Cerebrovascular diseases课件

– Arterial hypertention (hemorrhagic stroke) – Bleeding from Arterio-venous malformation (AVM) – Rupture of aneurysm of cerebral vessel – Coagulopathies – vasculitis
Primary stroke prevention – controlling of risk factors
• Hypertension (increases risk of stroke in4-5 times) • Smoking (1,5) • Diabetes. (2,5-4) • Lipids. • Cardiac Disease.
– Maintaining mild hypertension (if there is no evidence of hemorrhage) or at least normal blood pressure
• Maintaining of adequate intravessel volume • Controling heart output and arrhythmias • Controlling of glucose level
• Sudden and fast onset (seconds – minutes) • Unconsciousness (semicoma-coma) • Severe neurological deficit • Vegetative symptoms: high arterial pressure;
– Intubation for comatose patients – Supplementary oxygen
• Arterial pressure control
– Severe hypertention must be treated gently – decrease pressure to mild hypertention during several hours.
Cerebrovascular diseases
Cerebrovascular diseases
• Vascular occlusive diseases (ischemic stroke) • Intracerebral hemorrhage (hemorrhagic stroke)
Incidence of stroke
cascade
1. Acute resuscitation
• Respiration
– Intubation with ventilation for patients in coma – Supplementary oxygen for other patient
• Arterial pressure
– Medial hemorrhage (into basal ganglia) – Hemorrhage into brainstem
• Surgical + conservative - for other patients
Conservative treatment
• Respiration control
– Atrial fibrillation, (5) – valvular heart disease, (4) – myocardial infarction (5)
Secondary Stroke Prevention (After Transient Ischemic Attack or Ischemic Stroke)
picture
• Headaches, meningeal signs are not often • History of TIAs, no history o源自文库 hypertention
Treatment of acute ischemia
• 1. Acute resuscitation • 2. Reperfusion of the ischemic brain • 3. Decreasing cerebral metabolic demands • 4. Inhibition of the degradative ischemic
• Subarachnoid hemorrhage
– Rupture of aneurysm of cerebral vessel – Bleeding from Arterio-venous malformation (AVM)
Clinical signs of hemorrhagic stroke due to hypertension
Medial (thalamic) hematoma
Lobar hematoma
Brainstem (pontine) hemorrhage
Treatment
• Conservative only –
– for patients in clear consciousness or severe coma (GCS 3-5)
Clinical presentation of SAH
• Sudden onset • Severe headache • Meningeal signs • Minimal focal neurological deficit
• More rarely depressed level of
consciousness and major neurological deficit
• Subacute begining (acute in cases of embosilsm) • Consciousness is clear or short term lost of
consiousness. Not often unconsciousness
• Focal neurological deficit – main in clinical
bradycardia, red face and cyanotic limbs, sweating.
• Severe headache in contact patients
Diagnostic procedures
• Computed tomography (CT) • Angiography • EchoEG
• 150-600 new cases per 100.000 population
per year
• 2-3rd leading cause of death • 1st leading cause disability
Ischemic stroke
• Atherosclerosis of great cerebral vessels
• <20 ml/100g - ischemic stroke
Acute ischemia
• Transient Ischemic attack – neurological
deficit that resolves during 24 hours
• Reversible neurological deficit (minor
Common sites of atherosclerotic disease.
Normal blood flow
• 55 ml/100g per min - average
– 80-100 ml/100g per min for gray mater – 25-30 ml/100g per min for white matter
• Coagulative status control and correction
Surgical treatment
• Removal of intracerebral hematoma • Ventricular draining in case of occlusive
hydrocephalus
– Patients after stroke (strokes) that do not cause severe diability
• angiograms of cervical carotid artery showing varied
appearance of critical stenosis of the internal carotid artery.
• Aspirin 30-300 mg per day • Or Ticlopidine • Treatment or heart diseases • Surgical
Surgical prevention of ischemia
• EXTRACRANIAL-TO-INTRACRANIAL
CAROTID ARTERY BYPASS
• Possible only in cases of stenosis of great
brain vessels (common carotid, internal carotid, middle cerebral arteries) – endarterectomia in first 2-3 hours.
• CAROTID ENDARTERECTOMY
CAROTID ENDARTERECTOMY
• Indications
– Patients with TIAs with high grade stenosis of CCA or ICA confirmed with ultrasound-dopler and angiography
– Stenosis of vessels – Atherothromboembolism
• Cardiac embolism • Nonatherosclerotic vasculopaties and
hematological abnormalities
• Unknown
20-40%
15-30% 10-20% 10-30%
• A Smoothly tapered segmental narrowing. • B Sharply demarcated stenosis.
endarterectomy
Causes of nontraumatic intracranial hemorrhage
• Intracerebral hemorrhage
2. Reperfusion of the ischemic brain
• Thrombolytic therapy – recombinant
activator for tissue plasminogen
– In first 4-6 hours after onset – If intracerebral hemorrhage is excluded with
Diagnostic procedures for SAH
• CT • Lumbar puncture with CSF examination
– Blood in the CSF – High pressure of CSF – SAH and possible intracerebral hemorrhage
CT
• Hypervolemic Hemodilution Therapy • Anticoagulation ???
3. Decreasing cerebral metabolic demands
• Hypothermia ??? • Barbiturates
Surgical treatment for acute ischemia
stroke) – deficit that resolves completely during more then 24 hours
• Ischemic stroke – persistent neurological
deficit
Clinical presentations of ischemic stroke