Cerebrovascular Accidents Marc Norman, Ph.D. Department of Psychiatry Neuropsychiatry and Behavioral Medicine Neuropsychology Clinical Training Seminar 1 5 http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/18009.jpg 6 http://www.seattleavir.com/circlewillis.jpg http://science.nhmccd.edu/biol/cardio/willis.jpg 7 http://www.bioengineering.canterbury.ac.nz/graphics/cow_description.gif http://www.southeastiowaopenmri.com/clinicalphotos/circle_willis_3d_tof.jpg 8 9 without Permission 1
10 11 12 13 Vascular Distributions2 From Bigler 14 From Bigler 15 without Permission 2
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22 23 http://www.medem.com/medem/images/ama/ama_brain_stroke_lev20_thebraineffectsstroke_01.gif HTN Cardiac Diabetes Lupus Risk Factors Coagulopathies Ischemic Hemorrhage Types 24 25 Ischemic Hemorrhagic Onset 26 http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/17133.jpg 27 without Permission 4
28 29 http://ww2.heartandstroke.ca/images/english/stroke_isc_web.jpg http://www.uieh.n-i.nhs.uk/projects/stroke/images/haemorrhagic_stroke_sml.gif Aneurysm Blood filled balloon-like bulge Saccular (aka Berry aneurysm) round pouch and most common form Fusiform widening of an artery segment around the blood vessel, rather than just side of artery Microaneurysm in small vessels, most often lenticulostriate in basal ganglia. Common form of intracranial bleed and associated with hypertension 30 31 http://ww2.heartandstroke.ca/images/english/stroke_hem_web.jpg Embolism Intervention 32 33 without Permission 5
Embolization Vascular Malformations Arteriovenous Malformations (AVMs) Telangiectasias Typically small (capillary types of vessels) Venous Anomalies Cavernous Malformations Cavernous angiomas Cavernomas Cavernous hemangiomas 34 35 AVM Worm like Abnormal collection of ateries and veins Nidus - central collection Leak or rupture AVM2 36 http://www.neurosurgery.ufl.edu/images/avm1.jpg http://www.neurosurgery.ufl.edu/images/avm%20angio.jpg 37 http://www.brain-aneurysm.com Aneurysm Pic http://www.nlm.nih.gov/ medlineplus/ ency/images/ency/ fullsize/17031.jpg 38 39 without Permission 6
Venous Anomalies Deep venous anomalies Developmental Not arterial Most common malformation Often benign Cavernous Malformation aka Cavernoma, cavernous hemangioma Appear as tiny blood-filled brain caverns (or spinal) Abnormal, dilated vessels Can enlarge and/or bleed More common in Hispanics Hereditary link 40 41 Intracranial Hemorrhages Subdural Subarachnoid Epidural 42 43 Epidural Extra-Axial not in parenchyma, but within skull Extradural between dura and skull Caused by trauma Arterial high slow dangerous Causes intracranial pressure to rise quickly Epidural Onset LOC and then lucid Typical Onset Under 45 y/o Fall with brief LOC Feel better Hours later deteriorate LOC, vomiting CT convex deformity Need to treat 44 45 without Permission 7
Subdural Venous low flow Tearing of bridging veins in subdural space between dura and arachnoid CT - crescent shape Thunderclap headache 46 47 Subarachnoid Between arachnoid and pia From trauma or rupture from aneurysm or AVM Blood layers brain along sulci and fissures or fills cisterns Sudden onset of HA Emergent intervention Other Intracranial Hemorrhages Intraparenchymal in brain tissue Intraventricular in ventricle 48 49 Basal Ganglia Cerebellum Thalamus Pons Common Stroke Areas White matter / Internal capsule 50 51 http://www.nhlbi.nih.gov/health/dci/images/atrial_fib_stroke.jpg without Permission 8
Watershed Stroke Ischemic Border zones between two main distributions Hypotension is most common etiology 52 53 Watershed MRI Transient Ischemic Attack Transient Ischemic Attack Ischemic loss of blood flow Resolves with 24 hours Lacunar Stroke empty space Vascular occlusion 54 55 Lacunar Stroke Symptoms Weakness Tingling Coordination Balance Sudden Severe HA Confusion Falls Visual (fields) Sensory Dizziness 56 57 without Permission 9
Dominant Hemisphere Non-Dominant Hemisphere Aphasia Apraxia Visual Discrimination Anosognosia Broca s Wernike s Conduction Agnosia Acalculia Alexia Self-Awareness Hemi-inattention Transcortical Global 58 59 Symptoms in Women Parietal Sudden face and limb pain Sudden hiccups Sudden nausea Sudden general weakness Sudden chest pain Sudden shortness of breath Sudden palpitations Stroke.org 60 Dominant Reading Writing Gerstmann s Syndrome Sensory NonDominant Visual Spatial Sensory 61 Occipital Imaging Cortical Blindness Acute CT Anton s Syndrome No findings Subacute Hypodense Chronic Cystic 62 63 without Permission 10
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72 73 74 75 TPA Ischemic Known Onset 3 hours Treatment Carotid endarterectomy Stenting Angioplasty FACE ARMS SPEECH TIME Act F.A.S.T. Ask the person to smile. Does one side of the face droop? Ask the person to raise both arms. Does one arm drift downward? Ask the person to repeat a simple sentence. Are the words slurred? Can he/she repeat the sentence correctly? If the person shows any of these symptoms, time is important. Call 911 or get to the hospital fast. Brain cells are dying. 76 77 without Permission 12
Recovery Penumbra damaged area around the stroke Diaschysis depression of neural function (likely through metabolism and cerebral blood flow) caused by dysfunction in an anatomically separate but functionally related area 6-9 Months Age 78 79 without Permission 13