Cerebrovascular diseases件

1、cerebrovascular diseasescerebrovascular diseasesvascular occlusive diseases (ischemic stroke)intracerebral hemorrhage (hemorrhagic stroke)incidence of stroke150-600 new cases per 100.000 population per year2-3rd leading cause of death1st leading cause disabilityischemic strokeatherosclerosis of grea

2、t cerebral vessels20-40% stenosis of vessels atherothromboembolismcardiac embolism15-30%nonatherosclerotic vasculopaties and hematological abnormalities10-20%unknown10-30%common sites of atherosclerotic disease.normal blood flow55 ml/100g per min - average 80-100 ml/100g per min for gray mater 25-30

3、 ml/100g per min for white matter20 ml/100g - ischemic strokeacute ischemiatransient ischemic attack neurological deficit that resolves during 24 hoursreversible neurological deficit (minor stroke) deficit that resolves completely during more then 24 hoursischemic stroke persistent neurological defi

4、citclinical presentations of ischemic strokesubacute begining (acute in cases of embosilsm)consciousness is clear or short term lost of consiousness. not often unconsciousnessfocal neurological deficit main in clinical pictureheadaches, meningeal signs are not oftenhistory of tias, no history of hyp

5、ertentiontreatment of acute ischemia1. acute resuscitation2. reperfusion of the ischemic brain3. decreasing cerebral metabolic demands4. inhibition of the degradative ischemic cascade1. acute resuscitationrespiration intubation with ventilation for patients in coma supplementary oxygen for other pat

6、ientarterial pressure maintaining mild hypertension (if there is no evidence of hemorrhage) or at least normal blood pressuremaintaining of adequate intravessel volumecontroling heart output and arrhythmiascontrolling of glucose level2. reperfusion of the ischemic brainthrombolytic therapy recombina

7、nt activator for tissue plasminogen in first 4-6 hours after onset if intracerebral hemorrhage is excluded with cthypervolemic hemodilution therapyanticoagulation ?3. decreasing cerebral metabolic demandshypothermia ?barbituratessurgical treatment for acute ischemiapossible only in cases of stenosis

8、 of great brain vessels (common carotid, internal carotid, middle cerebral arteries) endarterectomia in first 2-3 hours. primary stroke prevention controlling of risk factorshypertension (increases risk of stroke in4-5 times)smoking (1,5)diabetes. (2,5-4)lipids. cardiac disease. atrial fibrillation,

9、 (5) valvular heart disease, (4) myocardial infarction (5)secondary stroke prevention (after transient ischemic attack or ischemic stroke)aspirin 30-300 mg per dayor ticlopidine treatment or heart diseasessurgicalsurgical prevention of ischemiaextracranial-to-intracranial carotid artery bypasscaroti

10、d endarterectomycarotid endarterectomyindications patients with tias with high grade stenosis of cca or ica confirmed with ultrasound-dopler and angiography patients after stroke (strokes) that do not cause severe diability angiograms of cervical carotid artery showing varied appearance of critical

11、stenosis of the internal carotid artery. a smoothly tapered segmental narrowing. b sharply demarcated stenosis.endarterectomycauses of nontraumatic intracranial hemorrhageintracerebral hemorrhage arterial hypertention (hemorrhagic stroke) bleeding from arterio-venous malformation (avm) rupture of an

12、eurysm of cerebral vessel coagulopathies vasculitissubarachnoid hemorrhage rupture of aneurysm of cerebral vessel bleeding from arterio-venous malformation (avm)clinical signs of hemorrhagic stroke due to hypertensionsudden and fast onset (seconds minutes)unconsciousness (semicoma-coma)severe neurol

13、ogical deficitvegetative symptoms: high arterial pressure; bradycardia, red face and cyanotic limbs, sweating.severe headache in contact patientsdiagnostic procedurescomputed tomography (ct)angiographyechoegmedial (thalamic) hematomalobar hematomabrainstem (pontine) hemorrhagetreatmentconservative o

14、nly for patients in clear consciousness or severe coma (gcs 3-5) medial hemorrhage (into basal ganglia) hemorrhage into brainstemsurgical + conservative - for other patientsconservative treatmentrespiration control intubation for comatose patients supplementary oxygenarterial pressure control severe

15、 hypertention must be treated gently decrease pressure to mild hypertention during several hours.coagulative status control and correctionsurgical treatment removal of intracerebral hematomaventricular draining in case of occlusive hydrocephalusclinical presentation of sahsudden onsetsevere headache

16、meningeal signsminimal focal neurological deficitmore rarely depressed level of consciousness and major neurological deficitdiagnostic procedures for sahct lumbar puncture with csf examination blood in the csf high pressure of csf sah and possible intracerebral hemorrhageangiography the main to reve

17、al the cause of sah aneurisms and arterio-venous malformationsaneurisms of cerebral arterieslocalization anterior cerebral a. and anterior communicans . - 45% internal carotid a. 32% middle cerebral a. 20% vertebrobasilar circulation 4%aneurisms of cerebral arteriessaccularothers (traumatic, atheros

18、clerotic, mycotic, neoplastic, inflamatory)saccular aneurisms ovoid-shaped outpouching of vessel wall, cased by congenital insufficiency of elastic component of vessel wallsah due to ruptured aneurismfirst rupture of aneurism sah onlyrepeated rupture in 20-50% of cases, most of them during 3-20 days

19、 after first 50-85% mortality after repeated rupture, intracerebral hemorrhage are often at repeated ruptureoften complicated with vasospasm and consequent ischemical changessurgical treatment of aneurismany aneurism should be excluded from circulation as early as possible putting clips on the neck of aneurism endovascular embolisation of aneurismwith coilswith balloonsangiography1 in first day2 3rd day angiospasm of middle cerebral atery3 4th day (after treatment)internal carotid bifurcation aneurysm.arteriovenous ma