What are the characteristics of cerebrovascular accident (CVA) syndromes?

From the Guidelines

Cerebrovascular accident (CVA) syndromes are characterized by a heterogeneous group of ischemic and hemorrhagic etiologies, often manifesting clinically as an acute neurologic deficit, also known as stroke or less commonly with symptoms such as headache or seizures.

Characteristics of CVA Syndromes

• Ischemic events: transient ischemic attacks and strokes, usually in carotid branches and watershed, can be both hypoperfusive and thromboembolic 1
• Hemorrhagic events: usually intracerebral or intraventricular, due to rupture of deep neovascularization collaterals and pseudoaneurysms, with occasional associated aneurysms 1
• Other neurological symptoms: headaches, neurocognitive impairment, secondary movement disorders, and associated conditions such as lupus erythematosus, rheumatoid arthritis, sickle cell disease, neurofibromatosis 1, and Down syndrome 1

Types of CVA Syndromes

• Ischemic: 87% of strokes, due to large-vessel disease, small-vessel disease, cardioembolism, or other mechanisms 1
• Hemorrhagic: 10% of strokes, due to intracerebral hemorrhage, subarachnoid hemorrhage, or other mechanisms 1
• Transient ischemic attacks (TIAs): acute loss of neurological function caused by an ischemic event with resolution of symptoms by 24 hours after onset 1

Diagnosis and Assessment

• Imaging modalities: CT, MRI, cerebral angiography, ultrasound, magnetic resonance angiography 1
• Assessment of functional status: complete/near-complete recovery, mild to moderate deficit, severe deficit 1

Management and Treatment

• Antithrombotic therapy: depends on type of cerebrovascular disease, prior symptomatic events, prior interventions, and perceived bleeding risk 1
• Anticoagulation: may be contraindicated in certain conditions, such as cerebral amyloid angiopathy, due to high risk of recurrent intracranial hemorrhage 1

From the Research

Characteristics of Cerebrovascular Accident (CVA) Syndromes

• CVA syndromes can be classified into two main categories: ischemic (85-90%) and hemorrhagic (10-15%) 2
• Ischemic CVA occurs when there is a focal symptomatic reversible or irreversible ischemia in the brain, resulting in transient ischemic attack (TIA) or acute ischemic stroke (AIS) respectively 3
• Hemorrhagic CVA is characterized by intracranial bleeding, leading to the formation of a focal hematoma, often located in the basal ganglia of the brain 2
• CVA syndromes can be caused by various mechanisms, including large artery atherosclerosis, cardioembolism, small vessel occlusion, and cerebral amyloid angiopathy 3, 2

Clinical Presentation and Diagnosis

• The clinical presentation of CVA syndromes can vary, but common symptoms include focal neurological signs, such as central facial palsy, speech disorders, and pyramidal signs 4
• Stroke mimics (SMs) are conditions that present similarly to CVA, potentially leading to diagnostic errors, and can include seizures, infections, and other conditions 4
• The accuracy and completeness of data collected by emergency medical teams (EMTs) can play a crucial role in the CVA diagnostic process, potentially reducing misdiagnoses of SMs 4

Risk Factors and Outcomes

• Prior peripheral arterial disease and cerebrovascular disease are independent predictors of adverse outcome in patients with acute coronary syndromes 5
• Patients with extra-cardiac vascular disease (EVD) are older, have more coronary risk factors, and receive more intensive medical treatment at baseline, but may receive less aggressive treatment, which can contribute to worse outcomes 5
• The presence of EVD is associated with more extensive coronary artery disease and worse outcome, including increased hazard of death, reinfarction, recurrent ischemia, stroke, and a composite of these events 5