CEREBROVASCULAR DISORDERS

Carotid Stenosis >>

Carotid artery stenosis, or carotid artery disease, is a narrowing of one or both of the two
major arteries that run up the neck and carry a large blood supply to the brain. The narrowing
is caused by a build-up of plaque on the inside lining of the blood vessel. Plaque build-up
(atherosclerosis) is caused when cholesterol, fat and other substances collect in the artery,
thereby decreasing the amount of blood flow. When blood flow is decreased, a transient
ischemic attack (TIA) or ischemic stroke can occur.
Signs and symptoms of carotid stenosis include:

past history of ischemic stroke

weakness, numbness or tingling in the face, arm or leg

vision changes

slurred speech

drooping face

Testing for carotid stenosis includes a doppler ultrasound of the neck, computed tomography
angiogram (CTA) scan of the neck, or magnetic resonance angiography (MRA).
The doppler ultrasound is a noninvasive test that reveals the carotid arteries, the amount of
blood flowing through them, and how much blockage is present.
A CTA is a noninvasive test that uses contrast dye to illuminate the vessels of the neck. It can
also be used to visualize the narrowed artery and to measure the extent to which an artery has
narrowed.
An MRA of the neck is similar to the CTA. It uses contrast dye injected through an IV to
illuminate the vessels in the neck.
How carotid stenosis is treated will depend on the extent of arterial blockage, the patients
symptoms, and his or her medical history. Depending on the severity, carotid stenosis can be
treated medically or surgically.
Medical treatment is suitable for patients who have a low percentage of stenosis (below 70
percent), are asymptomatic (without symptoms), or have medical conditions that increase the
risk of a surgical procedure.
Medical treatment for carotid stenosis consists of antiplatelet therapy with aspirin as
prescribed by a physician. Aspirin is a blood-thinning, antiplatelet medication that prevents
clotting in the narrowed arteries and allows blood to pass more easily. The major side effect

to aspirin therapy is increased risk of bleeding. Therefore, care should be taken to prevent
injury.
If aspirin therapy is not well tolerated, another antiplatelet drug, such as ticlopidine or
clopidogrel, may be used.
Additional medical therapies include regular blood pressure screenings and blood pressure
lowering medications, smoking cessation, cholesterol monitoring and cholesterol-lowering
medications, and limited alcohol consumption.
Carotid artery bypass is a surgical procedure that reroutes the blood supply around the
plaque-blocked area. A length of artery or vein is harvested from somewhere else in the body,
usually the saphenous vein in the leg or the ulnar or radial arteries in the arm. The vessel graft
is connected above and below the blockage so that blood flow is rerouted (bypassed) through
the graft. A bypass is typically used only when the carotid is 100 percent blocked. A complete
blockage is also known as carotid occlusion.
Carotid endarterectomy is a surgical procedure that removes the plaque build-up from the
inner lining of the carotid artery. This procedure improves blood flow through the artery into
the brain and prevents future ischemic strokes. A carotid endarterectomy is typically indicated
for patients who are symptomatic (have experienced a previous ischemic stoke or TIA) and
have greater than 70 percent vessel stenosis. Surgery reduces the five-year risk of stroke by
6.5 percent for patients with 50 to 69 percent stenosis, compared to an 80 percent risk
reduction for patients with greater than 70 percent stenosis. Patients with 50 percent stenosis
or lower do not show enough benefit from endarterectomy to outweigh the risks of the
procedure.
Cartoid endarterectomy requires general anesthesia. An incision is made in the neck, and
tissues are retracted until the carotid artery is visualized. The artery is clamped above and
below the area of stenosis. The artery is opened, the plaque is removed, and the artery is
closed again.
After a carotid endarterectomy it is extremely important to monitor blood pressure and take
medications as directed. It is equally important to quit smoking, limit alcohol consumption
and check cholesterol levels regularly.
Carotid angioplasty is an endovascular procedure performed by a neuro-radiologist during an
angiogram of the affected carotid vessel. The procedure takes place in the interventional
radiology suite.
During the cerebral angiogram, a catheter is inserted in the groin and threaded up to the
carotid vessels. A special catheter with a balloon surrounding the outside is used. The balloon
is inflated over the plaque, compressing the plaque down and creating a larger diameter for
increased blood flow to the brain. A stent is placed over the plaque to keep the plaque
compressed and the vessel opened.

This treatment for carotid stenosis is typically indicated for symptomatic patients who are 75
or older, are at increased risk for general anesthesia and surgery, have recurrent stenosis, or
have stenosis caused by previous radiation therapy.
Prior to a carotid angioplasty, certain medications (such as aspirin) are administered at least
two days prior to the procedure and on the day of the procedure. Plavix is also administered
the day of the procedure.
These medications are blood-thinning antiplatelet agents that protect against stroke during the
procedure and maintain free-flowing blood over the stent. Long-term antiplatelet therapy is
necessary, and patients receiving this endovascular treatment will be discharged home on
these medications

Arterivenous Malformations

An AVM is an abnormal tangle of blood vessels in the brain or spine. Some AVMs have no
specific symptoms and pose little or no risk to a persons life or overall health, while others
cause severe and devastating effects if they bleed and result in an intracerebral hemorrhage
(ICH).
Normally, large arteries carry blood from the heart to all areas of the body. As arteries branch,
they become smaller, eventually becoming capillaries. The capillary bed is where the blood
exchanges oxygen and nutrients and picks up waste. The blood travels from the capillary bed
back to the heart through veins. In an AVM, arteries connect directly to veins without a
capillary bed in between, creating a condition known as a high-pressure shunt or fistula.
Because the veins cannot handle the pressure of blood coming directly from the arteries, they
stretch and enlarge and the weakened blood vessels can rupture and bleed. The surrounding
normal tissues also may be damaged as the AVM steals blood from those areas.
Arteriovenous Malformations (AVM)
Signs and symptoms of an AVM vary depending on its location in brain. Stroke-like
symptoms such as confusion, loss of consciousness, headache, vision changes,
numbness/tingling sensation in arm or leg, slurred or garbled speech and/or facial droop are
common if the AVM results in an ICH. Sudden onset of seizures is another common symptom
of brain AVMs whereas spinal AVMs can cause severe sudden back pain, weakness or
paralysis in the arms or legs.
AVM treatment options include surgical removal, radiosurgery and/or endovascular
treatments. Often, multiple treatments are utilized to fully cure the AVM.
In some cases, a surgical opening is made in the skull (craniotomy) so the brain can be gently
retracted to locate the AVM. Using a variety of techniques such as laser and electrocautery,
the AVM is shrunken and dissected from normal brain tissue.

In endovascular treatment, small catheters are inserted through the groin and threaded up into
the blood vessels of the brain to deliver materials to occlude the abnormal vessels of the AVM
in a process called embolization. The materials allow for blood to no longer flows through the
malformation thus decreasing the likelihood of rupture and bleeding into the brain. These
procedures are performed in the angiography suites of the Radiology Department by a Neuro
Interventionalist. Many times a patient may undergo embolization of their AVM prior to
surgery in an effort to assist the surgeon to safely remove the abnormal vessels.
Radiosurgery aims a precisely focused beam of radiation at the abnormal vessels. After six
months to two years, the vessels gradually close off and are replaced by scar tissue. This
treatment is best suited for smaller AVMs and may take a long time to show effect (during
which time risk of hemorrhage exists). However, radiosurgery is a quick, painless, noninvasive out-patient procedure that requires no incision.
A cavernous malformation, also called cavernous hemangioma, is a cluster of abnormal blood
vessels. Viewed under a microscope, a cavernous malformation appears to be a blood-filled
cavern in the brain. These blood vessel malformations can also occur in brain stem, the spinal
cord, the covering of the brain (dura), or the nerves of the skull. The lesion may be compact,
and there is typically no brain tissue located within its walls. Cavernomas can cause small
hemorrhages or leaks within the enclosed cluster of vessels. Typically this blood does not
leak out into the rest of the brain tissue. Frequently patients diagnosed with a cavernoma will
have multiple cavernomas in various places in the brain.
Cavernomas are usually detected when the cavernoma bleeds, leading to signs and symptoms
such as: headaches, seizures, and other neurological deficits like vision changes, weakness in
an arm or leg, or changes in speech. Many times patients will describe multiple episodes of
headaches that will go away and then come back. These headaches occur in response to
leakage of blood or multiple small bleeds from the cavernoma.
Cavernoma treatment includes observation, surgical excision, or stereotactic radiosurgery.
If the cavernoma is surgically accessible and the patient is experiencing neurological
symptoms and/or seizures, surgical treatment is an option. Current microsurgical techniques
involve specialized approaches and sophisticated intra-operative neurological monitoring.
If a cavernoma is located in the brain stem, the patient will need specialized monitoring in the
operating room and possible placement of an external pacemaker to control vital functions
such as heart rate and breathing, since many of those functions are located in the brainstem.
Stereotactic radiosurgery treatment for symptomatic brainstem cavernomas may be used if
the risk of surgery is high or when lesions are surgically inaccessible.

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Hemorrhagic Stroke
Hemorrhagic strokes are caused by the breakage or blowout of a blood vessel in the brain,
as known as a hemorrhage. Hemorrhages can be caused by a number of disorders that affect
the blood vessels, including; long-standing high blood pressure, arteriovenous malformations,
and cerebral aneurysms. There are two types of hemorrhagic stroke: intracerebral and
subarachnoid.
In an ICH, bleeding occurs from the tiny arteries, or vessels, deep within the brain itself.
Common causes of ICH include hypertension (high blood pressure) and blood-thinning
medications, that can cause these thin-walled arteries to rupture and release blood into the
brain tissue. As the blood collects and forms a clot, or hematoma, it can grow and put
pressure on surrounding brain tissue. As blood spills into the brain, the area of the brain that
artery supplied is now deprived of oxygen blood, resulting in a stroke. As blood cells within
the clot die, toxins are released that further damage brain cells in the area surrounding the
hematoma.
Signs and symptoms of an ICH include: confusion, loss of consciousness, headache, vision
changes, numbness/tingling sensation in arm or leg, slurred or garbled speech and/or facial
droop.
When diagnosing a stroke, physicians work quickly to acquire a complete medical history.
This includes the patients symptoms, current and previous medical problems, medications
the patient is currently taking, and family history. A physical exam also is conducted.
To help determine the source and location of bleeding, physicians rely on diagnostic tests
such as computed tomography (CT) and computed tomography angiography (CTA). Both of
these scans are noninvasive X-rays that enable physicians to review the anatomical structures
within the brain to determine whether or not blood is present. The CT scan is a rapid and easy
way to determine the location, size, and pattern of the blood as well as any compression of
the surrounding brain tissue. The CTA scan is specifically designed to look at the blood
vessels within the brain and helps determine if the ICH was caused by a vascular
malformation.
A magnetic resonance imaging (MRI) scan, another noninvasive test, uses a magnetic field
and radio-frequency waves to give a detailed view of the soft tissues of your brain. Much like
the CTA, a magnetic resonance angiogram (MRA) provides visualization of the blood vessels
and structures of the brain.
An angiogram is an invasive procedure in which a catheter is inserted into an artery and
passed through the blood vessels to the brain. Once the catheter is in place, a contrast dye is
injected into the bloodstream to illuminate the blood vessels.

Depending on the size, location and the cause of bleeding, ICHs can be managed either
surgically or medically.
The goal of surgery is to remove as much of the blood clot as possible and stop the source of
bleeding if it is from an identifiable cause such as an AVM, aneurysm, or tumor. Depending
of the location of the clot either a craniotomy or a stereotactic aspiration may be performed.
Craniotomy involves cutting a hole in the skull with a drill to expose the brain and remove
the clot. Because of the increased risk to the brain, this technique is usually used only when
the hematoma is close to the surface of the brain or if it is associated with an AVM or tumor
that must be removed.
Stereotactic Aspiration is a less invasive technique preferred for large hematomas located
deep inside the brain. The procedure requires attaching a stereotactic frame to the head with
four pins. A small metal cage is placed over the frame. Next, a CT scan is obtained to help the
surgeon pinpoint the exact coordinates of the hematoma. Then the surgeon drills a small hole
about the size of a quarter in the skull. With the aid of the stereotactic frame, a hollow needle
is passed through the hole, through the brain tissue, directly into the clot. The hollow needle
is attached to a large syringe, which the surgeon uses to suction out as much of the clot as
possible.
Initial monitoring and management of patient with an ICH will typically occur in the neurointensive care unit. This alloss for close and careful observation of blood pressure control,
seizure activity, blood sugar, vital signs, and respiratory status.
An ICH causes brain tissue damage, compression on surrounding structures, and a shift in the
brain matter. These can all cause an increase in the intracranial pressure (ICP) or pressure
inside the brain. Increased ICP will cause worsening of the neurological exam and
compromise of the respiratory system. Frequent neurological and respiratory assessments will
be preformed in the ICU. Respiratory assistance via a breathing tube and ventilator may be
required to support oxygenation.
Medical management for an ICH begins with blood pressure control to help prevent rebleeding and expansion of the ICH. Blood pressure is typically kept <160/90 using
intravenous and oral anti-hypertensive medications. Precautions are taken to prevent very low
blood pressures, hypotension, which may lower blood flow to the brain. Achieving long-term
blood pressure control may require the patient to be discharged on a new blood pressure
medication or regimen. Follow-up with an internal medicine or primary care provider is
important in maintaining good blood pressure control and helps to prevent future ICH.
A potential complication of an ICH is seizure activity. In the intensive care unit, the patient
will be closely monitored for seizures and often times a short course of preventative antiseizure medications will be administered.
High blood sugars can be seen in the diabetic and non-diabetic patients. While hospitalized,
blood sugar will be monitored and treated with insulin therapy.

Pain is managed with oral or intravenous medications to promote comfort and healing.
To promote healing, proper nutrition is begun early during the patients hospital stay to
Depending on the size and location of the ICH, some patients may not be alert enough to eat
or unable to chew and swallow food safely. Speech therapists assess the ability to swallow
and take in adequate nutrition. Stomach feeding tubes can be used for patients who are unable
to eat on their own, and nasal feeding tubes can be used a short-term alternative. If long-term
feeding is required, a percutaneous endoscopic gastrostomy tube (PEG tube) can also be
used.
When the patients condition is medically stable, early mobilization with therapy will be
initiated to prepare for long term needs once discharged from the hospital