Cerebrovascular disease

A cerebrovascular disease is a vascular disease of the cerebral circulation. Arteries supplying

oxygen to the brain are affected resulting in one of a number of cerebrovascular diseases.[1] Most
commonly this is a stroke or mini-stroke and sometimes can be a hemorrhagic stroke.[1] Any of these
can result in vascular dementia.[2]
Hypertension (high blood pressure) is the most important contributing cause because it damages
the blood vessel liningexposing collagen where platelets aggregate to initiate a repair. If maintained
hypertension can change the structure of blood vessels (narrow, deformed). [3]
Blood pressure affects blood flow in narrowed vessels causing ischemic stroke, a rise in blood
pressure can cause tearing of vessels leading to intracranial hemorrhage. [4]
A stroke usually presents with an abrupt onset of a neurologic deficit, attributable to a focal vascular
lesion.[5] The neurologic symptoms manifest within seconds because neurons lack glycogen, so
energy failure is rapid.[6]

Types of stroke

Ischemic stroke,the most common is caused by a blockage of a blood vessel in the brain,
usually caused by thrombosis or emboli from a proximal arterial source or the heart, that leads
to the brain being starved of oxygen.[7] The neurologic signs and symptoms must last longer than
24 hours or the brain infarction is demonstrated, mainly by imaging techniques. [8]

Transient ischemic attack (TIA) also called a mini-stroke. This is a condition in which the
blood flow is quickly restored and the brain tissue can fully recover and the symptoms are only
transient, leaving no sequelae.[9] In order to diagnose this entity all neurologic signs and
symptoms must have been resolved within 24 hrs without evidence of brain infarction on brain
imaging.[10]

Subarachnoid haemorrhage where blood leaks out of blood vessels directly into or around
the brain.[1] The neurologic symptoms are produced by the blood mass effect on neural
structures, from the toxic effects of blood on the brain tissue, or by the increasing of intracranial
pressure.[11]

Causes[
Causes of cerebrovascular disease can be divided into: atherosclerosis, embolism, aneurysms, low
flow states, and other rare causes.[12] Major modifiable risk factors include:[13]

Hypertension

Smoking

Obesity

Diabetes.

Pathophysiology

Once a reduction in blood flow occurs, that lasts seconds the brain tissue suffers ischemia.[14][15] If the
interruption of blood flow is not restored in minutes, the tissue suffers infarction followed by tissue
death.[16] When the low cerebral blood flow persists for a longer duration, this may develop into an
infarction in the border zones (areas of poor blood flow between the major cerebral artery
distributions). In more severe instances, global hypoxia-ischemia causes widespread brain injury
leading to a severe cognitive sequelae called hypoxic-ischemic encephalopathy.[17]
Strokes can also result from embolisms, furthermore, embolisms block small arteries, causing
damage to occur.[4] Spontaneous rupture of a blood vessel in the brain causes a hemorrhagic stroke.
[18]
Another form of cerebrovascular disease includes aneurysms. Cerebral aneurysms can be
genetic in nature, due to a wall deformity of the artery. Such aneurysms are common in individuals
with genetic diseases ( connective tissue disorders, polycystic kidney disease, and arteriovenous
malformations).[19]

Brain infarct
The carotid arteries cover the majority of the cerebrum. The common carotid artery divides into the
internal and the external carotid arteries. The internal carotid artery becomes the anterior cerebral
artery and the middle central artery. The ACA transmits blood to the frontal parietal. From the basilar
artery are two posterior cerebral arteries. Branches of the basilar and PCA supply the occipital lobe,
brain stem, and the cerebellum.[20] Ischemia is the loss of blood flow to the focal region of the brain.
This produces heterogeneous areas of ischemia at the affected vascular region, furthermore blood
flow is limited to a residual flow. Regions with blood flow of less than 10 mL/100 g of tissue/min are
core regions (cells here die within minutes of a stroke).The ischemic penumbra with a blood flow of
<25 ml/100g tissue/min, remain usable for more time (hours). [21]
An ischemic cascade occurs where an energetic molecular problem arises. ATP consumption
continues in spite of insufficient production, this causes total levels of adenosine triphosphate to
decrease and lactate acidosis to become established (ionic homeostasis in neurons is lost). The
downstream mechanisms of the ischemic cascade thus begins. Ion pumps no longer transport
Ca2+ out of cell, this triggers release of glutamate, which in turn allows calcium into cell walls. In the
end the apoptosis pathway is initiated and cell death occurs.[22]

Evaluation[
Diagnosis of cerebrovascular disease is done by (among other diagnoses): [23]

clinical history

physical exam

neurological examination.

It is important to differentiate the symptoms caused by a stroke from those caused

by syncope (fainting) which is also a reduction in cerebral blood flow, almost always generalized, but
they are usually caused by systemic hypotension of various origins: cardiac arrhythmias, myocardial
infarction, hemorrhagic shock, among others.[24]

Treatment
Treatment for cerebrovascular disease includes medication, lifestyle changes and surgery.[4]
Examples of medications are:

antiplatelets (aspirin, clopidogrel)

blood thinners (heparin, warfarin)

antihypertensives (ACE inhibitors, beta blockers)

anti-diabetic medications.

Surgical procedures include:

endovascular surgery and vascular surgery (for future stroke prevention).

Source: www.wikipedia.org