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 Occlusion by major vessel

n

83
 If managed: If not 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
Possible:
Dx: PET scan, MRI,
cerebral angiography, Lysed or moved thrombus
lumbar puncture, from the vessel
EEG/ECG, skull x-ray,
carotid ultrasonography
Vascular wall becomes
TX: aspirin within 24
weakened and fragile
hrs, thrombolytics
within 3 hours, carotid
stenting, hypothermia,
anticoagulants, surgical Leaking of blood from the
decompression fragile vessel wall
(hemicraniectomy),
carotid endartectomy

TX: aspirin within 24 hrs,

thrombolytics within 3
hours, carotid stenting,
hypothermia, Guarded Prognosis
anticoagulants, surgical
decompression
(hemicraniectomy), carotid Cerebral Hemorrhage
endartectomy Sx:, headache,
unconsciousness,
If managed: If not managed nausea/vomiting,
Dx: CT scan, MRI, cerebral angiography, visual
arteriography, disturbances
lumbar puncture, skull x-ray
Tx: chronic hypertensives, surgical
decompression, evacuation and
aspiration, administration of fresh frozen Mass of blood forms and
plasma with fibrinogen or cryoprecipitate grows
Decreased
ICP Hematoma evacuation

Formation of cavity surrounded by dense gliosis 84

 < 30 ml 30-60 ml > 60 ml
hemorrhage hemorrhage hemorrhage

Good prognosis Intermediate Poor prognosis

prognosis
Vasospasm of
tissue and arteries
Blood seeps into the Formation of small
ventricles and large clots
CEREBRAL
Sx: dizziness, HYPOPERFUSION
Obstruction of CSF confusion,
passageway headache
Impaired distribution of
oxygen and glucose
Accumulation of CSF in
the ventricles
Tissue hypoxia and
cellular starvation
Ventricles dilate behind
the point of obstruction Lodges unto
other cerebral Cerebral Ischemia
arteries
Increased ICP
Initiation of ischemic
cascade

If managed: If not managed

Ventriculostomy,
VP shunt, ICP Anaerobic metabolism by
Monitoring mitochondria
Alternative route Unrelieved
for return of CSF obstruction Production of oxygen free
in the circulation radicals and other reactive
Generates large amounts Failure production of oxygen species
of lactic acid adenosine triphosphatase
Compression of
brain tissues will Guarded
Metabolic Acidosis Failure of energy dependent
not occur Prognosis
process
(ion pumping) 85
 Release of excitatory Damage to the blood
neurotransmitter glutamate vessel endothelium

Influx of calcium

Activates enzymes that Failure of

digest cell proteins, lipids mitochondria
and nuclear material

Further energy
depletion

Transient Ischemic Attack

If managed: If not managed

-t-PA (urokinase,
streptokinase)
-calcium channel Brain sustains an irreversible
blockers cerebral damage

Release of metalloprotrease
(zinc and calcium-dependent enzymes)
Guarded
Prognosis
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 Anterior cerebral Posterior Internal Carotid Vertebrobasilar Anteroinferior Posteroinferior

Cerebral Artery artery CerebraI Artery Artery System Cerebellar cerebellar

Lateral Frontal Lobe Occipital lobe; Branches into Cerebellum and Cerebellum Cerebellum
hemisphere, anterior and ophthalmic, PCA, brain stem
frontal, parietal medial portion of anterior choroidal,
and temporal temporal lobe ACA, MCA
lobes, basal
ganglia

87
 Sx: Sx: Sx: Sx:
Sx: Sx: Sx:
Contralateral contralateral Ipsilateral Ataxia,
Contralateral Mild Alternating
hemiparesis or hemiparesis ataxia, facial paralysis of the
hemiparesis, contralateral motor
hemiplegia, with facial paralysis, larynx and soft
foot and leg hemiparesis, weaknesses,
unilateral asymmetry, ipsilateral loss palate,
deficits greater intention ataxic gait,
neglect, altered contralateral of sensation in ipsilateral loss
than the arm, tremor, diffuse dysmetria,
consciousness sensory face, sensation of sensation in
foot drop, gait sensory loss, contralateral
, homonymous alterations, changes on face,
disturbances, pupillary hemisensory
hemianopsia, homonymous trunk and contralateral on
contralateral dysfunction, impairments,
inability to turn hemianopsia, limbs, body,
hemisensory loss of double vision,
eyes toward ipsilateral nystagmus, nystagmus,
alterations, conjugate homonymous
affected side, periods of Horner’s dysarthria,
deviation of gaze, hemianopsia,
vision changes, blindness, syndrome, Horner’s
eyes toward nystagmus, nystagmus,
dyslexia, aphasia if tinnitus, syndrome,
affected side, loss of depth conjugate
dysgraphia, dominant hearing loss hiccups and
expressive perception, gaze,
aphasia, aphasia, cortical hemisphere is paralysis, coughing,
agnosia, confusion, blindness, involved, Mild dysarthria, vertigo, nausea
memory deficits, amnesia, flat homonymous Horner’s 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,
coma

88
 If managed: If not
Palliative care- managed:
Frequent vital sign and
neurovital signs,
intubation, mechanical
ventilation, Continued insufficiency of blood
vasodilators, osmotic flow
diuretics,
ventriculostomy, ICP
monitoring
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 GUT Other systems
GIT
System System

Relaxation of
intestines and Sx: restlessness,
Loss of cardiac Relaxation of abnormal
muscle function sphincters thermoregulation,
venous valves
mental confusion,
increased secretions,
decreased urinary
output.
Sx: Sx:
bradycardi hypotensio
a n Loss of bowel
Failure of accessory Loss of lung control
Decreased muscles for breathing movement
cardiac output Neurogenic bladder Loss of sphincter
control
Sx:
apnea

Cardiopulmonary arrest

Systemic Failure

90
DEATH