(series of slides used in class)
Classification Of Cerebrovascular Disease
- Cardiogenic embolic
- Cause unspecified
More than 85% of the ACV bleeding and 45% of ischemic are linked in some way with hypertension.
- Serious damage to the artery wall (arterioesclerosis), with segmental dilatations especially in the territory of the middle cerebral artery and especially in the thalamus-striated.
- Tortuous arteries and hard and soft plaques occur, which in turn can be complicated by obstruction or migration of elements from ulceration, He generating emboli away.
Ã ¢??Hypertension prepares and cerebral hemorrhage â??
Frequently niques of ACV; the char- & shy; & shy sticas clini, generally correspond to the sudden appearance of any of the other & shy; following symptoms:
- Weakness or clumsiness on one side of the body
- Vision difficulty by one or both eyes
- Unusual severe headache in patient
- Dizziness or unsteadiness
- Slurred speech and language disorders
- Changes in sensitivity
Medical Conduct ACV:
- Rapid neurological examination should be performed but complete.
This should include: fundus and neck flexion.
- The char- & shy; sticas clini & shy; Nicas infarct (ischemia) may be identical to the bleeding: the haemorrhage may be associated earlier with signs of intracranial hypertension; myocardial be identified clini & shy; & shy solely yes; ndrome corresponding to a specific vascular territory & shy; fico.
- Severe headache
- Depression Awareness
- Nausea and vomiting
- Diplopia horizontal
- Papilledema or retinal hemorrhages
- Irritación changes & shy; ngea, Pain and stiff neck
- Occasionally unilateral mydriasis associated even a third full torque (rupture aneurysm DEA. Posterior communicating)
Perform emergency CT
If depression of consciousness appears before 24 be suspected stroke hs:
- increased intracranial pressure
- edema cerebral (large infarct)
- commitment brainstem
- crisis epiléptica
Risk Factors (unchangeable)
- Family history
Risk Factors (modifiable)
- Hypertension (87%)
- Diabetes (specially treated irregularly and discontinuous)
- Sedentary lifestyle
Other risk factors
- Bleeding disorders and blood: intravascular coagulation, Disseminated, hemophilia, anemia drepanocí­tica, leukemia,reduced levels of platelets in the blood.
- Use of aspirin or anticoagulant drugs (diluents Sangui & shy; neos)
- Liver disease (is generally associated with increased bleeding risk)
- Cerebral amyloid or brain tumors
- Atheromatosis thalamo-capsular arteries
- Arterial aneurysms pol & shy; gon Willis
- Arterial aneurysms micoticos (secondary branches)
- Malformaciones artery-venous
- Discrasias sanguí­neas
- Use cake & shy; na
Forms CLI & shy; tech-
- Login parenquimatosas
ACV Login parenquimatoso
Affects fifth and sixth decades of life, evoke the classic â?? cerebralâ spill?Â , acute, fulminant, surprises the patient in full activity or effort, con hemiplejí­a, altered consciousness.
87% patients have a history of hypertension unknown, Untreated or poorly treated.
The variety of adolescents and young adults, eruption consists acute blood in the subarachnoid space, dominates the aneurysm ruptures pol & shy; gon Willis.
It starts with an acute headache fiercely with each other & shy; & shy ndrome Meni; NGEO, central vomiting, photophobia and rachialgia.
It is a combination of the two previous forms and shapes are usually dumped into parenchymal intra subarachnoid space or AVMs.
Intracerebral hemorrhagic stroke
Table clini & shy; nico
Fulminant Table, agudí­simo (stroke) that surprises the guy in full swing, usually diurnal, with severe disorders of consciousness, hemiplejí­as facio braquio crurales, conjugate gaze palsy â??faces the injured?Â , etc..
- Thursday the sixth decade of her life
- Background of several years of hypertension
- Day in full activity or effort
- Acute onset, fulminant
- Often initial headache
- Blood pressure at admission
- Altered consciousness
- Deficit evident engine, hemiplejí­a facio braquio crural
- Absence of trauma or poisoning
- The Mayori & shy; to the intra-parenchymal hemorrhages are located in internal capsule and basal nuclei (75%)
- Penetrating arteries injured by HTA: Putamen, Marriage bed, Protuberance, Cerebellum, Lobar (angiopatí­a amiloí­dea en ancianos).
Other locations are (25%):
- Front: predominate confusion, psychomotor excitation, hallucinations, Engine biased focus attenuated (paresis) Motor apraxia
- Parietal: hemiparesis with sensory disorders Disorders of consciousness asomatognosia less quantitative & shy; to
- Occipitales: Contralateral homonymous hemianopia
- Temporal Key: Aphasia
- Brainstem: Severe alterations of consciousness, respiratory disorders Hemiplejí & shy; alternate as
- Cerebellum: Consciousness disorders, Yes ataxia and ipsilateral limb loss & shy; ndrome intracranial hypertension due to obstructive hydrocephalus
If the CT shows intracerebral hemorrhage:
- To determine the possible cause
- Order Panangiografí & shy; if cerebral arteriovenous malformation or tumor is suspected
- Request for urgent assessment Neurology & shy; & shy to neurosurgery; the
- Order urgent assessment by UCI if Glasgow is 8/15 or less or if there is deviation li & shy; higher average nea 5 mm or decreased perimesencephalic tanks
ACHh IP – Initial Treatment
The best results are obtained when the patient is managed in a multidisciplinary and timely, remains essential to notice the specialist is as early as possible.
The key objectives are
- Mitigate the extent of brain damage
- Prevent rebleeding
- Prevent sequelae
- Ensure basic functions: revival, cardiac massage, rescue breathing, suctioning intubation, etc.-
- Channeling pluriorificial
- Head to high 30 degrees
- Symptomatic (analgesia, antipyretics, sedation)
- Treating hypertension only if it exceeds 220 mmHg.
- Evaluate referral center more complex. Especially if no impairment of consciousness, progression of neurological damage, anisocoria, Failure to control high blood pressure or breathing difficulties
- Mannitol 15% delay before evacuation to a specialized center (100-150 cc to drip free)
The prognosis is generally grave (Almost mortality 50% to 48 hs.)
Is related to:
- Location of injury (worse prognosis for deep, for trunk and dumped to Ventri & shy; asses and / or produce hydrocephalus)
- Same size
- Serious disorder awareness (Mortality 90% income coma)Ã ¢?Â
- Intensity and duration of hypertensive crisis.
Hemorrhagic stroke Subarachnoid (HSA)
The most important thing is to think about their existence
Be very careful to:
- Moderate to severe headaches in young people with acute onset
- Headaches in which a neurological compromise is detected or minimal
- In assign etiologies vacancies, as liver or psychic origin
- Síndromes meníngeos mínimos
When in doubt an outpatient, perform symptomatic treatment and especially OBSERVE evolution, if the standard TAC doubts persist and if not possible lumbar puncture
If detection is late or retrospective should be advised immediately consult a specialist center with ambulance with the patient in absolute rest
1- With infectious etiologies of meningeal syndrome, especially meningitis purulentas:
- Sharper Initiation
- Good condition prior health
- Intense headache
- General absence of infectious syndrome
- CT scan revealed blood in the subarachnoid space
- Lumbar puncture LCR hemorrhagic
2- With producers boxes awareness deficit with or without focal neurological signs:
- Spontaneous HIP: predominate signs of neurological deficit and severe disorders of consciousness, but no meningeal syndrome
- Infectious processes, menningoencefalitis or abscesses: predominates septic, no hyperacute onset and sudden headache is not so marked and intensity, Antecedents missing
- TCE: is the most frequent cause of Bleeding subaracnoidea, no signs of violence and trauma history
3- With benign headaches such as migraines and tension headaches
- Chronicity and recurrence of cefaleico box
- No stiff neck and column, at most reduced mobility
- Usually conflicts and stress
- Frequent muscle contracture in other regions
- No neurological compromise
- Computerized Axial Tomography
- Lumbar Puncture
- Cerebral arteriography 4 vessels
Lumbar Puncture Indication
- Clinical picture of Subarachnoid Hemorrhage without possibilities for Axial Tomography.
- Suggestive clinical picture of Subarachnoid Hemorrhage in the presence of inconclusive signs Computerized Axial Tomography.
Etiology and Epidemiology
- The main cause of SAH is rupture of an intracranial aneurysm
- Congenital arterial aneurysms are dilations due to congenital absence of the middle layer I embryological remnants, which are usually pedunculated and settle mostly in the circle of Willis
- It is considered that among the 1 to the 2% of the population have this malformation (Autopsies); while the incidence of subarachnoid hemorrhage aneurysm is 10-20 patients 100.000 population per year
- Predominates in the fourth and fifth decade of life, with slight female predominance 3:2
- 33 % Cerebral-anterior communicating complex
- 33 % Carotid Siphon
- 33% Other locations
Between 15-20 % have multiple aneurysms
- On some occasions and given the growth of these birth defects can result neurological symptoms that are reminiscent of their presence
- Since most settling in the circle of Willis are the most common cranial nerve deficits, especially the oculomotor
- Another situation are incidental findings on the occasion of an imaging study performed for another reason; these patients should be referred to a specialist to evaluate the anatomical context, form, size, age, overall, etc.. and recommend a personalized treatment option
If the CT scan showed subarachnoid hemorrhage:
- Hunt and Hess Scale
- Scale Fisher
- Order coagulation tests
- Start Nimodipine IV 3 cc / h and increased to 5-8 cc / h lentamente monitorizando TAM
- Start IV phenytoin (125 mg c/8 hs)
- Request cerebral pan angiography
- Order urgent assessment by Neurosurgery
- Order urgent assessment by UCI if the Hunt and Hess is two or more or if Fisher is two or more
Hunt and Hess scale
(has prognostic value and guidance Treatment)Ã ¢?Â
(To assess post vasospasm – HSA)
Treatment of Aneurysms
Early complications (0-3days)
- Cerebral edema displacements
- Acute hydrocephalus
- Cardiac dysrhythmias
- Respiratory dysfunction
- Pulmonary Edema
Mediate complications (4-14 días)
- Subacute hydrocephalus
Late complications (>15 días)
- Chronic hydrocephalus
- Pulmonary embolism
- Vasoespasmo cerebral
- Disbalance hidroelectrolítico
Factors associated with rebleeding
- Elderly (> 70)
- Días 0-1 Subarachnoid Hemorrhage
- Poor neurological grading
- Moderate or severe systolic hypertension (170-240)
- Lumbar puncture in the presence of increased intracranial pressure
- Ventriculostomy to relieve PIC
- Associated with hypertension
- Abrupt withdrawal of antifibrinolytic therapy
- Abrupt intubation
Factors that predispose to vasospasm
- Major bleeding that fill the basal cisterns
- Días 4-14 after Subarachnoid Hemorrhage
- Hyponatremia ( Cerebral salt-losing syndrome)
- Hipovolemia ( Decreased blood volume or plasma)
- Recurrent Subarachnoid Hemorrhage
- Antifibrinolytic agents
- Hypotension ( Decreased intravascular volume or pharmacologically induced)
- Increased intracranial pressure
- Others ( Low cardiac output, disrritmias, hypoxia, anemias).
Roughly one 8-15% patients suffering from vasospasm in the first die 24 hours, without medical attention.
The mortality totals:
- 20-25% in the next 48 hours
- 44-56% in the 14 Initial comings
- 66% of 1-2 months after SAH
- Recurrent bleeding; generally more severe than the initial, It is estimated between 3 and 5% the annual risk
- ï? Neurological deficit generated added by embolisms in the aneurysmal sac impact distance
- Vascular occlusion of vessels where the aneurysm sits
- Epilepsy partial or focal
- Depending on the seriousness of the starting box:
- Dependent disorder initial awareness
- Depending on the location and size
- Experience specialist center
- Experience traffickers neurosurgeons
- Experience in the choice of therapeutic method
Between 15-30% not reach the Hospital
Coma deep initial: 87 % mortality with or without surgery
Incidental findings with cold treatment: 0,5% mortality and 2% morbidity
Hemorrhagic stroke Joint
Arteriovenous Malformations (MAV)
Grouped malformations of various kinds:
- true arteriovenous malformations
- venous malformations
- dural arteriovenous fistulas
- and capillary telangiectasias
AVMs are formed by a ball of dilated vessels that form an abnormal communication between the arterial and venous system, forming a fistula areriovenosa.
It is a developmental abnormality characterized by the persistence of an embryonic pattern of blood vessels.
The lesion is present from birth, the onset of symptoms typically occurs between 10 and 30 years old.
Recurrent Headache is a frequent complaint.
They can produce neurological symptoms through various mechanisms:
- First breakdown may occur in the subarachnoid space, into the cerebral ventricles, but it occurs most often in the brain parenchyma.
- In the absence of bleeding, epileptic crisis, progressive neurologic defect develops following a steal phenomenon of blood flow or because of mass effect malformation.
- Are shown in 0,1% population, prevalence 10 times lower than that of aneurysms
- Are the 90% supratentoriales.
- The average risk of bleeding has been evaluated in numerous studies of natural history, estimated in the 2-3% annual.
- After a second hemorrhage risk of rebleeding may increase to 25%. Clinical and neuroimaging at the time of diagnosis data can help predict the risk of future bleeding.
AVMs can bleed:
- brain parenchyma (60%)
- subarachnoid space (30%)
- ventricle (10%)
- Dependent risk factors dependent on the vital subject and factors related to the morphology, location and size of malformations.
- The scale of Spetzler helps to assess the risk of surgery.
- According to the overall assessment it can use the following approaches in isolation or in combination.
- Recurrent bleeding (2-3% annual)
- Progressive ischemia with increased neurological deficit (steal phenomenon)
- Bruising intra parenchymal expansive
- Obstructive hydrocephalus (Aracnoiditis reaction)
- Status epilepticus
- If evitan bleeding recurrences
- Epilepsy: Partial seizures, gral. Easy Control
- Possible increase in neurological deficit
Dr. Bernard Sonzini Astudillo