精神病學課件：Cerebrovascular Diseases(part II)

1、 Cerebrovascular Diseases(part II)OutlineIntroductionTransient Ischemic Attacks (TIA)Ischemic strokeIntracerebral HemorrhageSubarachnoid HemorrhageIntracerebral hemorrhage(ICH)Spontaneous Intracerebral Hemorrhage(SICH)Accounts for 2030% of all CVD30 day mortality: 3550%Brain hemisphere 80%, brain st

2、em and cerebellum 20%Etiology Primary ICH (78-88% cases)Hypertension (Essential, eclampsia, drug induced)Cerebral Amyloid Angiopathy (-50% individuals greater than 80 years old)Vascular malformationAneurysmAvmBleeding diathesis (體質(zhì)）, coagulopathyTumorTraumaVasculitisCT examplesPathophysiology Primar

3、y-immediate effectsHemorrhage growthIncreased ICPSecondary effectsEdemaIschemiaHemorrhage is dynamic; process continues for several hoursICH Hemorrhage GrowthHematoma growth occurs in patients with normal coagulation profilesHematoma growth occurs within the first few hours (up to 40% in the first 3

4、 hours) and is rare after 24 hoursIs associated with a worse outcomeHemorrhage Growth-PredictorsInitial Hematoma volumeIrregular shapeLiver diseaseHypertensionHyperglycemiaAlcohol useHypofibrinogenimaEdema & ischemic penumbraUp to 75% increase in volume in the first 24 hoursPeaks around 5 to 6 days

5、and lasts up to 14 daysEarly large edema relative to hematoma is a predictor of poor outcomeGlobal cerebral ischemiaVery elevated ICP and low cerebral perfusion pressureClinical featuresFeatures of intracranial hypertensionHeadache, vomiting, decreased level of consciousness (LOC)Correlated with hem

6、atoma size and prognosisProgressive over timeSeizures in lobar ICHFocal neurological deficits depending on the location of ICHFeatures of intracranial hypertensionHypertension (90%)Altered mental status (50%)Uncommon in patients with ischemic strokeHeadache (40%) : 17% with ischemic strokeVomiting (

7、49%) 2% Ischemic stroke; 45% with SAHSeizures (6-7%)Trend toward worse outcomeFocal neurological deficitsBasal ganglia (50%)Contralateral hemiparesis, sensory loss, hemianopiaLobar regions (20-50%)Contralateral hemiparesis or sensory loss, aphasia, neglect, or confusionThalamus (10-15%)Contralateral

8、 hemiparesis, sensory loss, gaze paresisPons (5-12%)Quadriparesis, facial weakness, decreased level of consciousnessCerebellum (1-5%)Ataxia, miosis, vertigoDiagnosisSudden onset of focal neurological deficitIncrease ICPHeadache, Decreased LOC, Elevated BPProgresses over minutes to hoursImaging studi

9、es reveal parenchymal beelding Hematoma growth seen during 24 h from the initial presentation at 35 hManagement principlesAirway supportDecreased level of consciousnessBulbar muscle dysfunctionIntracranial pressure controlBlood pressure controlAnticoagulation reversalSurgeryIntracranial pressure con

10、trol20% Manitol 125ml250ml ivgtt, q46h*57dFurosimide 2040mg iv or imif refractory to mannitol Glycerol Fructose 500ml ivgtt qdbidAcute management of BPBP200/110mmHg is an indication of blood loweringHow fast should BP be lowered?Rapidly lowering MAP by 15% does not lower CBFReductions of 20% can aff

11、ect CBFCurrent guidelines suggest a reduction of 20% in the first 24 hrsWhich agents should be used?Short and rapidly acting IV antihypertensiveLabetalol(拉貝洛爾), esmolol(艾司洛爾), hydralazine(肼苯噠嗪), nicardipine(尼卡地平), enalapril(依那普利，ACEI)Sodium nitroprusside(硝普鈉) and nitroglycerin（硝酸甘油） should be used w

12、ith caution d/t vasodilation and potential effect on ICPAnticoagulation associated ICHWarfarin is a Vit K antagonistInhibits biosynthesis of factors II, VII, IX, XMaximum effect is 48 hrs after administrationHigh dose Vitamin K 10-20 mg IV slow infusionEffect takes 12-24hrsHelps achieving sustained

13、reversal of INRFresh frozen plasma 15cc/kg 4UVolume overload, insufficient factor IXABO compatibility, thawing, infusion time (30hrs)Anticoagulation associated ICHICH associated with IV heparinRapidly normalize activated partial thromboplastin timeProtamine sulfate 0.250.75 mg per 100 U heparin, adj

14、usted for time since last heparin doseSlow IV injection (30ml, talamus 15ml)Cerebellum (10ml or 3cm in diameter)CSF drainageCommunicating hydrocephalusICH questionsWhat are clinical features of ICH?What are presentations of internal capsule hemorrhage?What are treatment principles of ICH?OutlineIntr

15、oductionTransient Ischemic Attacks (TIA)Ischemic strokeIntracerebral HemorrhageSubarachnoid HemorrhageSubarachnoid Hemorrhage(SAH)A bleeding into the subarachnoid spaceA rupture of a berry aneurysm or arteriovenous malformation (AVM)Internal carotid arteryPosterior communicating arteryaneurysmEpidem

16、iology of SAHIncidence about 10/100,000/yrMean age of onset 51 years55% womenmen predominate until age 50, then more womenRisk factorscigarette smokingHeavy alcohol intakehypertensionfamily historyCase fatality rates for SAHPopulation-based study in England with essentially complete case ascertainme

17、nt24 hour mortality: 21%7 days: 37%30 days: 44%Relative risk for patients over 60 years vs. younger = 2.95Pobereskin JNNP 2001;70:340-3Aneurysm: a balloon-like bulge or weakening of an artery wall that rupturesArteriovenous malformation (AVM)Others: dissecting aneurysm,arteritis, venous sinus thromb

18、osis, hypocoagulable disorders, brain tumor, congenital defect(1%) A severe head injury, usually occurs near the site of a skull fracture or intracerebral contusion. ETIOLOGYPATHOPHYSIOLOGYCommon sites of aneurysmsClinical featuresFemale preponderance(F:M=1.6:1)Symptom onset: exercise, emotional str

19、essSudden severe headache, 80% of patients“Worst headache in my life”3050% warning headache 2wks before aneurysms ruptureNausea and vomiting(77%)Confusion, stupor, comaseizureSymptoms Meningeal irritation sign: nuchal rigidity, Kernig sign and Brudzinski signNot obvious in older patientsOphthalmosco

20、pe: vitreous membrane hemorrhage, papilledema, retinal hemorrhageFocal neurological deficits: 3rd nerve palsySubhyaloid hemorrhageFlame and dot hemorrhagesRebleedingVasospasmHydrocephalusOthers: SeizuresOsmolar disturbancesMyocardial infarction and /or arrhythmiasCOMPLICATIONS Rebleeding associated

21、with 50% fatality rate 4% of re-bleeding occurs within the first 24 hours 20-30% within the first month and 3% per year thereafterRisk factors for re-bleeding:Higher initial blood pressure170 mmHgWorse neurological status on admission (coma)Headache and symptoms occur one more time or become worse,

22、CT shows more bleedingVasospasm 2030% of patients, is associated with delayed ischemia and deathSigns of ischemia appear 414days, most often at 7 daysPotential mechanismsRBC hemolysis and subsequent release of oxygen, Hb, and other active oxygen speciesSecondary effects -Vessel wall changes Hydrocep

23、halus 1520% patientsMay develops at any time. Acute, or over a few days or weeksProgressive drowsiness, gait difficulties, abulia(意志力喪失) with incontinenceCT scanning shows enlarged ventricles Diagnostic approachesCTSensitivity 9095% with in 24hrsintracerebral hemorrhage, mass effect, and hydrocephal

24、usMRI4 days 2wks, detects deoxygenated hemoglobinDSAUseful for aneurysm location and vasospasmDone within 3 d or after 4 wks to avoid rebleeding and vasospasmDiagnostic approachesLumbar puncture (LP)Suspected SAH with negative CT, not for first choiceBetter be performed 12 hrs after SAH“Traumatic Ta

25、p” occurs in up to 20% of LPs “Three tubes strategy” can be used to identify “traumatic tap”More subtle subarachnoid hemorrhageInterhemispheric fissureSylvian fissureSAH with early hydrocephalus(ACLS text)Initial angiogramRepeat angiogram showing vasospasm (small arrows)Vasospasm in acute SAHDiagnos

26、isAbrupt severe headache with vomiting and nausea, and /or decreased level of consciousnessMeningeal irritatation signPositive CT findings, DSA (aneurysm and vasospasm)Differential diagnosisSAH vs. other strokesSAH in older patients: no obvious headacheMeningitisHistory, symptom onset, CSF profiles,

27、 CT fails to show positive signs of hemorrhageTreatment principles General managementTreating cerebral hypertensionsee cerebral infarctionDealing with complicationsRebleedingVasospasmHydrocephalusEpilepsyHyponatremia (low blood sodium)Rebleeding Rest in peace for 46 wksAnalgesiaAntifibrinolytic ther

28、apy (23 wks), in combination with nimodipine to prevent ischemiamay be useful between presentation and early surgeryEACA (aminocaproic acid)Aminomethylbenzoic Acid (PAMBA)Blood pressure managementlabetalol, hydralazine, nicardipineSurgery early surgery (within first 3 days)Clipping, CoilingGuglielmi detachable coilBasilar artery aneurysm before coilingBasilar artery aneurysm after coilingVasospasmPrevention of arterial narrowingSubarachnoid blood removal (lumbar drai