7/25/2019 Vascular Avc

1/68

AVC

7/25/2019 Vascular Avc

2/68

Vom discuta:

1. ACCIDENTUL VASCULAR CEREBRAL

-ISCHEMIC

-TROMBOZA VENOASA CEREBRALA

-INFARCTUL MEDULAR

2. HEMORAGIA CEREBRALAINTRAPARENCHIMATOASA

SUBARAHNOIDIANA

7/25/2019 Vascular Avc

3/68

CLASIFICARE:

1. AVC ARTERIAL ISCHEMIC (~80%)

(embolic>trombotic>lacunar)

2. AVC ARTERIAL HEMORAGIC (~10-30%)H.INTRAPARENCHIMATOASA (~13%)

H.SUBARAHNOIDIAN (~12%)

4. AVC VENOS = TROMBOZ/TROMBOFLEBIT SISTEMVENOS CEREBRAL (~2%)

7/25/2019 Vascular Avc

4/68

ACCIDENTUL VASCULAR CEREBRAL (AVC):

= leziune cerebral acut cauzat de ntreruperea fluxului sanguin cerebral

=> URGEN NEUROLOGIC! +/- neurochirurgical/radiologic intervenional

- pacientul tipic vrstnic (dar ~ 15% mai tineri de 45-50 de ani)

- etiopatogenie heterogen factori de risc modificabili/nemodificabili

htt

p://www.eso-stroke.org/eso-stroke/stroke-information/faq/epidemiology-of-stroke.htmlAdams and Victors Principles of Neurology, 10th Ed.

http://www.eso-stroke.org/eso-stroke/stroke-information/faq/epidemiology-of-stroke.htmlhttp://www.eso-stroke.org/eso-stroke/stroke-information/faq/epidemiology-of-stroke.htmlhttp://www.eso-stroke.org/eso-stroke/stroke-information/faq/epidemiology-of-stroke.html

7/25/2019 Vascular Avc

5/68

EPIDEMIOLOGIE

inciden (Europa): 101-239/100.000 brbai, 63-158/100.000 femei

estimare prevalen 2030: 19% din populaie

= 1 din 6 persoane va face AVCn cursul vieii= 15 milioane de persoane fac AVCn fiecare an din care 5 milioane mor i

>5 milioane rmn cu dizabilitate

A TREIA CAUZ DE MORTALITATE LA NIVEL MONDIAL(dup boala cardiovascular)

a doua cauz de mortalitate la persoanele peste 60 de ani

cauz mportant de morbiditate (dizabilitate rezidual cu/fr pierdere deautonomie* calitatea vieii pacientului/anturajului &

ncrctura socio-economic)

http://www.eso-stroke.org/eso-stroke/stroke-information/faq/epidemiology-of-stroke.htmlhttp://www.who.int/cardiovascular_diseases/en/

*scale de activitate cotidian (e.g. scala Rankin modificat, indexul Barthel, ADL)

http://www.eso-stroke.org/eso-stroke/stroke-information/faq/epidemiology-of-stroke.htmlhttp://www.who.int/cardiovascular_diseases/en/http://www.who.int/cardiovascular_diseases/en/http://www.eso-stroke.org/eso-stroke/stroke-information/faq/epidemiology-of-stroke.html

7/25/2019 Vascular Avc

6/68

AVC costa

SUA, 2011; in fiecare an 795 000 nou AVC (610 000 prim episode,

185 000 recidive

1 in 20 morti in SUA (la fiecare 40 sec cineva face Avcsi la 4 min cineva moare)

40/100000 mor

2009 costuri SUA (directe + indirecte): $216.6 miliarde (86 / 130) CANCER vs 320.1miliarde

(195 /124) AVC

7/25/2019 Vascular Avc

7/68

http://www.eso-stroke.org/index.php?id=13799#topic2http://www.strokeforum.com/stroke-background/epidemiology.html

- mortalitatea la 30 de zile depinde de tipulde AVC (ischemie 8-15%, hemoragie

subarahnoidian 42-46%, hemoragieintraparenchimatoas 48-82%)

- mortalitatea la 180 de zile depinde de

comorbiditi /complicaii (pn la 25%corelabil cu un nou AVC) i creteexponenial cu vrsta (x2 la fiecare 5 ani>45 ani)

Mortalitatea datorata AVC

http://www.eso-stroke.org/index.php?id=13799http://www.strokeforum.com/stroke-background/epidemiology.htmlhttp://www.strokeforum.com/stroke-background/epidemiology.htmlhttp://www.eso-stroke.org/index.php?id=13799

7/25/2019 Vascular Avc

8/68http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf?ua=1

http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf?ua=1http://www.who.int/cardiovascular_diseases/en/cvd_atlas_15_burden_stroke.pdf?ua=1

7/25/2019 Vascular Avc

9/68

7/25/2019 Vascular Avc

10/68

populaie educat+

serviciu medical de

urgen dedicat

PROGNOSTICUL AVC

DEPINDE DE PROMPTITUDINEA

I CORECTITUDINEA NGRIJIRII MEDICALE ACORDATE

1. sistem prespital2. uniti de urgene neurovasculare(stroke unit) GHIDURI CLINICE

3. programe de RECUPERARE FUNCIONAL

http://www.eso-stroke.org/eso-stroke/stroke-information/faq/epidemiology-of-stroke.html

http://www.eso-stroke.org/eso-stroke/stroke-information/faq/epidemiology-of-stroke.htmlhttp://www.eso-stroke.org/eso-stroke/stroke-information/faq/epidemiology-of-stroke.html

7/25/2019 Vascular Avc

11/68

- la nivel mondial incidena e n scdere (prevenie mai bun)DAR populaia mbtrnete (!!)

-n Romnia incidena e n posibil cretere (?erori sistematice de raportare)

- mortalitatea e n scdere => prevalena=> morbiditatea (!)

TENDINE:

cea mai bun strategie = PREVENIA

~90% din AVC pot fi prevenite

http://www.world-stroke.org/education/stroke-riskometer

http://www.world-stroke.org/education/stroke-riskometerhttp://www.world-stroke.org/education/stroke-riskometerhttp://www.world-stroke.org/education/stroke-riskometer

7/25/2019 Vascular Avc

12/68

DIAGNOSTIC POZITIV= clinic (fr alt explicaie) + imagistic cerebral

TABLOU CLINIC AVC = deficit neurologic focal cu instalare ictal

! ANAMNEZ: dg dif: hipoglicemie, sincopa, crize epileptice focale

CT cerebral = TDMcerebral: exclude/confirmhemoragia

intraparenchimatoas

IRM (DWI/ADC):

beneficiu suplimentar nanumite situaii

7/25/2019 Vascular Avc

13/68

2 teritorii vasculare:anterior=CAROTIDIAN

posterior=VERTEBRO-BAZILAR

7/25/2019 Vascular Avc

14/68

VASCULARIZAIA ARTERIAL CEREBRAL(artere cervico-cerebrale):

Sursa: Baehr& Frotscher, Duus Topical Diagnosis in Neurology, 4th Ed.

7/25/2019 Vascular Avc

15/68

Adams and Victors Principles of Neurology, 10th

Ed.Baehr& Frotscher, Duus Topical Diagnosis in Neurology, 4th Ed

SISTEMUL ARTERIAL CAROTIDIAN (ANTERIOR):

Crosa aortei a. brahiocefalic + a.carotid comun stng + a. subclavie

stngA. brahiocefalic a. carotidcomun dreapt + a. subclaviedreaptA. carotid comun a.carotid intern + a. carotid externa

IRIGA GLOBUL OCULAR SI PARTEA

ANTERIOARA A CREIERULUI

(HOMUNCULUSUL MOTOR, ARIILE VORBIRII)

A. carotid intern (ACI):- ramuri laterale = a. oftalmic + a.coroidal anterioar + a. comunicantposterioar- ramuri terminale = a. cerebralanterioar + a. cerebral medie

ACA

ACM

ACi

7/25/2019 Vascular Avc

16/68

SISTEMUL ARTERIAL VERTEBRO-BAZLILAR (POSTERIOR):

Adams and Victors Principles of Neurology, 10th

Ed.Baehr& Frotscher, Duus Topical Diagnosis in Neurology, 4th Ed

A. subclavie a. vertebral

A. vertebral dr + stg => a. bazilar(jonciune bulbo-pontin)

Ramuri a. vertebral (intracranian):- a. spinal anterioar- a. spinal posterioar- a. cerebeloas postero-inferioar

A. bazilar:- ramuri laterale = ramuri perforante

(mediane i paramediane) + aa.

circumfereniale lungi (a.cerebeloas antero-inferioar + a.cerebeloas superioar)

- ramuri terminale = a. cerebralposterioar dr + stg

IRIGA TRCH.CEREBRAL SI

CEREBEL:

SD.CEREBELOS

SD.ALTERNE (NERV

CRANIAN SI HEMIPAREZACONTROLATERALA)

7/25/2019 Vascular Avc

17/68

ANASTOMOZE ARTERIO-ARTERIALE:

Sursa: Baehr& Frotscher, Duus Topical Diagnosis in Neurology, 4th Ed.

1. Poligonul lui Willis (anastomoz circulaieanterioar circulaie posterioar)

DIN PACATE, NUMAI LA ~40% ESTE COMPLET

FUNCTIONAL, IN REST VARIANTE

2. Anastomoze cu aa. leptomeningeale

3. Anastomoze cu sistemul carotidian extern

(de regul via a. oftalmic)4. Anastomoze cu ramurile extracraniene ale

aa. vertebrale

EXISTA ANASTOMOZE INTRE

ART.SUPERIFICALE SI PROFUNDE SI

ANTERIOR-POSTERIOR:

BACK-UP IN CAZ DE OCLUZIE ARTERIALA.

7/25/2019 Vascular Avc

18/68

7/25/2019 Vascular Avc

19/68

Adams and Victors Principles of Neurology, 10 th Ed.

7/25/2019 Vascular Avc

20/68

TERITORII ARTERIALE CEREBRALE (CIRCULAIA POSTERIOAR):

Sursa: Moeller& Reif, Pocket Atlas of Sectional Anatomy, Vol I: Head and Neck, 3 rd Ed.

A.cerebeloas postero-inferioar (din vertebral):A.cerebeloas antero-inferioar (din bazilar)A.cerebeloas superioar (din bazilar)

SD.CEREBELOS=ATAXIE

A.cerebral posterioar (ACP, din bazilar, la nivelul fosei interpedunculare):

-ramuri perforante (P1, P2)

talamus, parial mezencefal

-ramuri corticale

a.occipital medial (occipitali parietal), a.occipital lateral(regiune inferioar lob temporal)

HEMIANOPSIE OMONIMA IZOLATA

(infarct unilat)

SAU CECITATE CORTICALA

(infarct bilat)

7/25/2019 Vascular Avc

21/68

AVC (ARTERIAL) ISCHEMIC= deficit neurologic focal, persistnd peste 24 de ore, corelabil cu ntreruperea fluxului

sanguin n teritoriul respectiv (i.e. infarct)

-exist i infarcte cerebrale silenioase clinic (demonstrabile imagistic)

ATAC ISCHEMIC TRANZITOR (AIT) = deficit neurologic focal tranzitor, atribuibil unui

teritoriu arterial, persistnd sub 24 de ore (de fapt sub 2 ore, tipic sub 20 de minute)

Progres tehnologic AIT = deficit neurologic focal tranzitor cauzat de ischemie

cerebral focal, fr infarct (IRM)

AIT = URGEN NEUROLOGIC!

- riscul AVC post AIT: ~17% la 90 de zile (riscul la 7 zile scor ABCD = age, blood

pressure, clinica, durata)

7/25/2019 Vascular Avc

22/68

CREIERUL ARE NEVOIE DE MULT OXIGEN

FIZIOLOGIE:

Creierul=2% din greutateacorpului dar 20% din

consumul de oxygen inrepaus

Necesar O2 : 3 3.5ml/100gm/min

Copii: 5 ml/100gm/min

Creierul are un metabolismridicat

De aceea creierul are nevoie deun flux sanguin constant siconsistent

55ml/100gm/min

requires moreare nevoi

energetice

crescutesubstrate

dar nu

poate stoca

energia

7/25/2019 Vascular Avc

23/68

FIZIOPATOLOGIE:

-la 20-40ml/100g/min disfuncie cerebral(ischemie)

-la 10-15ml/100g/min leziune tisular ireversibil(necroz)

AVC = miez (necroz) + penumbr(ischemie)

Penumbra = esut potenial salvabil DAR la risc denecrozare

NB! Reinstituirea prompt a

fluxului sanguin cerebralpoate salva penumbra

(AVC = URGEN)

La periferia penumbrei circulaie de lux = RISC detransformare hemoragic!

7/25/2019 Vascular Avc

24/68

7/25/2019 Vascular Avc

25/68

7/25/2019 Vascular Avc

26/68

7/25/2019 Vascular Avc

27/68

SINDROAME VASCULARE CIRCULAIE POSTERIOAR:

1.ACP segment precomunicant: hemihipoestezie contralateral,hemianopsie homonim contralateral i agnozii vizuale, rar afazietalamic; segment post-comunicant: hemianopsie homonim

contralateral, agnozii vizuale

2. A. cerebeloas postero-inferioar: sindrom Wallenberg (ipsilateral:sindrom Horner, parz de vl palatin, hemiataxie, hipoestezie termo-algic hemifa; contralateral: hipoestezie termo-algic membre). NU

ARE DEFICIT MOTOR

NB! indic localizarea posterioar: afectarea de nervi cranieni (diplopie, vertij,disfagie sever, disfonie sever, dizartrie sever), sindroame alterne

7/25/2019 Vascular Avc

28/68

Galluci& al, Radiographic Atlas of Skull and Brain Anatomy, 2005

TERTORII DE GRANI!

Vulnerabile e la batranii care fac

hipotensiune si au vasoreglare proasta

7/25/2019 Vascular Avc

29/68

DIAGNOSTIC POZITIV: anamnez (INSTALARE BRUSCA)+ examen clinic + CTcerebral

NB! absena modificrilor CT nu exclude diagnosticul de AVC ischemic, darexclude AVC hemoragic

Trebuie stabilita cauza AVC

ischemic, pentru a preveni un

nou AVC

Embolie din cord; vas-vasTromboza (vas mare sau vas mic)

Hipodebit

Factori ce tin de sange: coagulopatii, policitemii

Factori ce tin de vas: inflamatie

7/25/2019 Vascular Avc

30/68

Cum gandesc cauza unui AVC ischemic:

Cord? (embolie)

Vas? (embolie v-v; obstructie)

Sange? (coagulare++; vascozitate++)

7/25/2019 Vascular Avc

31/68

Caz: sunteti de garda si

Un pacient de 20 de ani, student si sportiv (arte martiale amatori) prezintadoua episoade de cate 15 minute de scadere AV OS cu o zi inainte deprezentare. Se prezinta adus de prietena sa pentru ca nu si-a mai gasitcuvintele in timp ce se afla la facultate si nu mai putea scrie; isi revinedupa o ora; la examinare, are pupila miotica OS, fara alte semneneurologice. Se simte bine si nu vrea sa ramana internat. Ce ati face?

1. L-ati trimite acasa, pentru ca si-a revenit; 2. L-ati trimite la oftalmolog 3. L-ati sfatui sa nu se mai sperie asa usor, si eventual sa nu mai asculte

sfaturile prietenei sale

4. L-ati trimite la medicul de familie sa faca analize de sange

5. altceva decat 1-4

7/25/2019 Vascular Avc

32/68

7/25/2019 Vascular Avc

33/68

AIT este MARE URGENTA NEUROLOGICA

RISCUL DE AVC CONSTITUIT!!!!!!

Chiar daca se simt bine, opriti-i!

EKG TDM cerebral obligatoriu + bilant vascular

Ce cauza credeti ca s-ar afla cel mai probabil la origineaAIT carotidiene la pacientul mentionat?

1. ateroscleroza

2. embolii cardiace

3. disectia de A. carotida

7/25/2019 Vascular Avc

34/68

Disectia de a. carotida: semne in teritoriileramurilor emergente din ACI: a.oftalamica(amauroza), afazie, hemipareza predominant

facio-brahiala (ACM), hemiparezapredominant crurala (ACA)

+ex.Doppler cervical

Dupa TDM: anticoagulare sau antiagregant

NU se scade TA ca in disectia de aorta

7/25/2019 Vascular Avc

35/68

NB!!! DISECIA ARTERIAL (la tineri)

7/25/2019 Vascular Avc

36/68

AVC ATEROTROMBOTICPLACA DE ATEROM:

Sursa: Anne G. Osborn, Osborns Brain Imaging, 2012Sursa: Baehr& Frotscher, Duus Topical Diagnosis in Neurology, 4th

Ed.

( )

7/25/2019 Vascular Avc

37/68

7/25/2019 Vascular Avc

38/68

ALTE CAUZE de AVC in afara ATS CARE IN DEARTERELE MARI:

Anne G. Osborn, Osborns Brain Imaging, 2012Mowzoon & Flemming, Neurology Board Review: An Ilustrated Guide, 1st Ed.

RAR: FIBRODISPLAZIE MUSCULAR

RAR: BOALA MOYAMOYA, DSA

(mai ales la asiatici, uneori AVC

hemoragic)

ARTERE EXTRACRANIENE:

-disecie (post traumatic/spontan)- vasculit artere extracraniene (eg Takayasu, ACG)- vasculopatie post-radic- fibrodisplazie muscular

ARTERE INTRACRANIENE

- disecie

-vasculite (primitiv SNC, sistemiceautoimune/autoinflamatorii,

infecioase)-vasculopatii non-inflamatorii (post-radic,

moyamoya, medicamentoase, boal Degos, sd.Susac, post-partum, limfom

intravascular; ANEVRISM TROMBOZAT)

RAR: VASCULIT CEREBRAL

7/25/2019 Vascular Avc

39/68

7/25/2019 Vascular Avc

40/68

AVC embolic e cel mai frecvent AVC

ischemic

investigati cordul: cautati aritmii

emboligene sau alte surse de embolie

7/25/2019 Vascular Avc

41/68

7/25/2019 Vascular Avc

42/68

Abordare practica AVC

Suspiciunea de AVC la UPU: daca exista SectieNeurologie in apropiere = cheama Neurologul

-daca sub 4.5h TROMBOLIZA?

7/25/2019 Vascular Avc

43/68

7/25/2019 Vascular Avc

44/68

Din punct de vedere al urgentistului care

suspecteaza AVC ischemic:

Nu pune perfuzie glucoza daca nu ehipoglicemic

Nu scadea tensiunea arteriala

TDM cerebral obligatoriu

7/25/2019 Vascular Avc

45/68

Inainte de a considera un deficit ca AVC : excludeti traumatismul cranian

7/25/2019 Vascular Avc

46/68

7/25/2019 Vascular Avc

47/68

7/25/2019 Vascular Avc

48/68

7/25/2019 Vascular Avc

49/68

DIAGNOSTIC ETIOPATOGENIC AVC ISCHEMIC i AIT

BILAN CEREBRO-VASCULAR STANDARD

- EKG- ecografie duplex artere cervico-cerebrale

- ecografie cardiac transtoracal

IN CAZURI SELECIONATE- montiorizare EKG 1-7 zile (pn la cumularea a 30 de zile n primele 6 luni conform

ASA/AHA dac AVC embolic criptogen)- ecografie cardiac transesofagian- angioCT artere cervico-cerebrale

- angioRM artere cervico-cerebrale

- angiografie cu substracie digital (DSA), de regul pre-intervenie vascular(endarterectomie, stentare)

- bilan trombofilii genetice/ dobndite i/sau alte patologii multi-sistemice (boliautoimune, boli metabolice etc)

- polisomnografgie (APNEE DE SOMN!)

NB! EVALUAREA FACTORILOR CLASICI MODIFICABILI DE RISC VASCULAR

7/25/2019 Vascular Avc

50/68

Diagnosticul AVC ischemic URGEN!

PRIORITI:

1. Terapie de recanalizare (tromboliz/fibrinoliz farmacologic): DA/NU?- tPA iv, uniti neurovasculare-Programul Naional de fibrinoliz n AVC ischemice acute (!primele 3ore de la debut)- candidat tromboliz = criterii de includere, fr criterii de excludere +CONSIMMNT INFORMAT

NB! tromboliza mecanic aduce beneficiu (2014), neimplementat nc pe scal larg

2. Profilaxie secundar:- antiagregant plachetar / anticoagulant, depinznd de mecanismul AVC

- controlul optim al factorilor modificabili de risc vascular

3. Prevenirea complicaiilor precoce i tardive:- ulcere de decubit, tromboz venoas profund (+/-TEP), bronhopneumonie deaspiraie, depresie

7/25/2019 Vascular Avc

51/68

7/25/2019 Vascular Avc

52/68

7/25/2019 Vascular Avc

53/68

7/25/2019 Vascular Avc

54/68

7/25/2019 Vascular Avc

55/68

7/25/2019 Vascular Avc

56/68

PROFILAXIE SECUNDAR AVC ISCHEMIC / AIT

7/25/2019 Vascular Avc

57/68

PROFILAXIE SECUNDAR AVC ISCHEMIC / AIT:

Corecie factori de risc vascular :-HTA: iniiere terapie antihipertensiv dup primele zile de la AVC dacTAS140mmHg i/sau TAS90mmHg; la cei anterior tratai, reluarea terapieiantihipertensive la cteva zile dup AVC; TA int < 140/90mmHg (la cei cu AVClacunar, rezonabil chiar

7/25/2019 Vascular Avc

58/68

ATEROMATOZ CAROTIDIAN EXTRACRANIAN SIMPTOMATIC (ASA/AHA):

7/25/2019 Vascular Avc

59/68

ATEROMATOZ CAROTIDIAN EXTRACRANIAN SIMPTOMATIC (ASA/AHA):

-AIT/AVC ischemic carotidian n ultimele 6 luni i stenoz carotidianipsilateral sever (70-99% documentat prin imagistic non-invaziv):endarterectomie carotidan, dac riscul perioperator estimat 70% non-invaziv/ >50% invaziv care au contraindicaie de endarterectomie, dac risculperioperator estimat 50% arter mare intracranian: aspirin 325mg/zi- stenoz 70-99% + AVC/AIT recent: asocierea clopidogrel75mg/zi, 90 de zile + TAS int

7/25/2019 Vascular Avc

60/68

Baehr& Frotscher, Duus Topical Diagnosis in Neurology, 4th Ed.Mowzoon & Flemming, Neurology Board Review: An Ilustrated Guide, 1st Ed

SISTEM VENOS CEREBRAL = SINUSURI VENOASE + vene

7/25/2019 Vascular Avc

61/68

7/25/2019 Vascular Avc

62/68

TROMBOZ SINUS VENOS CEREBRAL:

= infarct venos (de regul hemoragic), femei- sub 1-2% din totalul AVC (rar)

- mortalitate la 30 de zile ~5%- recuren 2-4%

FACTORI DE RISC TRANZITORI: sarcin/post-partum, anticoncepionale orale/ altemedicamente (corticosteroizi, tamoxifen), infecii ORL/ fa/ sistemice (contiguitate /

drenaj venos), deshidratare, traumatisme craniene, puncie lombar/ alte proceduri,cateter venos central jugular

FACTORI DE RISC PERMANENI: cancere (SNC, hematologice, altele), boli inflamatoriisistemice (boal Behcet, sarcoidoz, LES/ alte vasculite, boala inflamatorie intestinal),trombofilii genetice (factor V Leiden, hiperhomocisteinemie, deficit de protein C i S,deficit de antitrombin etc), alte stri procoagulante (sindromul antifosfolidic,hemoglobinuria paroxistic noctun, sindromul nefrotic), fistula arterio-dural

7/25/2019 Vascular Avc

63/68

7/25/2019 Vascular Avc

64/68

7/25/2019 Vascular Avc

65/68

7/25/2019 Vascular Avc

66/68

7/25/2019 Vascular Avc

67/68

7/25/2019 Vascular Avc

68/68