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As discussed below, the term stroke is applied to a sudden focal neurologic syndrome, speci cally the type due to cerebrovascular disease The term cerebrovascular disease designates any abnormality of the brain resulting from a pathologic process of the blood vessels Pathologic process is given an inclusive meaning namely, occlusion of the lumen by embolus or thrombus, rupture of a vessel, an altered permeability of the vessel wall, or increased viscosity or other change in the quality of the blood owing through the cerebral vessels The vascular pathologic process may be considered not only in its grosser aspects embolism, thrombosis, dissection, or rupture of a vessel but also in terms of the more basic or primary disorder, ie, atherosclerosis, hypertensive arteriosclerotic change, arteritis, aneurysmal dilation, and developmental malformation Equal importance attaches to the secondary parenchymal changes in the brain resulting from the vascular lesion These are of two main types ischemia, with or without infarction, and hemorrhage and unless one or the other occurs, the vascular lesion usually remains silent The only exceptions to this statement are the local pressure effects of an aneurysm, vascular headache (migraine, hypertension, temporal arteritis), multiple small vessel disease with progressive encephalopathy (as in malignant hypertension or cerebral arteritis), and increased intracranial pressure (as occurs in hypertensive encephalopathy and venous sinus thrombosis) Also, persistent acute hypotension may cause ischemic necrosis in regions of brain between the vascular territories of cortical vessels, even without vascular occlusion The many types of cerebrovascular diseases are listed in Table 34-1, and the predominant types during each period of life, in Table 34-2 660
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Incidence of Cerebrovascular Diseases
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Stroke, after heart disease and cancer, is the third most common cause of death in the United States Every year there are in this
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Copyright 2005, 2001, 1997, 1993, 1989, 1985, 1981, 1977, by The McGraw-Hill Companies, Inc Click here for terms of use
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Table 34-1 Causes of cerebral abnormalities from alterations of arteries and veins 1 2 3 4 5 6 Atherosclerotic thrombosis Transient ischemic attacks Embolism Hypertensive hemorrhage Ruptured or unruptured saccular aneurysm or AVM Arteritis a Meningovascular syphilis, arteritis secondary to pyogenic and tuberculous meningitis, rare infective types (typhus, schistosomiasis, malaria, mucormycosis, etc) b Connective tissue diseases (polyarteritis nodosa, lupus erythematosus), necrotizing arteritis Wegener arteritis, temporal arteritis, Takayasu disease, granulomatous or giantcell arteritis of the aorta, and giant-cell granulomatous angiitis of cerebral arteries Cerebral thrombophlebitis: secondary to infection of ear, paranasal sinus, face, etc; with meningitis and subdural empyema; debilitating states, postpartum, postoperative, cardiac failure, hematologic disease (polycythemia, sickle cell disease), and of undetermined cause Hematologic disorders: anticoagulants and thrombolytics, clotting factor disorders, polycythemia, sickle cell disease, thrombotic thrombocytopenic purpura, thrombocytosis, intravascular lymphoma, etc Trauma and dissection of carotid and basilar arteries Amyloid angiopathy Dissecting aortic aneurysm Complications of arteriography Neurologic migraine with persistent de cit With tentorial, foramen magnum, and subfalcial herniations Miscellaneous types: bromuscular dysplasia, with local dissection of carotid, middle cerebral, or vertebrobasilar artery, x-irradiation, unexplained middle cerebral infarction in closed head injury, pressure of unruptured saccular aneurysm, complication of oral contraceptives Undetermined cause in children and young adults: moyamoya disease and others
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Table 34-2 Cerebrovascular diseases characteristic of each age period 1 Prenatal circulatory diseases leading to a Porencephaly b Hydranencephaly c Hypoxic-ischemic damage d Unilateral cerebral infarction 2 Perinatal and postnatal circulatory disorders resulting in a Cardiorespiratory failure and generalized ischemia etat marbre b Periventricular infarcts c Matrix hemorrhages and ischemic foci in premature infants d Hemorrhagic disease of the newborn 3 Infancy and childhood: vascular diseases associated with a Ischemic infarction b Congenital heart disease and paradoxical embolism c Moyamoya d Bacterial endocarditis, rheumatic fever, lupus erythematosus e Sickle cell anemia f Mitochondrial disorders (MELASa) g Homocystinuria and Fabry s angiokeratosis 4 Adolescence and early adult life: vascular occlusion or hemorrhage with a Pregnancy and puerperium b Estrogen-related stroke c Migraine d Vascular malformations e Premature atherosclerosis f Arteritis g Valvular heart disease h Sickle cell anemia i Antiphospholipid arteriopathy, plasma C-protein de ciency and other coagulopathies j Moyamoya, Takayasu disease k Arterial dissections l Amyloid angiopathy 5 Middle age a Atherosclerotic thrombosis and embolism b Cardiogenic embolism c Primary (hypertensive) cerebral hemorrhage d Ruptured saccular aneurysm e Dissecting aneurysm f Fibromuscular dysplasia 6 Late adult life a Atherosclerotic thrombotic occlusive disease b Embolic occlusive disease c Lacunar state d Brain hemorrhage (multiple causes) e Multi-infarct dementia f Binswanger disease
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More than any other organ, the brain depends from moment to moment on an adequate supply of oxygenated blood Constancy of the cerebral circulation is assured by a series of baroreceptors and vasomotor re exes under the control of centers in the lower brainstem In Stokes-Adams attacks, for example, unconsciousness occurs within 10 s of the beginning of asystole In animal experiments and probably in humans, the complete stoppage of blood ow for longer than 5 min produces irreversible damage Brain tissue deprived of blood undergoes ischemic necrosis or infarction (also referred to as a zone of softening or encephalomalacia) Obstruction of an artery by thrombus or embolus is the usual cause of focal ischemic damage, but failure of the circulation and hypotension from cardiac decompensation or shock, if severe and prolonged enough, can produce focal as well as diffuse ischemic changes Cerebral infarcts vary greatly in the amount of congestion and hemorrhage found within the softened tissue Some infarcts are devoid of blood and therefore pallid ( pale infarction); others show mild congestion (dilatation of blood vessels and escape of red blood cells), especially at their margins; still others show an extensive
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Mitochondrial encephalomyopathy, lactic acidosis, and stroke Reproduced by permission from Salam-Adams and Adams
extravasation of blood from many small vessels all through the infarcted tissue (red or hemorrhagic infarction) Some infarcts are all of one type, either pale or hemorrhagic; many are mixed The reason for the occurrence of hemorrhagic infarction almost always, occurring in cases of cerebral embolism is not fully un-
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