler Carotid duplex Carotid angiography

23. 24 Cardiac assessment Electrocardiography Chest x-ray Cardiac enzymes Holter monitor Additional studies Complete blood count PT, APTT Electrolytes Blood glucose level Renal and hepatic studies Lipid profile Arterial blood gases analysis

24. 25 MANAGEMENT : MEDICAL MANAGEMENT : Platelet-inhibiting medications : Aspirin , dipyridamole [Persantine], clopidogrel [Plavix], and ticlopidine [Ticlid]). Currently the most cost-effective antiplatelet regimen is aspirin 50 mg/d and dipyridamole 400 mg/d. Thrombolytic therapy : Recombinant t-PA is a genetically engineered form of t PA, a thrombolytic substance made naturally by the body. The minimum dose is 0.9 mg/kg; the maximum dose is 90 mg.

25. 26 Eligibility Criteria for t-PA Administration Age 18 years or older Clinical diagnosis of stroke with NIH stroke scale score under 22 Time of onset of stroke known and is 3 hours or less BP systolic ≤ 185; diastolic ≤ 110 Not a minor stroke or rapidly resolving stroke No seizure at onset of stroke Not taking warfarin (Coumadin) Prothrombin time ≤ 15 seconds or INR ≤ 1.7 Not receiving heparin during the past 48 hours with elevated partial thromboplastin time.

26. 27 Platelet count ≥ 100,000 No acute myocardial infarction No prior intracranial hemorrhage, neoplasm, arteriovenous malformation or aneurysm No major surgical procedures within 14 days No stroke or serious head injury within 3 months No gastrointestinal or urinary bleeding within last 21 days Not lactating or postpartum within last 30 days

27. Adjuvant…. Airway Oxygenation Ventilation Blood pressure; below 220/120 mm Hg . to maintain CPP Blood glucose Body temperature; hypothermia Body fluid status; hypervolemia DVT prophylaxis; heparin 5000U b.d S/C Other vital organ function..

28. 29 Surgical management Carotid endarterectomy : Removal of an atherosclerotic plaque or thrombus from the carotid artery to prevent stroke in patients with occlusive disease of the extracranial cerebral arteries. This surgery is indicated for patients with symptoms of TIA or mild stroke found to be due to severe (70% to 99%) carotid artery stenosis or moderate (50% to 69%) stenosis with other significant risk factors . Craniotomy ; life saving intervention, prevents secondary ischemic injury

29. 30 2. Hemorrhagic strokes Acute hemorrhagic stroke results from intracranial hemorrhage or sub arachnoid hemorrhage. Hemorrhagic strokes account for 1 2 % of cerebrovascular disorders and 4-time more likely to cause death I ntracerebral hemorrhage from a spontaneous rupture of small vessels accounts for approximately 80% of hemorrhagic strokes and is primarily caused by uncontrolled hypertension Factor VII …?

30. Classification Based on location of hemorrhage Blood located within the brain proper is called an intraparenchymal hemorrhage. Blood located in the epidural , subdural, or subarachnoid spaces is referred to as epidural hematoma , subdural hematoma, or subarachnoid hemorrhage ,

31. 32 CLINICAL MANIFESTATIONS Severe headache Loss of consciousness Rigidity of the back and neck (nuchal rigidity) Pain in spine due to meningeal irritation Visual disturbance (visual loss, diplopia, ptosis ) Dizziness Hemiparesis

32. 33 ASSESSMENT AND DIAGNOSTIC FINDING : DIAGNOSTIC EVALUATION : CT Scan : To determine the size and location of the hematoma as well as presence or absence of ventricular blood. Cerebral angiography : To confirm the diagnosis of an aneurysm or AVM. Lumber puncture PREVENTION: Control hypertension. Stop smoking. Stop to take alcohol. Avoid to take high cholesterol diet

33. 34 SURGICAL MANAGEMENT Craniotomy : Many patients with a primary intracerebral hemorrhage are not treated surgically. However, surgical evacuation is strongly recommended for the patient with a cerebellar hemorrhage if the diameter exceeds 3 cm. Surgical evacuation is most frequently accomplished via a craniotomy.

34. 35 POST OPERATIVE COMPLICATIONS : Intraoperative embolization Postoperative internal artery occlusion Fluid and electrolyte disturbances

35. Management of anesthesia Limit the increase of transmural pressure of aneurysm sac Maintenance of ICP (medication, lumber CSF drainage, hyperventilation, loop diuretics) Maintenance of cpp without HTN; invasive BP Normovolemia; central line Mild hypothermia Avoidance of HTN during laryngoscopy BARBITURATE, PROPOFOL FOR INDUCTION NDMR to facilitate laryngoscopy Depth of anesthesia

36. Maintenance of anesthesia Volatile iso, des, sevo TIVA; with fentanyl, remifentanil, propofol Monitoring of Blood pressure invasive CVC Temperature Emergence Prompt; if possible Use of labetalol, Esmolol, lidocaine Frequent neurologic assessment

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