Neurosurgery: Cerebrovascular Accident (CVA)

Cerebrovascular Accident (CVA/Stroke)

Definitions

  • Transient Ischemic Attach (TIA)
    • Acute Symptomatic Neurologic Dysfunction of Vascular Etiology
    • *Classic Definition: Lasting Less Than 24 Hours
    • *Newer Definition: Neurologic Deficit Due to Ischemia without Acute Infarction (No Associated Time Limit)
  • Cerebrovascular Accident (CVA/Stroke)
    • Acute Symptomatic Neurologic Dysfunction of Vascular Etiology
    • Lasting More Than 24 Hours

Background

  • TIA Risk for CVA in 48 Hours: 4-10%
  • Often Takes 2 Weeks to Determine the Full Clinical Effects
    • Ischemic Tissue Recovers or Expires
  • Incidence is Declining with Improved Medical Therapy
    • 5th Most Common Cause of Death – Previously Third

Types/Causes

  • Ischemic Stroke – Most Common in US (87%)
    • Embolus (Most Common)
      • Sources: ICA #1 & Heart #2
    • Thrombosis
  • Hemorrhagic Stroke
    • Intracerebral Hemorrhage
    • Subarachnoid Hemorrhage (SAH)

Risk Factors

  • Hypertension – #1 Risk Factor
  • Tobacco
  • Obesity
  • Poor Diet
  • Lack of Physical Activity
  • Male Sex
  • Elderly
  • Black/Hispanic Race
  • Atrial Fibrillation
  • Hypercholesterolemia
  • Diabetes

Aphasia

  • Wernicke’s Area
    • Effects: Comprehension
    • Site: Left Temporal Lobe
  • Broca’s Area
    • Effects: Speech
    • Site: Left Posterior Frontal Lobe

Acute Stroke Treatment

  • Tx: Primarily Medical
  • Consider Alteplase (tPA) for Acute Ischemic Stroke in Adults with Symptom Onset < 4.5 Hours
    • Exclusion Criteria:
      • Intracranial Hemorrhage or Question of SAH
      • History of Intracranial Hemorrhage
      • Neurosurgery or Head Trauma in Last 3 Months
      • Active Internal Bleeding
      • GI Bleeding in Last 3 Weeks
      • Acute Bleeding Diathesis
        • Plt < 100,000
        • INR > 1.7
        • Current Use of Direct Thrombin Inhibitors
        • Current Use of Direct Factor Xa Inhibitors
        • Therapeutic Dosing of Lovenox
      • Uncontrolled HTN (SBP > 185 or DBP > 110)
      • Infective Endocarditis
      • Brain Tumor
  • Role of Surgical/Endovascular Mechanical Thrombectomy is Evolving
  • Long-Term Interventions: Aspirin, Statin & Blood Pressure Control