Cerebrovascular Accident

DRG Category: 014

Mean LOS: 6.4 days

Description: MEDICAL: Specific Cerebrovascular

Disorders Except TIA DRG Category: 027 Mean LOS: 3.9 days Description: MEDICAL: Traumatic Stupor and

Coma, Coma > 1 hour DRG Category: 002 Mean LOS: 9.8 days Description: SURGICAL: Craniotomy for Trauma, Age > 17

Cerebrovascular accident (CVA), or "stroke," is the interruption of normal blood flow in one or more of the blood vessels that supply the brain. The tissues become ischemic, leading to hypoxia or anoxia with destruction or necrosis of the neurons, glia, and vasculature. CVA is the third leading cause of death in the United States and affects more than 600,000 Americans annually with 160,000 deaths per year. The incidence of first-time strokes is approximately 400,000 per year, but as the population ages, the incidence will increase to 1 million per year by 2050.

A CVA is an acute neurological injury that occurs because of changes in the blood vessels of the brain. The changes can be intrinsic to the vessel (atherosclerosis, inflammation, arterial dissection, dilation of the vessel, weakening of the vessel, obstruction of the vessel) or extrinsic, such as when an embolism travels from the heart. Although reduced blood flow interferes with brain function, the brain can remain viable with decreased blood flow for long periods of time. However, total cessation of blood flow produces irreversible brain infarction within 3 minutes. Once the blood flow stops, toxins released by damaged neurons, cerebral edema, and alterations in local blood flow contribute to neuron dysfunction and death. Complications of CVA include unstable blood pressure, sensory and motor impairment, infection (encephalitis), pneumonia, contractures, and pulmonary emboli.

Thrombosis, embolism, and hemorrhage are the primary causes of CVA. In cerebral thrombosis, the most common cause of CVA, a blood clot obstructs a cerebral vessel. The most common vessels involved are the carotid arteries of the neck and the arteries in the vertebrobasilar system at the base of the brain near the circle of Willis. Cerebral thrombosis also contributes to transient ischemic attacks (TIAs), which are temporary episodes (10 to 30 minutes) of poor cerebral perfusion caused by partial occlusion of the arterial lumen. A thrombotic CVA that causes a slow evolution of symptoms over several hours is called a stroke in evolution. When the condition stabilizes, it is called a completed stroke.

In an embolic CVA, a clot is carried into the cerebral circulation, usually by the carotid arteries. Blockage of an intracerebral artery results in a localized cerebral infarction. Hemorrhagic CVA results from hypertension, rupture of an aneurysm, arteriovenous malformations, or bleeding disorder. Risk factors thought to cause blood vessel changes that cause vessel walls to be more susceptible to rupture and hemorrhage include elevated low-density lipoprotein (LDL) and lowered high-density lipoprotein (HDL) levels, cigarette smoking, and a sedentary lifestyle.

Stroke is considered a complex disease with both genetic and environmental risk factors. Several susceptibility loci have been reported. Variants in the gene encoding phosphodiesterase 4D

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