Hypertension smoking alcohol cholesterol and drugs

Hypertension is the most common risk factor for spontaneous intracerebral hemorrhage and the frequency has been estimated to be between 70 and 80 . The causative role of hypertension is supported by the high frequency of left ventricular hypertrophy in autopsy of patients with ICH. The role of hypertension and the beneficial effect of antihypertensive treatment with regard to risk of ICH were verified in several large clinical trials. In the PROGRESS trial 21 the relative risk of ICH was...

Energy requirements of brain tissue

The energy demand of the nervous tissue is very high and therefore sufficient blood supply to the brain must be maintained consistently. A normal adult male's brain containing approx. 130 billion neurons (21.5 billion in the neocortex) 49 comprises only 2 of total body mass, yet consumes at rest approximately 20 of the body's total basal oxygen consumption supplied by 16 of the cardiac blood output. The brain's oxygen consumption is almost entirely for the oxidative metabolism of glucose, which...

Embolic stroke

Infective endocarditis (IE) is an infection of the endocardium, a thin tissue layer that lines heart valves and mural myocardium (Figure 18.1). The incidence of IE Table 18.1. Infectious causes of stroke and associated mechanisms. Table 18.1. Infectious causes of stroke and associated mechanisms. Staphylococcus aureus, Streptococcus spp., Enterococcus spp., Aspergillus spp., and others Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, and others Mycobacterium...

Clinical and neuroimaging features of cardioembolic ischemic strokes

Although cardioembolism may cause almost any clinical stroke syndrome, some features are statistically linked to this cause and are therefore characteristic (Table 2.3). However, it should be borne in mind that the positive predictive value of clinical features suggesting cardioembolism is very modest, at only about 50 20, 21 . Conversely, some clinical and neuro-imaging syndromes, such as a lacunar syndrome found on dw-MRI to be due to a single small infarct, are very unlikely to be due to...

Bilateral blindness top of the basilar artery

Top Basilar Artery Stroke

Sudden cortical blindness is a rare symptom of TIA or stroke and has been explained by an occlusion of the top of the basilar artery at the origin of the posterior cerebral arteries 11 . The visual field defects may be Figure 9.4. Blind sight. A 65-year-old patient with known Parkinson's disease and vascular risk factors (diabetes mellitus, hypertension, obesity and smoking) suddenly lost muscle tone and consciousness. On admission he was awake, responded to verbalcommands and was partially...

Hyperviscosity and low flow

Blood flow in the brain is determined by the size of blood vessels, blood pressure and hemorrheological factors ofthe blood. Abnormal changes ofblood plasma with hematological disease (e.g. Waldenstrom's macro-globulinemia or paraproteinemia), increase in cell counts (e.g. in diseases such as polycythemia vera, ery-throcytosis or hyperleukotic leukemias), and decreased red cell deformability (sickle-cell anemia, spherocytosis, hemoglobinopathies) lead to a hyperviscous state 9 . Cerebral blood...

Atrial fibrillation

Atrial fibrillation (AF) is a strong independent risk factor for ischemic stroke 120 . The prevalence of atrial fibrillation (AF) increases with age, ranging from 0.1 among persons younger than 55 years to 9 among persons older than 80 years it is almost 4 for persons older than 60 years 121 . AF is therefore primarily a risk factor in the older population. A long-term increase in AF has been projected until 2050 121 . This is not caused only by the aging population but probably also by a...

Cardioembolic sources major and minor

There are several cardiac disorders that may constitute a source of embolus, but not all sources pose equal threats. They are commonly divided by origin in the heart (atrial, valvular, ventricular) and potential for embolism (high risk versus low or uncertain risk, or major versus minor) (Table 2.2). The clinically most important cardioembolic sources are non-rheumatic atrial fibrillation (AF), infective endocarditis, prosthetic heart valve, recent myocardial infarction, dilated cardiomyopathy,...

The principle of functional and activation studies using positron emission tomography PET

The energy demand of the brain is very high and relies almost entirely on the oxidative metabolism of glucose (see Chapter 1). Mapping of neuronal activity in the brain can be primarily achieved by quantitation of the regional cerebral metabolic rate for glucose (rCMRGlc), as introduced for autoradiographic experimental studies by Sokoloff et al. 7 and adapted for positron emission tomography (PET) in humans by Reivich et al. 8 . The cerebral metabolic rate for glucose (CMRGlc) can be...

Disturbances of emotional expression control

The prevalence of crying in acute stroke patients has been estimated at between 12 and 27 , but disorders of emotional expression control are more frequent (11-40 ) and often appear delayed after stroke onset 37 . This disorder consists of uncontrollable outbursts of laughing, crying or both, with paroxysmal onset, transient duration of seconds or minutes, stereotyped, precipitated by nonspecific or inappropriate stimuli but also by appropriate stimuli in an inappropriate context. Patients...

Intracranial vasculopathies caused by virus and bacterial infection

Intracranial Infection

Varicella zoster virus (VZV) vasculopathy may often be clinically silent but may present with stroke and can be diagnosed because of the following symptoms, signs and findings (for review Nagel et al. 28 ). (1) About two-thirds of patients have a history of zoster rash, particularly ophthalmic-distribution zoster or a history of chicken pox. There is a delay between the onset of zoster chicken pox and the onset of stroke averaging 4.1 months (range between same day and 2.5 years). But about...

Stroke manifestations of systemic disease

Infective and non-infective endocarditis multi-territorial pattern of ischemic stroke Endocarditis of the heart and its valves in particular can be classified into infective and non-infective types. The vast majority of endocarditis is secondary to infections caused by bacterial (Staphylococcus aureus, coagulase-negative Staphylococcus or Enterococcus) or, rarely, fungal (Candida, Aspergillus) organisms 19 . Cerebral embolism from infected valves is the central mechanism of neurological injury...

Clinical syndromes

Clinical presentation of spontaneous ICH depends on site and size. Therefore, clinical investigation as well as neuroimaging are both important for a reliable diagnosis. All attempts to make a probabilistic diagnosis on clinical grounds alone to differentiate between ischemic and hemorrhagic stroke have not been considered satisfactory 45 . In our series of 1539 ICH cases we have located 45 in the putaminal region and in the thalamus, 34 in a lobar location, 5 in the cerebellum, about 4 in the...

Hereditary causes of stroke single gene disorders and their clinical presentation

Narp Syndrome

CADASIL (cerebral autosomal dominant arteriopa-thy with subcortical infarcts and leukoencephalo-pathy), Fabry disease and MELAS (mitochondrial encephalopathy lactic acidosis and stroke) are genetic disorders associated with their own clinical and radiological presentation. Genetic and pathological research suggests that the accumulation of the ectodomain of the NOTCH 3 protein is associated with severe ultrastructural alterations of the arteriolar wall 30 . The earliest clinical manifestation...

Coexistence of coronary heart disease and stroke

There is a frequent coexistence of coronary heart disease and stroke, most probably due to common atherosclerotic risk factors such as arterial hypertension, diabetes mellitus, smoking, and hypercholes-terolemia. A history of symptomatic coronary heart disease, either myocardial infarction or angina pec-toris, is found in up to 33 of patients with ischemic stroke 21 . An autopsy study of patients with fatal stroke found coronary plaques in 72 , coronary stenosis in 38 and myocardial infarction...

Types of acute cerebrovascular diseases

Numbers relating to the frequency of the different types of acute CVD are highly variable depending on the source of data. The most reliable numbers come from the in-hospital assessment of stroke in the Framingham study determining the frequency of complete stroke 60 were caused by athero-thrombotic brain infarction, 25.1 by cerebral emboli, 5.4 by subarachnoid hemorrhage, 8.3 by intracerebral hemorrhage and 1.2 by undefined diseases. In addition, isolated transient ischemic attacks (TIAs)...

Ischemic strokes and transient ischemic attacks caused by low cerebral flow posterior circulation

Transient Cerebral Ischemic Attacks

Rotational vertebral artery occlusion (RVAO) and stroke Rotational vertebral artery occlusion (RVAO) is caused by mechanical compression of vertebral arteries during head rotation. The vertebral artery is usually compressed at the atlantoaxial C1 -C2 level. Tendinous insertions, osteophytes or degenerative changes resulting from cervical spondylosis may be the cause of compression. Most RVAO patients exhibit an ipsilateral stenosis or vessel malformation (e.g. hypoplasia) and a contralateral...

Clinical clues to differentiate posterior from anterior circulation strokes

Important clinical symptoms and signs point to a posterior circulation stroke and should be recognized. Preceding TIAs and strokes in the days and hours before are more frequent in the posterior circulation. Similarly, headache is more frequent in the posterior circulation, is typically ipsilateral to the infarct, and may have features of primary headaches such as migraine 10 . Past diplopia, tilt of the vision, true rotatory or linear vertigo, drunken-type gait, hiccup, bilateral or crossed...

Molecular mechanisms of injury progression Figure

In the border zone of permanent focal ischemia or in the ischemic territory after transient vascular occlusion, cellular disturbances may evolve that cannot be explained by a lasting impairment of blood flow or energy metabolism. These disturbances are referred to as molecular injury, where the term molecular does not anticipate any particular injury pathway (Figure 1.8). The molecular injury cascades (Figure 1.8) are interconnected in complex ways, which makes it difficult to predict their...

Bradycardia and tachycardia

If brady- or tachycardia is observed in a stroke patient, the initial diagnostic steps are very similar and aim to assess the clinical severity and to differentiate between cardiac and non-cardiac causes. A suggested practical approach to stroke patients with brady- or tachycardia is given in Table 7.1. Brady- or tachycardia causes symptoms such as dizziness, light-headedness, spells or fainting. These symptoms may erroneously be interpreted as epileptic seizures. Thus, Holter monitoring to...

Poststroke fatigue

Another common and disabling late sequel of stroke is general fatigue 90, 91 . It is important to distinguish between normal fatigue, which is a state of general tiredness that is a result of overexertion and can be ameliorated by rest, and pathological fatigue, which is a more chronic condition, not related to previous exertion and not ameliorated by rest. Many other central and peripheral neurological conditions, beside stroke, are known to be a cause of fatigue, including multiple sclerosis,...

Psychotic disorders hallucinations and delusions

Psychotic disorders due to stroke are rare. They are classified according to the predominant symptom, with prominent hallucinations or with delusions. Delusions are of two main types delusional misiden-tification syndromes and delusional ideation. This can be observed in patients with Wernicke's aphasia and severe comprehension defect. Kumral and Ozturk 35 found that delusions started 0-3 days after stroke, and the predominant types were mixed, perse-cutory, jealousy and suspicion. Delusional...

The anterior inferior cerebellar artery AICA

The AICA vascularizes the dorsolateral inferior pons, the antero-inferior cerebellum, the cochlea, the labyrinth, and the Vlllth cranial nerve. Major variations of the extent of cerebellar supply by the three cerebel-lar arteries may make localization to the AICA difficult unless certain cranial nerve deficits are present. The classic AICA syndrome includes vertigo with vomiting and nystagmus (vestibular nuclei, vestibular nerve or labyrinthine artery), ipsilateral deafness with tinnitus...

The posterior cerebral artery PCA

The PCA is subdivided into four segments with associated clinical presentation. An occlusion of the proximal segment (P1 or precommunal) usually causes a total PCA infarction, including upper midbrain, variable parts of the thalamus and posterior hemispheric territory. Occlusions of the P2 (or postcommunal) segment before the branching of the thalamogeniculate arteries provoke ischemic lesions in the lateral thalamus and the hemispheric PCA territory. Lastly, cortical PCA branch occlusion...