Cerebrovascular-diseases教学讲解课件

Cerebrovascular 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 great cerebral vessels20-40%Stenosis of vesselsAtherothromboembolismCardiac 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 mater25-30 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 deficitClinical 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 hypertentionTreatment of acute ischemia1.Acute resuscitation2.Reperfusion of the ischemic brain3.Decreasing cerebral metabolic demands4.Inhibition of the degradative ischemic cascade1.Acute resuscitationRespirationIntubation with ventilation for patients in comaSupplementary oxygen for other patientArterial pressureMaintaining 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 recombinant activator for tissue plasminogenIn first 4-6 hours after onsetIf intracerebral hemorrhage is excluded with CTHypervolemic Hemodilution TherapyAnticoagulation?3.Decreasing cerebral metabolic demandsHypothermia?BarbituratesSurgical treatment for acute ischemiaPossible only in cases of stenosis 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,(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 BYPASSCAROTID ENDARTERECTOMYCAROTID ENDARTERECTOMYIndicationsPatients with TIAs with high grade stenosis of CCA or ICA confirmed with ultrasound-dopler and angiographyPatients 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.A Smoothly tapered segmental narrowing.B Sharply demarcated stenosis.endarterectomyCauses of nontraumatic intracranial hemorrhageIntracerebral hemorrhageArterial hypertention(hemorrhagic stroke)Bleeding from Arterio-venous malformation(AVM)Rupture of aneurysm of cerebral vesselCoagulopathiesvasculitisSubarachnoid hemorrhageRupture of aneurysm of cerebral vesselBleeding from Arterio-venous malformation(AVM)Clinical signs of hemorrhagic stroke due to hypertensionSudden and fast onset(seconds minutes)Unconsciousness(semicoma-coma)Severe neurological 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 only for patients in clear consciousness or severe coma(GCS 3-5)Medial hemorrhage(into basal ganglia)Hemorrhage into brainstemSurgical+conservative-for other patientsConservative treatmentRespiration controlIntubation for comatose patientsSupplementary oxygenArterial pressure controlSevere 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 headacheMeningeal signsMinimal focal neurological deficitMore rarely depressed level of consciousness and major neurological deficitDiagnostic procedures for SAHCT Lumbar puncture with CSF examinationBlood in the CSFHigh pressure of CSFSAH and possible intracerebral hemorrhageAngiography the main to reveal the cause of SAH aneurisms and arterio-venous malformationsAneurisms of cerebral arteriesLocalizationAnterior cerebral a.and anterior communicans.-45%Internal carotid a.32%Middle cerebral a.20%Vertebrobasilar circulation 4%Aneurisms of cerebral arteriesSaccularOthers(traumatic,atherosclerotic,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 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 possiblePutting clips on the neck of aneurismEndovascular embolisation of aneurismWith coilsWith balloonsAngiography1 in first day2 3rd day angiospasm of middle cerebral atery3 4th day(after treatment)Internal carotid bifurcation aneurysm.Arteriovenous malformations heterogeneous group of vascular developmental anomalies of the braincomposed 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.Schematic drawing of AVMClinical presentations of AVMsIntracranial hemorrhageIntraparenchymalSubarachnoidSeizuresheadache,progressive neurological deficit,cardiac failure.DiagnosisAngiographyMRIAngiographyMRI AVM in occipital lobeTreatment of AVMsObservationSurgical excisionEndovascular embolizationRadiosurgeryHamma-knifeLinear proton acceleratorHamma-knife谢谢你的阅读v知识就是财富v丰富你的人生谢谢！