Cerebro-vascular Diseases — Clinical Neurology & Neurosurgery (4th-Year BPT)
Comprehensive student-friendly guide: definitions (stroke, TIA, RIA), classifications, risk factors, causes, stroke syndromes, investigations, differentials, and medical & surgical management.
Introduction — Clinical Neurology & Neurosurgery Focus
Cerebro-vascular diseases (CVD) primarily affect the brain’s blood vessels and are a leading cause of mortality, morbidity and long-term disability worldwide. For physiotherapists, understanding the pathology, clinical syndromes, investigations and management options is essential for planning safe and effective rehabilitation.
Quick definitions:
- Stroke — a sudden focal neurological deficit caused by a vascular event (ischemia or hemorrhage) in the brain.
- TIA (Transient Ischemic Attack) — transient (<24 hr, commonly <1 hr) neurological deficit due to focal brain ischemia without infarction.
- RIA (Reversible Ischemic Attack) — similar to TIA but with complete recovery; historical term (use clinically with caution).
- Stroke in Evolution — progressive worsening of neurological deficit over hours to days.
- Lacunar Infarct — small, deep infarct (usually <15 mm) in subcortical structures due to occlusion of small penetrating arteries.
Classification of Stroke
1. By pathology
| Type | Mechanism | Examples |
|---|---|---|
| Ischemic | Arterial occlusion → reduced blood flow → infarction | Thrombotic stroke, embolic stroke, lacunar infarct |
| Hemorrhagic | Blood vessel rupture → intracerebral hematoma or subarachnoid hemorrhage (SAH) | Intracerebral hemorrhage, SAH |
| Venous infarcts | Cerebral venous sinus thrombosis → venous congestion and infarction | CVST (e.g., superior sagittal sinus thrombosis) |
2. By symptoms / vascular territory (syndromic)
Examples: Middle cerebral artery (MCA) syndrome — contralateral hemiparesis (face & arm > leg), aphasia (dominant hemisphere); Posterior circulation — cerebellar signs, cranial nerve palsies, visual field defects.
3. By timing
- Acute (first 24–72 hours)
- Subacute (days to weeks)
- Chronic (months and beyond)
Risk Factors & Causes
Major modifiable risk factors
- Hypertension (leading cause for hemorrhagic and ischemic stroke)
- Diabetes mellitus
- Dyslipidaemia
- Smoking & tobacco use
- Alcohol abuse
- Obesity & physical inactivity
- Atrial fibrillation and other cardiac sources of emboli
- Carotid artery atherosclerosis
Non-modifiable risk factors
- Age (risk rises with age)
- Sex (males higher risk early; females higher lifetime risk)
- Family history and genetic predisposition
Causes of Ischemic Stroke
TOAST classification (for ischemic stroke mechanism) — useful for clinicians:
| TOAST subtype | Typical cause |
|---|---|
| Large-artery atherosclerosis | Carotid/vertebral plaques → thrombosis or artery-to-artery embolus |
| Cardioembolism | AF, MI, prosthetic valves, atrial thrombus → embolic occlusion |
| Small-vessel (lacunar) | Hypertensive arteriolosclerosis causing lacunar infarcts |
| Other determined etiology | Dissection, vasculitis, thrombophilia, drug use |
| Undetermined | Cryptogenic strokes |
Causes of Hemorrhagic Stroke
- Hypertensive intracerebral hemorrhage (common: basal ganglia, thalamus, pons)
- Cerebral amyloid angiopathy (lobar hemorrhages in older adults)
- Ruptured aneurysm → subarachnoid hemorrhage (thunderclap headache)
- Vascular malformations (AVM)
- Anticoagulant therapy / bleeding diathesis
Stroke Syndromes — Clinical Patterns
Recognizing syndromes helps localize lesion and infer vessel involvement.
Middle Cerebral Artery (MCA) Syndrome
- Contralateral hemiparesis (face & arm > leg)
- Contralateral hemisensory loss
- Aphasia (dominant hemisphere) or neglect (non-dominant)
- Gaze preference toward side of lesion
Anterior Cerebral Artery (ACA) Syndrome
- Contralateral leg weakness and sensory loss
- Behavioural changes and abulia (medial frontal lobe involvement)
Posterior Circulation Syndromes
- Cerebellar infarct → ataxia, dysarthria, nausea/vomiting
- Brainstem infarct → cranial nerve deficits, crossed signs, respiratory compromise (high risk)
- Visual field defects (occipital lobe)
Lacunar Syndromes
- Pure motor hemiparesis (posterior limb of internal capsule) — common lacunar presentation
- Pure sensory stroke, sensorimotor stroke, ataxic hemiparesis
Important: Posterior circulation strokes can deteriorate rapidly and threaten airway/breathing — urgent neuro assessment is essential.
Investigations
Initial workup depends on stability, but early imaging is mandatory.
Emergency (first-line)
- Non-contrast CT (NCCT) head — fast, detects hemorrhage. Critical to exclude bleed before thrombolysis.
- CT Angiography (CTA) — to detect large vessel occlusion (LVO) for thrombectomy decisions.
- CT Perfusion (CTP) / MRI DWI — identify salvageable penumbra vs core infarct (in select cases).
Secondary / Etiologic workup
- ECG & continuous cardiac monitoring (AF detection)
- Transthoracic / transesophageal echocardiography (cardiac source)
- Carotid duplex ultrasound (for carotid stenosis)
- Blood tests: glucose, electrolytes, full blood count, coagulation profile, lipid profile, inflammatory markers
- Special tests: thrombophilia screen (young stroke), vasculitis panel (suggestive features)
Differential Diagnosis
Not every sudden neurological deficit is stroke. Consider:
- Hypoglycaemia — mimics stroke; check capillary glucose immediately
- Seizure with post-ictal paresis (Todd’s palsy)
- Migraine with brainstem aura
- Brain tumour / abscess — subacute presentation
- Multiple sclerosis relapse — younger adults with previous history
- Functional neurological disorders — inconsistent exam findings
- Peripheral nerve palsy (e.g., Bell’s palsy vs cortical facial palsy)
Medical & Surgical Management
Ischemic Stroke — Acute Management
- ABC + stabilization — airway, breathing, circulation, glucose correction.
- Time is brain: Determine onset time and eligibility for reperfusion.
- IV thrombolysis (e.g., alteplase) — within window (commonly up to 4.5 hours in many protocols). Strict inclusion/exclusion criteria apply.
- Mechanical thrombectomy — for large vessel occlusion up to 6–24 hours in selected patients with favourable imaging (core-penumbra mismatch).
- Antiplatelet therapy — aspirin (immediate if no thrombolysis contraindication). Dual antiplatelet therapy may be used short-term for minor stroke/TIA.
- Anticoagulation — indicated for cardioembolic stroke (AF) after evaluating hemorrhagic risk; timing post-stroke is individualized.
- BP management — permissive hypertension often allowed acutely for ischemic stroke (specific targets depend on reperfusion therapy decisions).
Hemorrhagic Stroke — Acute Management
- Stabilize ABCs, correct coagulopathy (vitamin K, PCC, platelet transfusion if indicated).
- Control blood pressure to reduce ongoing bleeding (rapid reductions may be harmful — follow local protocols).
- Neurosurgical consult: evacuation of large intracerebral hematoma, decompression for impending herniation.
- Subarachnoid hemorrhage (ruptured aneurysm): urgent neurosurgery/interventional radiology for aneurysm clipping/coiling.
Secondary Prevention & Rehabilitation
- Address vascular risk factors: BP control, diabetes management, lipid lowering (statins), smoking cessation.
- Antiplatelet/anticoagulant therapy tailored to mechanism.
- Early mobilization and interdisciplinary rehabilitation (physio, OT, speech therapy).
- Education for patients/families and home exercise adherence strategies.
Role of the Physiotherapist: early assessment of neurological deficits, positioning, prevention of complications (contractures, DVT), progressive task-oriented training, gait re-education, balance, and functional retraining.
Physiotherapy — Practical Rehabilitation Notes (for 4th-Year BPT)
Rehab is evidence-based and individualized. Key principles:
- Early Assessment: neurological exam, NIH Stroke Scale (for severity), baseline mobility & function.
- Prevent medical complications: respiratory care, skin integrity, DVT prophylaxis (mobilization, compression).
- Task-specific training: gait training, sit-to-stand, transfers using massed practice and feedback.
- Neuro-plasticity driven approaches: constraint-induced movement therapy, mirror therapy, functional electrical stimulation (FES).
- Education & family training: safe handling, home program, community reintegration.
Sample Physiotherapy Plan (first 6 weeks)
- Week 1–2: prevention, positioning, PROM, bed mobility, initiate sitting balance.
- Week 2–4: standing balance, static & dynamic weight shift, assisted gait (parallel bars), FES for weak dorsiflexors.
- Week 4–6: graded community ambulation, task-specific practice (stairs, uneven surfaces), endurance conditioning.
Quick Reference & Mnemonics
FAST
Face, Arm, Speech, Time — immediate red flag for stroke. If positive, call emergency services.
BEFAST
Balance, Eyes, Face, Arm, Speech, Time — includes posterior circulation signs.
TOAST
Remember the ischemic mechanism categories for investigations and secondary prevention.
Further Reading & References
This summary is intended for educational purposes. For detailed clinical guidelines & reviews see: Physiopedia (for related neuro topics), the American Heart Association/American Stroke Association guidelines, and up-to-date local stroke protocols.