Cerebrovascular diseases

1. Cerebrovascular diseases

2. Cerebrovascular diseases • Vascular occlusive diseases (ischemic stroke) • Intracerebral hemorrhage (hemorrhagic stroke)

3. Incidence of stroke • 150-600 new cases per 100.000 population per year • 2-3rd leading cause of death • 1st leading cause disability

4. Ischemic stroke • Atherosclerosis of great cerebral vessels 20-40% • Stenosis of vessels • Atherothromboembolism • Cardiac embolism 15-30% • Nonatherosclerotic vasculopaties and hematological abnormalities 10-20% • Unknown 10-30%

5. Common sites of atherosclerotic disease.

6. 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 • <20 ml/100g - ischemic stroke

7. Acute ischemia • Transient Ischemic attack – neurological deficit that resolves during 24 hours • Reversible neurological deficit (minor stroke) – deficit that resolves completely during more then 24 hours • Ischemic stroke – persistent neurological deficit

8. Clinical presentations of ischemic stroke • 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 picture • Headaches, meningeal signs are not often • History of TIAs, no history of hypertention

10. Treatment of acute ischemia • 1. Acute resuscitation • 2. Reperfusion of the ischemic brain • 3. Decreasing cerebral metabolic demands • 4. Inhibition of the degradative ischemic cascade

11. 1. Acute resuscitation • Respiration • Intubation with ventilation for patients in coma • Supplementary oxygen for other patient • Arterial pressure • 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

12. 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 CT • Hypervolemic Hemodilution Therapy • Anticoagulation ???

13. 3. Decreasing cerebral metabolic demands • Hypothermia ??? • Barbiturates

14. Surgical treatment for acute ischemia • Possible only in cases of stenosis of great brain vessels (common carotid, internal carotid, middle cerebral arteries) – endarterectomia in first 2-3 hours.

15. 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. • Atrial fibrillation, (5) • valvular heart disease, (4) • myocardial infarction (5)

16. Secondary Stroke Prevention (After Transient Ischemic Attack or Ischemic Stroke) • Aspirin 30-300 mg per day • Or Ticlopidine • Treatment or heart diseases • Surgical

17. Surgical prevention of ischemia • EXTRACRANIAL-TO-INTRACRANIAL CAROTID ARTERY BYPASS • CAROTID ENDARTERECTOMY

18. CAROTID ENDARTERECTOMY • Indications • 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

19. angiograms of cervical carotid artery showing varied appearance of critical stenosis of the internal carotid artery. • ASmoothly tapered segmental narrowing. • BSharply demarcated stenosis.

20. endarterectomy

21. Causes of nontraumatic intracranial hemorrhage • Intracerebral hemorrhage • Arterial hypertention (hemorrhagic stroke) • Bleeding from Arterio-venous malformation (AVM) • Rupture of aneurysm of cerebral vessel • Coagulopathies • vasculitis • Subarachnoid hemorrhage • Rupture of aneurysm of cerebral vessel • Bleeding from Arterio-venous malformation (AVM)

22. Clinical signs of hemorrhagic stroke due to hypertension • Sudden and fast onset (seconds – minutes) • Unconsciousness (semicoma-coma) • Severe neurological deficit • Vegetative symptoms: high arterial pressure; bradycardia, red face and cyanotic limbs, sweating. • Severe headache in contact patients

23. Diagnostic procedures • Computed tomography (CT) • Angiography • EchoEG

24. Medial (thalamic) hematoma

25. Lobar hematoma

26. Brainstem (pontine) hemorrhage

27. Treatment • Conservative only – • for patients in clear consciousness or severe coma (GCS 3-5) • Medial hemorrhage (into basal ganglia) • Hemorrhage into brainstem • Surgical + conservative - for other patients

28. Conservative treatment • Respiration control • Intubation for comatose patients • Supplementary oxygen • Arterial pressure control • Severe hypertention must be treated gently – decrease pressure to mild hypertention during several hours. • Coagulative status control and correction

29. Surgical treatment • Removal of intracerebral hematoma • Ventricular draining in case of occlusive hydrocephalus

30. Clinical presentation of SAH • Sudden onset • Severe headache • Meningeal signs • Minimal focal neurological deficit • More rarely depressed level of consciousness and major neurological deficit

31. Diagnostic procedures for SAH • CT • Lumbar puncture with CSF examination • Blood in the CSF • High pressure of CSF • SAH and possible intracerebral hemorrhage • Angiography – the main to reveal the cause of SAH – aneurisms and arterio-venous malformations

32. Aneurisms of cerebral arteries • Localization • Anterior cerebral a. and anterior communicans . - 45% • Internal carotid a. – 32% • Middle cerebral a. – 20% • Vertebrobasilar circulation – 4%

33. Aneurisms of cerebral arteries • Saccular • Others (traumatic, atherosclerotic, mycotic, neoplastic, inflamatory) • Saccular aneurisms – ovoid-shaped outpouching of vessel wall, cased by congenital insufficiency of elastic component of vessel wall

35. SAH due to ruptured aneurism • First rupture of aneurism – SAH only • Repeated rupture in 20-50% of cases, most of them during 3-20 days after first • 50-85% mortality after repeated rupture, • Intracerebral hemorrhage are often at repeated rupture • Often complicated with vasospasm and consequent ischemical changes

36. Surgical treatment of aneurism • Any aneurism should be excluded from circulation as early as possible • Putting clips on the neck of aneurism • Endovascular embolisation of aneurism • With coils • With balloons

37. Angiography • 1 – in first day • 2 – 3rd day – angiospasm of middle cerebral atery • 3 – 4th day (after treatment)

39. Internal carotid bifurcation aneurysm.

41. Arteriovenous malformations • heterogeneous group of vascular developmental anomalies of the brain • composed of a mass of abnormal arteries and veins of different sizes. • Functionally, they represent direct artery-to-vein shunting with no intervening capillaries, • angiographically are seen as early filling of veins.

42. Schematic drawing of AVM

43. Clinical presentations of AVMs • Intracranial hemorrhage • Intraparenchymal • Subarachnoid • Seizures • headache, • progressive neurological deficit, • cardiac failure.

44. Diagnosis • Angiography • MRI

45. Angiography

46. MRI – AVM in occipital lobe

47. Treatment of AVMs • Observation • Surgical excision • Endovascular embolization • Radiosurgery • Hamma-knife • Linear proton accelerator

48. Hamma-knife