FACULTY OF MEDICINE UNIVERSITY IN PRISHTINA

UNIVERSITETI I PRISHTINËS FAKULTETI I MJEKËSISË

DIABETES AND CEREBROVASCULAR

DISEASE

Authors:
1. HALIL Z. AJVAZI, MD, Mr. Sc.,
2. VALBONA GOVORI, MD, PHD.,

PRISHTINA
12/06.2009
 Acute stroke is the leading cause of
disability in the modern society.

 In developed countries it is the

second cause of death, and in
Kosova the leading cause of death.
 RISK FACTORS FOR
STROKE

 Nonmodifiable

 Modifiable
 Nonmodifible

 Age
 Sex
 Race-ethnicity
 Heredity
 Modifiable

 Hypertension
 Cardiac disease (particularly atrial
fibrillation)
 Diabetes
 Hypercholesterolemia
 Cigarette smoking
 Excessive use of alcohol
 Physical inactivity
 Classiffication of
Cerebrovascular disease
regarding the duration of
symtpoms
-Transient insufficiency of cerebral
circulation
TIA
RIND
- Persistent insufficiency
cerebral infarction
cerebral haemorrhagia
 TIA (Transient ischemic
brain attack)

- neurological symptoms clear

completely in less than 24 hours
(mean duration of 14 minutes in
carotid-distribution and 8 min in
vertebrobasilar ischemia)
- reversible ischemia without brain
lesion (13% of patients had silent
brain infarction)
 Causes of TIA

 atherosclerosis of
cerebrovascular arteries
 cardioembolic
 hypercoagulable states
 arterial dissection
 arteritis
 aneurysm
 arteriovenous malformation
 Risk of stroke for patients with TIA is
24% to 29% in the first 5 years after
event.

 Risk is higher in the first month and

highest in patients with hemispheric
TIA and carotid stenosis over 70%
(40% rate of stroke in 2 years).
 RIND (Reversible ischemic
neurologic deficite)

 Ischemic cerebral dysffunction in

which the symptoms clear
completely in the period of 2 weeks
(“small stroke” ?)
 Classiffication of stroke
regarding the cause

 Ischemic
cerebrovascular infarction
80%

 Haemorrhagic
intracerebral haemorrhagia
15%
subarachnoidal haemorrhagia
STROKE WARNING SIGNS
 sudden numbness or weakness of
the face, arm of leg, especially on
one side of the body
 sudden confusion, trouble speaking
or understanding
 sudden trouble of seeing in one or
both eyes
 sudden trouble of walking, dizziness,
loss of balance or coordination
 sudden, severe headache with no
 Diagnosis of TIA

 Course of disease, determination of risk

factors
 Neurological examination
 Laboratory exams (glucose, blood count,
electrolytes, acidobasic status,
coagulation)
 Neuroradiological examinations
- imaging of the brain
- imaging of the vessels
 ECG and cardiological examination
(ultrasound of the heart)
 Neuroradiological
examination
 Imaging of the  Imaging of the vessels
brain - identifying occlusive
arterial disease
- identifying the
- localizing the
lesion
occlusion in
- determining the extracranial or
type of lesion intracranial vessels
- localizing the lesion - quantifying the degree
of occlusion
- quantifying the - determining the
lesion patology
- determining the - identifying other
age of lesion vascular lesions
 Imaging of the brain

 CT (computed tomography)
 MRI (magnetic resonance imaging)
 SPECT (single-photon emission
computed tomography)
 CT scan
- gold standard

 initial diagnostic evaluation to

exclude a rare lesion (subdural
hematoma or brain tumor)
 limited role in evaluation of patients
with vertebrobasilar TIAs
 limited role in identifying lessions
such as subdural hematoma that are
isodense with surrounding
parenchyma
 MRI
- more expensive, time-
consuming, less available

 no indication for rutine MRI of

patients with TIA
 detects acute and small infarcts
 detects small infarcts in brain stem
and cerebellar regions
 SPECT

- to differentiate ischemia from

epilepsy as the cause of transient
neurological deficit (“cold” vrs. “hot”
areas)
 Imaging of the vessels

 NONINVASIVE – a contrast agent is

not necessary
 RELATIVELY NONINVASIVE – a
contrast agent is administred
intravenously
 INVASIVE – a contrast agent is
injected intra-arterially
 Noninvasive imaging –
initial diagnostic test
 Carotid duplex or Doppler ultrasonography –
gold standard in inital diagnostic

 MRA (magnetic resonance arteriography)

- imaging of the extracranial carotid,
vertebrobasilar and major intracranial vessels,
but leads to overestimation of degree of stenosis
- not reliably for atheromatous ulcerations,
fibromuscular dysplasia and dissection
- insufficient specificity to establish an indication
for carotid endarterectomy
 Relatively noninvasive
imaging

 CT angiography – screening method

in patients with presumed
atherosclerosis of the carotid
bifurcation
 Invasive imaging
 Conventional radiographic
angiography
– reference standard of the diagnostic
effort to identify surgically accessible and
remediable carotid lesions

- recommended for a symptomatic patient

when noninvasive tests indicate more
than 70% occlusion
- for a diagnosis of dissection, vasculitis,
aneurysm or embolism
- fails to demonstrate some vascular
mural changes (intraplaque hemorrage
and trombus attached to the arterial wall)
 Therapy for TIA-s

 RISK FACTOR MANAGEMENT

 MEDICAL THERAPY

 SURGICAL MANAGEMENT
Risk factor management

 Treatment of hypertension (BP lower than

140/90 mmHg, for diabetics lower than
130/85 mmHg)
 Cigarette smoking should be discontinued
 Coronary artery disease, cardiac
arrhythmias, congestive heart failure and
valvular heart disease should be treated
appropriately
 Excessive use of alcohol should be
eliminated (1-2 drinks per day are
associated with reduction in stroke rates)
Risk factor menagemet –
cont.
 Treatment of hyperlipidemia (diet,
maintenance of ideal body weight,
regular physical activity, lipid-
lowering agents if neccessary)
 Fasting glood glucose less than 6,25
mmol/l – 126 mg/dcl (diet, oral
hypoglycemics or insulin as needed)
 Physical activity (30-60 minutes of
exercise 3 to 4 times per week)
Medical therapy of TIA-s

 Antiplatelet agents

 Anticoagulants
 Antiplatelet agents

 Aspirin (50 to 325 mg daily)

 Clopidogrel (75 mg daily)
 Ticlopidin (250 mg twice daily)
 Aspirin and extended-release
dipyridamole (25 mg+200 mg twice
daily)

All acceptable options for initial

therapy.
 Anticoagulants
 therapy of choice for stroke
prevention in patients with atrial
fibrilation who have had TIA or are
high-risk patients (history of
hypertension, poor left vetricular
function, rheumatic mitral valve
disease, prosthetic heart valves,
systemic embolism, age over 75
years)

 recommendation: target INR

 Surgical management
 Carotid endarterectomy
- stenosis of 70% to 99% - absolute
indication
- stenosis of 50% to 69% - optional
treatment depending sex, age and
comorbidity
 Transluminal angioplasty with
intravascular placement of stents
 Extracranial-Intracranial Bypass
(superficial temporal to middle cerebral
artery bypass)
FACULTY OF MEDICINE UNIVERSITY IN
PRISHTINA
UNIVERSITETI I PRISHTINËS FAKULTETI I MJEKËSISË

Tema:
DIABETES
AND CEREBROVASCULAR DISEASE

Authors:
1. HALIL AJVAZI, MD, Mr. Sc.,
2. VALBONA GOVORI, MD, PHD.,

PRISHTINA
12/06.2009