Transcript Diagnostics of Brain Infarction

Brain infarction
Stroke
is acute disorders of cerebral circulation,
rapidly developing clinical signs of focal (at
times global) disturbance of cerebral function,
lasting more than 24 hours or leading to death
with no apparent cause other then that of
vascular origin
According to World Health Organization
classification all cerebrovascular diseases are
divided into 3 groups:
1. Premonitary
and initial symptoms of brain blood supply
insufficiency
2. Acute cerebral blood circulation disturbances
a) Dynamic cerebral blood circulation disturbances
• Hypertonic crisis
• Acute hypertonic encephalopathy
b) Strokes:
Haemorrhage
• subdural, epidural
• intracerebral haemorrhage
• ventricular hemorrage
Ischemic
• Brain infarction (nonembolic)
• Brain infarction (embolic)
• Brain infarction (thrombotic)
According to World Health Organization
classification all cerebrovascular diseases are
divided into 3 groups:
3. Dyscirculative encephalopathy or chronic
cerebral blood circulation insufficiency or
slowly progressive insufficiency of cerebral
blood circulation
• I st
• II st
• III st
• Dyscirculative myelopathy or chronic
spinal blood circulation insufficiency
Brain infarction
Classification
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Athetothrombotic
Cardioembolic
Hemodynamic
Lacunar
Haemorhoeological
Lacunar stroke
Penumbra
Center of
infarction
Penumbra
Penumbra
Brain tissue, which we can save
Благодаря любезности J. Saver
Penumbra
The most common causes of brain
infarction
• Atherosclerotic lesion of MAH
• Combination of atherosclerosis with
hypertension
• Chronic ischemic heart disease with rhythm
disorders
• Combination of atherosclerosis with diabetes
• Rheumatism, heart abnormalities (inborn and
acquired)
• Vasculitis
• penumbra
Pathogenetic mechanism of
atherotrombotic ischemic stroke
Atherotrombosis and
microcirculation
Embolism
Adapted from: Topol EJ, Yadav JS. Circulation 2000; 101: 570–80, and Falk E et al.
Circulation 1995; 92: 657–71.
Microvascular embolism
Clinical features
Acute period of brain infarction is divided
into three stages:
• Precursors
• Apoplectic stroke
• Focal signs
Clinical features
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Precursors - transient ischemic attacks in the same
region where brain infarction is developed. Gradually
during several hours focal neurologic symptoms are
developed.
• The prevalence of focal symptoms over the general
cerebral ones.
• General cerebral symptoms manifest as
- Headache
- Vomiting
- consciousness disorders
Focal symptoms depend on localization of the infarction,
damaged vessel and state of collateral blood
circulation.
Territory of Middle cerebral artery
Middle cerebral artery
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Hemiplegia
Hemianesthesia
Gaze paresis
Speech disorders (motor, sensory, total aphasia)
Apracto – agnostic syndrome (lesion is right hemisphere)
Hemianopsia
Apraxia
Alexia
Acalculia
Anozognosia, and autotopognosia (lesion is right
hemisphere)
• Astereognosis
• Agraphia
Infarction in main branch of middle
cerebral artery
CT scan
• Infarction in right
parietal-occipital
region (posterio
branch of middle
cerebral artery
Postischemic cist
Postischemic cist
Postischemic cist
Anterior cerebral artery
• Spastic hemiparesis with the prevalence in
proximal part of upper extremity and distal part
of lower extremity
• Symptoms of oral automatism
• Psychiatric disorders
• Dysphagia
• Dysphonia
• Astasia, abasia
• Motor aphasia
• Retention of urine.
Infarction in anterior cerebral artery
Haemorrhagic transformation
Posterior cerebral artery
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Hemianopsia
Visual agnosia
Hemianesthesia
Hyperpathia
Desorientation in space and time
Optical gnosis
Postischemic cist
Territory of Vertebral artery
Vertebral artery
In case of extracranial lesion:
• systemic dizziness
• Hearing disorders
• Visual disorders
• eye movements disorders
• Vestibular and equilibrium disorders
• paresis with sensory disturbances in extremities
• some patients have “ drop- attacks “.
Basilar artery
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loss of consciousness
eye movements disorders
pseudobulbar syndrome
tetraplegia
muscle tone disturbance
cerebellar symptoms
cortical blindness
vital functions disorders.
Diagnostics of Brain Infarction
The main peculiarities are:
• Before stroke period in the previous
history ( TIA in anamnesis )
• The beginning of the stroke is gradual
• Data of somatic and neurological status
• Additional methods of diagnostics
Diagnostics of Brain Infarction
The main peculiarities are:
• Before stroke period in the previous
history ( TIA in anamnesis )
• The beginning of the stroke is gradual
• Data of somatic and neurological status
• Additional methods of diagnostics
Diagnostics of Brain Infarction
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Rheologic disturbances
Liquor is pellucid, without significant changes.
EEG - There is focus of pathologic activity
USG finds out occlusion, stenosis of carotid and
vertebral arteries
• CT reveals hypodensive focus on the second
day
• MRI helps to find out small focuses and those,
located in the brain stem
Stenosis of internal carotid
artery
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1- PCA, 2- ICA, 3- syphone of ICA, 5- CCA.
Адаптовано з E.Topol. Atlas of Atherothrombosis.- 2005
Strokes treatment
Nondifferential treatment includes:
• Prevention and treatment of pulmonary
insufficiency
• Liquidation of heart – vascular disorders
• Brain edema treatment
• Normalization of water – electrolytes balance
and acid – alkali balance
• Osmosis correction
• Improving of brain metabolism
• Liquidation of hyperthermia and other
autonomic disorders
Differential treatment of brain
infarction
• To renew blood circulation in zone of
ischemia
• To correct rheologic and coagulative
properties of blood, to improve
microcirculation
• To prevent disorders of cerebral
metabolism
• To decrease brain edema
• To treat brain hypoxia
To renew blood circulation in zone of
ischemia
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Actilaza 100 mg I / v by drops every 2 – 3 hours.
Inhibitors of glutamat excretion ( difenin, nimotop,
MgSO4) are used. Nimotop is used 15 mg in 1500
ml of physiologic solution i/v by drops, or in tablets
30 – 60 mg 4 times per day.
In order to improve perfusion we use cavinton 20
mg I /v by drops
At hyperperfussion we use
• euphyllini 10 ml 2.4 % solution,
• penthoxiphyllini,
• diuretics ( manitol 15 % 100 – 200 ml ) ,
• albumini 100 ml I / v.
To improve microcirculation
anticoagulative therapy :
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heparini 5 000 U 4 times per day during 5 – 7 days, the
2 500 U during next 3 –4 days.
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Fraxiparini is considered to be even more effective .
Antiagregants are used also :
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penthoxiphyllini 5 – 10 ml 2 % solution I /v by drops
during 10 days, then 200 mg 3 –4 times per day up to
1 month.
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Sermioni 4 mg I / v by drops during 10 days , then 1
tablet 3 times per day up to 1 month.
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Ticlid 250 mg twice a day.
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Aspirini 250 mg once a day.
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Dipiridamoli 1 – 2 ml i/v by drops during 10 days , then
25 mg 2 –3 times per day.