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country approximately 700,000 cases of stroke roughly 600,000 ischemic lesions and 100,000 hemorrhages, intracerebral or subarachnoid with 175,000 fatalities from these causes Since 1950, coincident with the introduction of effective treatment for hypertension, there has been a substantial reduction in the frequency of stroke This was most apparent three decades ago, as treatment for high blood pressure became a public health focus Among the residents of Rochester, Minnesota, Broderick and colleagues documented a reduction of 46 percent in cerebral infarction and hemorrhage when the period 1975 1979 was compared with 1950 1954; Nicholls and Johansen reported a 20 percent decline in the United States between 1968 and 1976 Both sexes shared in the reduced incidence During this period, the incidence of coronary artery disease and malignant hypertension also fell signi cantly By contrast, there has been no change in the frequency of aneurysmal rupture Interestingly, despite the continued improvement in the treatment of hypertension, the incidence rate of stroke for the period 1980 1984 was 17 percent higher than that for 1975 1979, a feature attributed by Broderick and coworkers to the widespread use of computed tomography (CT), which increased the detection of less severe strokes In the last decade, according to the American Heart Association, the mortality rate from stroke has declined by 12 percent, but the total number of strokes may again be rising

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

03-15-2005

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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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

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

03-20-2005

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