Cerebrovascular diseases

(Investigations, management & complications)

By Prem Hansheena

Stroke
Investigations Aims 1. To confirm the vascular nature of the lesion 2. Distinguish cerebral infarction from haemorrhage 3. Identify the underlying vascular disease & risk factors

Investigations
FBC with PT, APTT Neuroimaging - CT with contrast media - MRI MRI diffusion weighted imaging - others Vascular imaging Duplex ultrasound - MR angiography - CT angiography - intra-arterial contrast angiography Cardiac investigations ECG - Transthoracic/transoesophageal echocardiogram

Management
Aims of management are : Minimising the volume of brain that is irreversibly damaged Preventing complications Reducing the patients disability through rehab Reducing the risk of recurrent episodes

Managing acute stroke

Airway can protect his/her airway, swallow without evidence of aspiration,swallow screen, nil by mouth if swallowing is unsafe Breathing oxygen saturation Circulation check peripheral perfusion, pulse, BP, treat with fluid replacement, antiarrhythmics, inotropic drugs Hydration screen for signs of dehydration, fluids parenterally or by NG tube

 Nutrition - assess nutritional status & provide supplements Medication BP unless there is heart failure/renal failure, evidence of hypertensive encephalopathy or aortic dissection, DO NOT lower the BP in the 1st week since cerebral perfusion may decrease. Blood glucose check & treat with insulin when >11.1mmol/L. Monitor closely to avoid hypoglycemia. Temperature check for pyrexia, antipyrectics Pressure areas Incontinence constipation, urinary retention

Supportive care
Early admission of patients to a specialised stroke care unit Detect dysphagia allows hydration, feeding & medication to be given safely. Insertion of a ventricular drain / decompressive surgery in obstructive hydrocephalus Anti oedema agents such as mannitol or artificial ventilation & surgical decompression

Thrombolysis
IV thrombolysis with recombinant tissue plasminogen activator if given within 3 hours of symptom onset, there is improvement in overall outcome. This increases the risk of haemorrhagic transformation of the cerebral infarct and may be fatal.

Aspirin
Aspirin 300mg daily, should be started immediately after an ischemic stroke unless rtPA has been given. Reduces risk of early recurrence May be given by rectal suppository or by nasogastric tube in dysphagic patients.

Heparin
Anticoagulation Reduces the risk of early ischemic recurrence & venous thromboembolism Offset definite increase in risk of both intracranial & extracranial haemorrhage. Intracranial haemorrhage must be excluded on brain imaging before considering anticoagulation. Should not be used in routine management of acute stroke.

Carotid endarterectomy & angioplasty

Carotid endarterectomy reduces the risk of subsequent strok ein patients who have suffered a stroke in the carotid territory, when there is severe ipsilateral stenosis of the carotid artey. In asymptomatic carotid stenosis, endarterectomy has a smaller benefit.

Complications
Chest infection Epileptic seizures DVT/ pulmonary embolism Painful shoulder Pressure sores Urinary infection Constipation Depression & anxiety

Subarachnoid haemorrhage
Investigations Lumbar puncture after 12 hours of symptom onset CT Cerebral angiography

Management
Insertion of platinum coils into an aneurysm (via an endovascular procedure) Or surgical clipping of the neck of the aneurysm Arteriovenous malformations managed by surgical removal, ligation of blood vessel that feed or drain the lesion, injection of material to occlude the fistula or draining veins. Nimodipine 30-60mg IV for 5-14 days, followed by 360mg orally for a further 7 days to prevent vasospasm in the acute phase

Complications
Obstructive hydrocephalus Delayed cerebral ischaemia due to vasospasms Hyponatremia Chest infection Venous thrombosis

Thank you