Acute ischemic disorders of the cerebral circulation - etiology, clinical features, pathogenesis, vascuar pools, prevention, therapy
Definition: Acute ischemic stroke is a sudden neurological deficit caused by interruption of cerebral blood flow, resulting in brain ischemia and infarction.
- It accounts for about 80–85% of all strokes.
Etiology (Causes)
A. Thrombosis (most common): Occlusion of cerebral arteries due to atherosclerosis.
- Risk factors: Hypertension. Diabetes mellitus. Hyperlipidemia. Smoking
B. Embolism
- Sources: Atrial fibrillation (most important). Myocardial infarction. Valvular heart disease. Endocarditis
C. Hemodynamic (Hypoperfusion): Severe hypotension. Shock. Cardiac arrest
Pathogenesis
Ischemic Cascade: Arterial occlusion → ↓ cerebral blood flow → ↓ oxygen and glucose → ATP depletion → neuronal injury → infarction.
Important Concepts
- Ischemic Core: Irreversibly damaged tissue
- Ischemic Penumbra: Hypoperfused but viable tissue. Main target of acute treatment
Clinical Features
- General Characteristics: Sudden onset. Focal neurological deficit. Symptoms depend on affected vascular territory
Vascular Syndromes (Vascular Pools)
A. Middle Cerebral Artery (MCA) Syndrome (Most Common)
- Contralateral: Hemiparesis (face and arm > leg). Hemisensory loss
- Additional findings: Aphasia (dominant hemisphere). Hemineglect (non-dominant hemisphere). Homonymous hemianopia
B. Anterior Cerebral Artery (ACA) Syndrome
- Contralateral: Leg weakness > arm weakness. Leg sensory loss
- Frontal lobe signs: Abulia (lack of initiative). Personality changes. Urinary incontinence
C. Posterior Cerebral Artery (PCA) Syndrome
- Findings: Contralateral homonymous hemianopia. Visual agnosia. Memory impairment. Thalamic sensory syndrome
D. Vertebrobasilar (Posterior Circulation) Syndrome
- Brainstem/Cerebellar Signs: Vertigo. Diplopia. Dysphagia. Dysarthria. Ataxia. Cranial nerve deficits
Diagnosis
- Emergency Brain CT
- First investigation: Excludes hemorrhage
- MRI: More sensitive for early ischemia
- Additional Studies: CT angiography/MR angiography. Carotid Doppler ultrasound. ECG. Echocardiography