A cerebrovascular accident or CVA is also known as stroke is when part of the brain loses its blood supply and the part of the body part that the blood-deprived brain cells control stops working. This loss of blood supply can be ischemic because of lack of blood flow, or hemorrhagic because of bleeding into brain tissue. A cerebrovascular accident is an emergency because strokes can lead to death or permanent disability. There are opportunities to treat ischemic strokes but that treatment needs to be started in the first few hours after the signs of a stroke begin.
- Cerebral thrombosis- there is a formation or development of a blood clot or thrombus within the cerebral arteries or their branches.
- Cerebral embolism- there are traveling bits of matter (thrombi, tissue, fat, air and bacteria) that produce occlusion and infarction in the cerebral arteries.
- Cerebral hemorrhage- there is abnormal bleeding as a result of the rupture of blood vessels (extradural, subdural, subarachnoid, and intracerebral).
- Cardiac disease (rheumatic valvular disease, endocarditis, arrhythmias, and cardiac surgery).
- Diabetes, metabolic syndrome.
- Transient ischemic attacks.
- Paralysis, one side of the body, or sometimes both lower limbs, presentation is depending on the artery of involvement.
- Numbness or weakness in the arm, face, and leg, especially on one side of the body
- Difficulty in speaking or understanding speech
- Some sort of confusion
- Vision problems, such as trouble seeing in one or both eyes with blurred or double vision. This commonly happens in case of damage to the occipital region.
- Difficulty in standing and walking
- Loss of coordination and balance
- Severe and sudden headache with unknown cause
Neurological clinical syndrome. Characteristic signs and symptoms associated with occlusion of specific cerebral vessels.
- Internal carotid artery (ICA) syndrome: ICA arises off an ophthalmic branch, and terminates in the anterior cerebral artery (ACA) and middle cerebral artery (MCA); occlusions commonly produce signs and symptoms of MCA involvement with a reduced level of consciousness; ACA may also be affected; lesions involving MCA and ACA distributions may produce massive edema, brain herniation, and death.
- ACA syndrome: ACA supplies anterior two-thirds of the medial cerebral cortex; occlusions produce contralateral sensory loss and hemiparesis, with the leg more involved than the arm. Occlusions proximal to the anterior communicating artery produce minimal deficits due to contralateral circulation (Circle of Willis).
- MCA syndrome: MCA supplies lateral cerebral cortex, basal ganglia, and large portions of the internal capsule; occlusions produce contralateral sensory loss and hemiparesis, with arm involved more than leg; may also produce motor speech dysfunction (Broca’s area); perceptual dysfunction (parietal sensory association cortex); homonymous hemianopsia (optic radiation, internal capsule); loss of conjugate gaze to the opposite side (frontal eye fields); sensory ataxia (parietal lobe).
- Vertebrobasilar artery syndrome: two vertebral arteries arise off the subclavian arteries and supply the ventral surface of the medulla and the posterior inferior aspect of the cerebellum before joining to form the basilar artery at the junction of the pones and the medulla; the basilar artery supplies the ventral portion of the pones and terminates in the posterior cerebral artery (PCA). Numerous syndromes may occur.
- Medial medullary syndrome (vertebral artery occlusion or branch of a lower basilar artery): produces ipsilateral paralysis of the tongue, contralateral paralysis of arm and leg with impaired sensation.
- Lateral medullary syndrome (vertebral, posterior inferior cerebellar, or basilar artery occlusion): produces ipsilateral cerebellar symptoms (ataxia, vertigo, nausea, vomiting, and nystagmus), Horner’s syndrome (miosis, ptosis, decreased sweating); dysphagia, impaired speech diminished gag reflex; sensory loss of an ipsilateral arm, trunk or leg; contralateral loss of pain and temperature of half of the body, sometimes face.
- Basilar artery syndrome: produces brainstem signs and symptoms and PCA signs and symptoms; locked-in syndrome (basilar artery occlusion at the level of the pons): occlusion produces quadriplegia and bulbar paralysis; anarthria with preserved consciousness, the patient is unable to move or speak, but has a full cognitive function; often fatal. The sensation may be intact.
- Medial inferior pontine syndrome (occlusion of an anterior inferior cerebellar artery): it produces 2 types of symptoms one is ipsilateral signs and symptoms for example cerebellar ataxia and nystagmus, paralysis of conjugate gaze (to the side of the lesion), deafness, diplopia. Contralateral signs and symptoms for example hemiparesis and impaired sensation.
- PCA syndrome: PCA and posterior communicating arteries supply the midbrain, temporal lobe, diencephalon, and posterior third of the cortex; occlusions may produce homonymous hemianopsia, contralateral sensory loss, thalamic syndrome, voluntary movements, transient contralateral hemiparesis, Weber’s syndrome, and visual symptoms (paralysis, of vertical eye movements, miosis, ptosis, decreased pupillary light reflex); occlusions proximal to posterior communicating artery produce minimal deficits owing to collateral circulation.
- Generalized signs of increased intracranial pressure
- Level of consciousness, cognitive function.
- Speech and communication.
- Examine for aphasia with lesions of parieto-occipital cortex of the dominant hemisphere (typically left hemisphere).
- Examine for perceptual deficits with lesions of the parietal lobe of the non-dominant hemisphere (typically right hemisphere).
- Patients with lesions of the left hemisphere (right hemiplegia) are slow, cautious, hesitant, and insecure
- Patients with lesions of the right hemisphere (left hemiplegia) are impulsive, quick, indifferent; often exhibit poor judgment and safety, overestimating their abilities, while underestimating their problems.
- Sensory deficits
- Superficial, proprioceptive, and combined sensations of contralateral extremities, trunk, and face.
- Hearing, vision; examine for homonymous hemianopsia.
- Cranial nerve function with the brainstem, vertebrobasilar strokes.
- Motor function
- Presence of abdominal tone and primitive reflexes
- Loss of selective movements
- Presence of paresis; incoordination, motor programming deficits (apraxia)
- Postural and balance deficits.
Check for the gait patterns.
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