Cerebrovascular Disease

How the brain's blood supply works

The brain uses about 20% of the body's oxygen. Blood reaches it through two carotid arteries at the front of the neck and two vertebral arteries at the back, which connect at the base of the brain (the circle of Willis) and branch into smaller vessels. Brain cells begin to die within minutes without blood flow, which is why problems with these vessels cause sudden, serious symptoms.

Types of cerebrovascular disease

Symptoms

Many types cause no symptoms until a stroke or TIA. Learn BE FAST:

• Balance: sudden loss of balance or coordination
• Eyes: sudden vision loss or double vision
• Face: drooping on one side
• Arms: weakness or numbness in one arm
• Speech: slurred, strange or unable to speak or understand
• Time: call 911 immediately

Other signs include sudden severe headache, confusion and numbness on one side. Small vessel disease causes a slower picture: slowed thinking, difficulty with planning and attention, mood changes, unsteady walking and bladder urgency.

Causes and risk factors

Modifiable

• High blood pressure: the single most important risk factor for both ischemic and hemorrhagic stroke
• Smoking
• Diabetes
• High LDL cholesterol
• Atrial fibrillation: increases stroke risk about fivefold by allowing clots to form in the heart
• Physical inactivity, obesity and poor diet
• Heavy alcohol use
• Sleep apnea
• Chronic kidney disease

Non-modifiable

• Age: risk roughly doubles each decade after 55
• Family history of stroke
• Previous stroke or TIA
• Ancestry: stroke is more common in Black Americans, partly due to higher rates of hypertension

Diagnosis

• CT scan of the head: the first test in suspected stroke, to rule out bleeding
• MRI: detects small and early strokes and small vessel disease
• CT or MR angiography: shows narrowing, blockages, aneurysms and dissections
• Carotid ultrasound: checks for neck artery narrowing
• ECG and heart rhythm monitoring: looks for atrial fibrillation
• Echocardiogram: looks for heart sources of clots
• Blood tests: cholesterol, blood sugar, clotting and kidney function

Treatment

Acute stroke

• Clot-busting medicine (thrombolysis) for eligible ischemic strokes, usually within 4.5 hours of symptom onset
• Mechanical thrombectomy: removing a clot from a large artery, effective up to 24 hours in selected patients
• Hemorrhagic stroke: blood pressure control, reversal of blood thinners and sometimes surgery

Prevention after stroke or TIA

• Antiplatelet medicines such as aspirin or clopidogrel, or anticoagulants for atrial fibrillation
• High-intensity statins
• Blood pressure control, usually to below 130/80 mmHg
• Carotid endarterectomy or stenting for significant symptomatic carotid narrowing
• Diabetes control and lifestyle changes

Aneurysms and malformations

Monitoring, endovascular coiling, surgical clipping, embolization or focused radiation depending on size, location and risk.

Complications

• Paralysis or weakness, speech and swallowing problems
• Memory and thinking problems, and vascular dementia
• Depression and anxiety
• Seizures
• Falls, pneumonia, blood clots and pressure sores after major stroke

Prevention

• Check blood pressure regularly and treat it if raised.
• Stop smoking.
• Be active for at least 150 minutes a week.
• Eat a diet rich in vegetables, fruit, whole grains and fish, and low in salt.
• Keep a healthy weight.
• Limit alcohol.
• Manage diabetes and cholesterol.
• Get an irregular pulse checked for atrial fibrillation.

Frequently asked questions

What is cerebrovascular disease?

Cerebrovascular disease is a group of conditions affecting the blood vessels that supply the brain. It includes stroke, TIA, carotid artery narrowing, aneurysms, vascular malformations and small vessel disease, which can lead to vascular dementia.

What are the symptoms of cerebrovascular disease?

Many people have no symptoms until a stroke or TIA, which causes sudden face drooping, arm weakness, speech problems, vision loss, loss of balance or a severe headache. Small vessel disease can cause gradual slowing of thinking, mood changes and walking problems.

What is the most common cause of cerebrovascular disease?

Atherosclerosis, the buildup of fatty plaque in arteries, is the most common underlying process, and high blood pressure is the most important risk factor. Smoking, diabetes, high cholesterol and atrial fibrillation also play major roles.

Can cerebrovascular disease be reversed?

Damage from a completed stroke is usually permanent, although the brain can partly recover with rehabilitation. Further damage can be prevented by controlling blood pressure, cholesterol and diabetes, stopping smoking, and taking prescribed medicines.

Is cerebrovascular disease the same as stroke?

Not exactly. Stroke is the most common and serious result of cerebrovascular disease, but the term also includes TIAs, artery narrowing, aneurysms, vascular malformations and small vessel disease, some of which cause no symptoms.