SCHEMATIC PATHOPHYSIOLOGY

Predisposing Factors:

Precipitating Factors:

1) Age

1) Hypertension

2) Heredity

2) Cigarette Smoking

3) Race

3) Diabetes Meliitus

4) Sex

4) Carotid or other Artery Disease

5) Prior Stroke, TIA or heart attack

5) Atrial Fibrillation

6) Socioeconomic Factors

6) Other heart disease

7) Sickle cell disease
8) Undesirable levels of cholesterol
9) Poor diet
10) Physical inactivity
11) Obesity
12) Alcohol Abuse
13) Drug Abuse

Atherosclerosis

Formation of Plaque deposits

Thrombosis
Hypertensio
n

Occlusion by major vessel

83

If managed:
Actual:
Dx:
Cranial CT scan (6/16/08)
Capsuloganglionic bleed
Lacunar infarct,
Bilateral Internal Carotid
Ateriosclerosis
Doppler (6/16/08)
Mean flow velocities and
pulsatility index of both
anterior and posterior
circulation within normal
limits
EEG/ECG, skull x-ray,
carotid ultrasonography

If not managed

Possible:
Dx: PET scan, MRI,
cerebral angiography,
lumbar puncture,
EEG/ECG, skull x-ray,
carotid ultrasonography

Lysed or moved thrombus

from the vessel

Vascular wall becomes

weakened and fragile

TX: aspirin within 24

hrs, thrombolytics
within 3 hours, carotid
stenting, hypothermia,
anticoagulants, surgical
decompression
(hemicraniectomy),
carotid endartectomy

TX: aspirin within 24 hrs,

thrombolytics within 3
hours, carotid stenting,
hypothermia, Guarded Prognosis
anticoagulants, surgical
decompression
(hemicraniectomy), carotid
endartectomy

Leaking of blood from the

fragile vessel wall

Cerebral Hemorrhage

If managed:
Dx: CT scan, MRI, cerebral angiography,
arteriography,
lumbar puncture, skull x-ray
Tx: chronic hypertensives, surgical
decompression, evacuation and
aspiration, administration of fresh frozen
plasma with fibrinogen or cryoprecipitate
Decreased
ICP

If not managed

Sx:, headache,
unconsciousness,
nausea/vomiting,
visual
disturbances

Mass of blood forms and

grows

Hematoma evacuation
Formation of cavity surrounded by dense gliosis

84

< 30 ml
hemorrhage

30-60 ml
hemorrhage

> 60 ml
hemorrhage

Good prognosis

Intermediate
prognosis

Poor prognosis
Vasospasm of
tissue and arteries

Blood seeps into the

ventricles

Formation of small
and large clots
Sx: dizziness,
confusion,
headache

Obstruction of CSF
passageway

CEREBRAL
HYPOPERFUSION

Accumulation of CSF in
the ventricles
Ventricles dilate behind
the point of obstruction

Tissue hypoxia and

cellular starvation
Lodges unto
other cerebral
arteries

Cerebral Ischemia

Increased ICP

Initiation of ischemic
cascade

If managed:
Ventriculostomy,
VP shunt, ICP
Monitoring

If not managed

Alternative route
for return of CSF
in the circulation

Unrelieved
obstruction

Compression of
brain tissues will
not occur

Impaired distribution of
oxygen and glucose

Anaerobic metabolism by
mitochondria

Guarded
Prognosis

Generates large amounts

of lactic acid

Failure production of
adenosine triphosphatase

Metabolic Acidosis

Failure of energy dependent

process
(ion pumping)

Production of oxygen free

radicals and other reactive
oxygen species

85

Release of excitatory
neurotransmitter glutamate

Damage to the blood

vessel endothelium

Influx of calcium

Activates enzymes that

digest cell proteins, lipids
and nuclear material

Failure of
mitochondria
Further energy
depletion

Transient Ischemic Attack

If managed:
-t-PA (urokinase,
streptokinase)
-calcium channel
blockers

Guarded
Prognosis

If not managed
Brain sustains an irreversible
cerebral damage
Release of metalloprotrease
(zinc and calcium-dependent enzymes)
Break down of collagen, hyaluronic acid and
other elements of connective tissue
Structural integrity loss of brain
tissue and blood vessels
Breakdown of the protective
Blood Brain Barrier

86

Cerebral edema

Vascular Congestion

Compression of tissue

Increased intracranial
pressure

Impaired perfusion and

function

Middle
Cerebral Artery

Anterior cerebral
artery

Posterior
CerebraI Artery

Internal Carotid
Artery

Vertebrobasilar
System

Anteroinferior
Cerebellar

Posteroinferior
cerebellar

Lateral
hemisphere,
frontal, parietal
and temporal
lobes, basal
ganglia

Frontal Lobe

Occipital lobe;
anterior and
medial portion of
temporal lobe

Branches into
ophthalmic, PCA,
anterior choroidal,
ACA, MCA

Cerebellum and
brain stem

Cerebellum

Cerebellum

87

Sx:

Sx:

Sx:

Ipsilateral

Ataxia,

ataxia, facial

paralysis of the

paralysis,

larynx and soft

ipsilateral loss

palate,

of sensation in

ipsilateral loss

face, sensation

of sensation in

changes on

face,

trunk and

contralateral on

limbs,

body,

nystagmus,

nystagmus,

Horners

dysarthria,

syndrome,

Horners

tinnitus,

syndrome,

hearing loss

hiccups and

Sx:

Sx:

Sx:

Contralateral

Contralateral

Mild

contralateral

Alternating

hemiparesis or

hemiparesis,

contralateral

hemiparesis

motor

foot and leg

hemiparesis,

with facial

unilateral

deficits greater

intention

asymmetry,

ataxic gait,

neglect, altered

than the arm,

tremor, diffuse

contralateral

dysmetria,

consciousness

foot drop, gait

sensory loss,

sensory

contralateral

, homonymous

disturbances,

pupillary

alterations,

hemisensory

hemianopsia,

contralateral

dysfunction,

homonymous

impairments,

inability to turn

hemisensory

loss of

hemianopsia,

double vision,

eyes toward

alterations,

conjugate

ipsilateral

homonymous

affected side,

deviation of

gaze,

periods of

hemianopsia,

vision changes,

eyes toward

nystagmus,

blindness,

nystagmus,

dyslexia,

affected side,

loss of depth

aphasia if

conjugate

dysgraphia,

expressive

perception,

dominant

gaze,

aphasia,

aphasia,

cortical

hemisphere is

paralysis,

coughing,

agnosia,

confusion,

blindness,

involved, Mild

dysarthria,

vertigo, nausea

memory deficits,

amnesia, flat

homonymous

Horners

memory loss,

and vomiting

vomiting

affect, apathy,

hemianopsia,

syndrome,

disorientation,

shortened

perseveration,

carotid bruits

drop attacks,

attention span,

dyslexia,

tinnitus,

loss of mental

memory

hearing loss,

acuity, apraxia,

deficits, visual

vertigo,

incontinence

hallucinations

dysphagia,

hemiplegia,

Sx:

weaknesses,

coma

88

If managed:
Palliative careFrequent vital sign and
neurovital signs,
intubation, mechanical
ventilation,
vasodilators, osmotic
diuretics,
ventriculostomy, ICP
monitoring

If not managed:

Continued insufficiency of blood

flow

Further compression of tissues

Poor cerebral perfusion
Coma
Poor improvement
Cerebral Death

Poor
Prognosis
Loss of neural feedback
mechanisms

Cessation of physiologic
functions

89

Cardiovascular

Pulmonary

System

System

GUT

GIT

Other systems

Relaxation of
Loss of cardiac

Relaxation of

muscle function

venous valves

Sx:
bradycardi
a

Decreased

Sx: restlessness,
abnormal
thermoregulation,
mental confusion,
increased secretions,
decreased urinary
output.

intestines and
sphincters

Sx:
hypotensio
n

Loss of bowel

Failure of accessory

Loss of lung

muscles for breathing

movement

control
Neurogenic bladder

cardiac output

Loss of sphincter
control

Sx:
apnea

Cardiopulmonary arrest
Systemic Failure

DEATH

90