CEREBROVASCULAR ACCIDENT Cerebrovascular accident (CVA, stroke or brain attack) is injury or death to parts of the brain caused by an interruption

in the blood supply to that area causing disability, such as paralysis or speech impairment. It can be divided into two major categories: ischemic (85%), in which vascular occlusion and significant hypoperfusion occur, and hemorrhagic (15%), in which there is extravasation of blood into the brain or subarachnoid space. Although there are some similarities between the two broad types of stroke, differences exist in etiology, pathophysiology, medical management, surgical management, and nursing care. The term brain attack has been promoted to highlight that time-dependent tissue damage occurs and to raise awareness of the need for rapid emergency treatment, similar to that with heart attack. TYPES Ischemic stroke An ischemic stroke, cerebrovascular accident (CVA), or brain attack is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. The term brain attack is being used to suggest to health care practitioners and the public that a stroke is an urgent health care issue similar to a heart attack. Urgency is needed on the part of the public and health care practitioners for rapid transport of the patient to a hospital for assessment and administration of the medication. Ischemic strokes are subdivided into five different types based on the cause: large artery thrombotic strokes (20%), small penetrating artery thrombotic strokes (25%), cardiogenic embolic strokes (20%), cryptogenic strokes (30%), and other (5%). Large artery thrombotic strokes are caused by atherosclerotic plaques in the large blood vessels of the brain. Thrombus formation and occlusion at the site of the atherosclerosis result in ischemia and infarction (deprivation of blood supply). Small penetrating artery thrombotic strokes affect one or more vessels and are the most common type of ischemic stroke. Small artery thrombotic strokes are also called lacunar strokes because of the cavity that is created after the death of infarcted brain tissue. Cardiogenic embolic strokes are associated with cardiac dysrhythmias, usually atrial fibrillation. Embolic strokes can also be associated with valvular heart disease and thrombi in the left ventricle. Emboli originate from the heart and circulate to the cerebral vasculature, most commonly the left middle cerebral artery, resulting

in a stroke. Embolic strokes may be prevented by the use of anticoagulation therapy in patients with atrial fibrillation. The last two classifications of ischemic strokes are cryptogenic strokes, which have no known cause, and strokes from other causes, such as illicit drug use, coagulopathies, migraine, and spontaneous dissection of the carotid or vertebral arteries. Ischemia may be transient and resolve within 24 hours, be reversible with resolution of symptoms over a period of 1 week (reversible ischemic neurological deficit [RIND]), or progress to cerebral infarction with variable effects and degrees of recovery. Hemorrhagic stroke Hemorrhagic strokes are caused by bleeding into the brain tissue, the ventricles, or the subarachnoid space. Hemorrhagic strokes are primarily caused by intracranial or subarachnoid hemorrhage. The most common predisposing factors are advancing age and hypertension. Other causes of hemorrhage are aneurysm, trauma, erosion of the vessels by tumors, arteriovenous malformations, blood coagulation disorders, vasculitis, and drugs. EPIDEMIOLOGY According to the World Health Organization, 1 in ten in the 55 million deaths that occurs every year worldwide is due to stroke and two-thirds of which occur in people living among developing countries. Strokes are much more common among older people than among younger adults, usually because the disorders that lead to strokes progress over time. Over two thirds of all strokes occur in people older than 65. Slightly more than 50% of all strokes occur in men, but more than 60% of deaths due to stroke occur in women, possibly because women are on average older when the stroke occurs. According to the latest WHO data published in April 2011 Stroke Deaths in Philippines reached 40,245 or 9.55% of total deaths. The age adjusted Death Rate is 82.77 per 100,000 of population ranks Philippines #106 in the world. RISK FACTORS Among the major risk factors for stroke are age (65-74 years old), sex (male: 19% greater risk), race (African Americans: 60% greater risk), family history, hypertension, smoking, diabetes mellitus, asymptomatic carotid stenosis, sickle cell disease, hyperlipidemia, and atrial fibrillation. Other less well-documented risk factors include obesity, physical inactivity, alcohol and drug abuse, hypercoagulability disorders, hormone replacement therapy, and oral contraceptive use.

CLINICAL MANIFESTATIONS Ischemic Stroke An ischemic stroke can cause a wide variety of neurologic deficits, depending on the location of the lesion (which vessels are obstructed), the size of the area of inadequate perfusion, and the amount of collateral (secondary or accessory) blood flow. The patient may present with any of the following signs or symptoms:

COMPARISON OF LEFT HEMISPHERIC STROKES Left Stroke Hemispheric Right Stroke

AND

RIGHT

Hemispheric

Paralysis or weakness on right side of the body Right visual field deficit Aphasia (expressive, receptive or global) Altered ability intellectual

Paralysis or weakness on left side of the body Left visual field deficit Spatial-perceptual deficits Increased distractibility Impulsive behavior and poor judgment Lack of awareness of deficits

Numbness or weakness of the face, arm, or leg, especially on one side of the body Confusion or change in mental status Trouble speaking or understanding speech Visual disturbances Difficulty walking, dizziness, or loss of balance or coordination Sudden severe headache

Slow cautious behavior

Other symptoms that may be observed more frequently in patients with acute intracerebral hemorrhage (compared with ischemic stroke) are vomiting, an early sudden change in level of consciousness, and possibly focal seizures due to frequent brain stem involvement. In addition to the neurologic deficits (similar to those of ischemic stroke), the patient with an intracranial aneurysm or AVM may have some unique clinical manifestations. Rupture of an aneurysm or AVM usually produces a sudden, unusually severe headache and often loss of consciousness for a variable period of time. There may be pain and rigidity of the back of the neck (nuchal rigidity) and spine due to meningeal irritation. Visual disturbances (visual loss, diplopia, ptosis) occur if the aneurysm is adjacent to the oculomotor nerve. Tinnitus, dizziness, and hemiparesis may also occur.

Motor, sensory, cranial nerve, cognitive, and other functions may be disrupted. Hemorrhagic Stroke The patient with a hemorrhagic stroke can present with a wide variety of neurologic deficits, similar to the patient with ischemic stroke. The conscious patient most commonly reports a severe headache. A comprehensive assessment reveals the extent of the neurologic deficits. Many of the same motor, sensory, cranial nerve, cognitive, and other functions that are disrupted after ischemic stroke are also altered after a hemorrhagic stroke.

Cardioembolic stroke is occlusion of cerebral vessels with debris from a cardiac source. An embolus may consist of platelet aggregates, thrombus, platelet-thrombi, cholesterol, calcium, bacteria, etc. Most embolic debris contains platelet aggregates. However, no single mechanism is responsible for the development of cardiac emboli. The specific underlying cardiac disease determines the pathophysiology and natural history, and hence each cardioembolic source must be considered individually. Emboli secondary to chamber abnormalities (eg, atrial fibrillation, acute myocardial infarction) are induced mainly by stasis, whereas those secondary to valve involvement are the result of endothelial abnormalities with attachment of material (eg, platelets, bacteria) to their free borders. The nature of the embolus differs depending on the source (eg, calcified

particles from calcific valves, neoplastic cells from myxomas). This must be considered when choosing specific therapies; no single treatment covers the wide variety of heart disease that can cause embolism to the brain. Emboli from the heart are distributed evenly throughout the body according to cardiac output, but more than 80% of symptomatic or clinically recognized emboli involve the brain. Of emboli to the brain, approximately 80% involve the anterior circulation (ie, carotid artery territory), whereas 20% involve the vertebrobasilar distribution, proportional to the distribution of cerebral blood flow. Once emboli have reached the cerebral circulation, they obstruct brain-supplying arteries, causing ischemia to the neurons and to the blood vessels within the area of ischemia. In contrast to

thrombi, emboli are attached loosely to the vascular walls and thus commonly migrate distally. When this occurs, reperfusion of the damaged capillaries and arterioles allows blood to leak into the surrounding infarcted tissue. This explains the more frequent association of hemorrhagic infarction with cardiogenic embolism than with other causes of ischemic stroke. In the great majority of patients with hemorrhagic infarcts, the hemorrhagic transformation does not cause clinical worsening because the bleeding involves necrotic tissue. Approximately 20% of ischemic strokes are considered cardioembolic. The annual incidence is estimated at approximately 146,000 cases. In the United States, atrial fibrillation represents the most common cause of cardioembolic stroke and is a major cause of stroke in the elderly. Worldwide, the estimated frequency of cardioembolic strokes varies from 12-31% of ischemic strokes, depending on the criteria applied for definition, extent of the evaluation. The risk of a cardioembolic event rises with age. The older the cohort, the higher the estimated frequency of cardioembolic stroke because of the rapidly increasing prevalence of atrial fibrillation in elderly persons. Elderly women are particularly affected, whereas black and Hispanic individuals reportedly have a lower frequency of cardioembolic strokes than white persons, reflecting the respective prevalence of atrial fibrillation among these groups. Stroke will soon be the most common cause of death worldwide. Stroke is the third leading cause of death in the Western world, after heart disease and cancer], and causes 10% of world-wide deaths. The incidence of stroke increases exponentially from 30 years of age, and etiology varies by age. Hemorrhagic transformation is a complication of ischemic stroke; it occurs in about 10% of patients. The spectrum of hemorrhagic transformation ranges from minor petechial bleeding (hemorrhagic infarct) to major mass-producing hemorrhage (parenchimal hemoatoma). Historically, hemorrhagic infarction, initially designated as "red softening," has long been recognized by neuropathologists to occur as a natural consequence of ischemic brain injury. Several early theories were advanced to explain the pathogenesis of secondary bleeding into a bland (pale, anemic) infarction. Hemorrhagic infarction resulted from the embolic occlusion of end arteries followed by venous reflux into damaged vascular beds. tThe retrograde filling and the distension with blood of the venous and capillary void distal to the plug and the subsequent diapedesis of red corpuscles through the vessel wall, damaged secondarily by the loss of their normal blood supply. Hemorrhagic changes may occur early, often within 2 days, following embolic infarction. Potential importance of collateral circulation in the genesis of secondary bleeding occurs.