pemicu 2 dua

8/16/2019 Pemicu 2 dua

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Pemicu 2

StevenOctavianus

405080098


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Cerebrovascular Diseases•

CVD

any abnormality of the brain resultingfrom a athologic rocess of the bloo! vessels"inclu!ing occlusion of the lumen byembolus#thrombus" ruture of a vessel" an

altere! ermeability of the vessel $all"increase! viscosity or other change in the%uality of the bloo! &o$

• Cerebrovascular !iseases inclu!e some of the

most common an! !evastating !isor!ers' – ischemic stro(e

– hemorrhagic stro(e

– cerebrovascular anomalies such as intracranialaneurysms an! arteriovenous malformations )*V+s,-


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Causes of cerebral abnormalities

•

*therosclerothicthrombosis

• .ransient ischemicattac(s

• /mbolism• yertensive

hemorrhage

•

*rteritis• 1uture!

• *rteriovenoususmalformation

• ematologic!isor!ers

• .rauma an!!issection of

caroti! an! basilararteries

• Comlications ofarteriograhy

• *myloi!angioathy

• Cerebral

thrombohlebitis


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CVD Characteristic of each age erio!

• Prenatal

– Porencehaly – y!ranencehaly

– ioic3ischemic !amage

– nilateral cerebral infarction

• Perinatal an! ostnatal –

Car!ioresiratory failure – Periventricular infarcts

– emorrhagic !isease of thene$born

• nfancy an! chil!hoo! – schemic infarction

– Congenital heart !isease

– Sic(le cell anemia

– 6acterial en!ocar!itis

– 1heumatic fever

– S7/

• +i!!le age – *therosclerotic

thrombosis an! embolism

– Car!iogenic embolism

– yertensive cerebralhemorrhage

– 1uture! saccularaneurysm

– *rterial !issection

• 7ate a!ult life – *therosclerotic thrombotic

acclusive !isease

– /mbolic !isease

– 7acunar stro(e

– 6rain hemorrhage


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1is( factor for stro(e

• yertension

• *trial brilation

•

D+• Smo(ing

• yerlii!emia

•

yercoagulable state


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Stro(e Symtoms

• Su!!en numbness or $ea(ness of face" armor leg" esecially on one si!e of the bo!y

• Su!!en confusion" trouble un!erstan!ing orsea(ing

• Su!!en trouble seeing in one or both eyes

• Su!!en trouble $al(ing" !iiness" loss ofbalance or coor!ination

• Su!!en severe hea!ache $ith no (no$n

cause


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Other Symtoms

• Su!!en nausea" fever an! vomiting"!istinguishe! from a viral illness by rai!onset )minutes or hours vs- !ays,

• 6rief loss of consciousness or erio! of!ecrease! consciousness)fainting" confusion" convulsions or coma,


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*nterior Cerebral *rtery

• .he *C* is !ivi!e! into t$osegments' the recommunal )*:,circle of ;illis" or stem" $hich

connects the internal caroti! arteryto the anterior communicatingartery" an! the ostcommunal )*2,

segment !istal to the anteriorcommunicating artery


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+i!!le cerebral artery


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Signs and symptoms: Structures involved

– Paralysis of the contralateral face" arm" an! leg< sensory

imairment over the same – +otor ahasia'

– Central ahasia" $or! !eafness" anomia" =argon seech"sensory agrahia" acalculia" aleia" nger agnosia" right3leftconfusion )the last four comrise the >erstmann syn!rome,'Central, suprasylvian speech area and parietooccipital cortex of

the dominant hemisphere

– Con!uction ahasia' Central speech area (parietal operculum)

– *ractognosia of the non!ominant hemishere" anosognosia"hemiasomatognosia" unilateral neglect" agnosia for the left halfof eternal sace" !ressing ?araia"? constructional ?araia"?

!istortion of visual coor!inates" inaccurate localiation in thehalf el!" imaire! ability to =u!ge !istance" usi!e3!o$nrea!ing-

– omonymous hemianoia )often homonymous inferior%ua!rantanoia,'

–

Paralysis of con=ugate gae to the oosite si!e


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*nterior cerebral artery


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• Signs and symptoms:Structures involved

– Paralysis of oosite foot an! leg' Motor leg area

– * lesser !egree of aresis of oosite arm' Arm area of cortex or

bers descending to corona radiata

– Cortical sensory loss over toes" foot" an! leg' Sensory area for footand leg

– rinary incontinence' Sensorimotor area in paracentral lobule

– Contralateral gras re&e" suc(ing re&e" gegenhalten )aratonic

rigi!ity,' Medial surface of the posterior frontal lobe; lielysupplemental motor area

– *bulia )a(inetic mutism," slo$ness" !elay" intermittent interrution"lac( of sontaneity" $hisering" re&e !istraction to sights an!soun!s' !ncertain locali"ation#probably cingulate gyrus andmedial inferior portion of frontal, parietal, and temporal lobes

– mairment of gait an! stance )gait araia,' $rontal cortex nearleg motor area

– Dysraia of left limbs" tactile ahasia in left limbs' Corpuscallosum


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Posterior Cerebral *rtery

• n @5A of cases" both PC*s arise from the bifurcationof the basilar artery< in 20A" one has its origin fromthe isilateral internal caroti! artery via the osteriorcommunicating artery< in 5A" both originate from the

resective isilateral internal caroti! arteries• P: Syn!romes

– nfarction usually occurs in the isilateral subthalamus an!me!ial thalamus an! in the isilateral cerebral e!unclean! mi!brain

• P2 Syn!romes

– Occlusion of the !istal PC* causes infarction of the me!ialtemoral an! occiital lobes-


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• +e!ial me!ullary syn!rome)occlusion of vertebral artery or of

branch of vertebral or lo$er basilarartery, – On si!e of lesion

–

Paralysis $ith atrohy of half thetongue' %psilateral t&elfth nerve

– On si!e oosite lesion

– Paralysis of arm an! leg" saring face<

imaire! tactile an! roriocetivesense over half the bo!y' Contralateral

pyramidal tract and medial lemniscus


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• 2- 7ateral me!ullary syn!rome )occlusion of any of ve vesselsmay be resonsibleBvertebral" osterior inferior cerebellar"suerior" mi!!le" or inferior lateral me!ullary arteries,

• On si!e of lesion – Pain" numbness" imaire! sensation over half the face' 'escending

tract and nucleus fth nerve

– *taia of limbs" falling to si!e of lesion' !ncertain#restiform body,cerebellar hemisphere, cerebellar bers, spinocerebellar tract ()

– ystagmus" !iloia" oscillosia" vertigo" nausea" vomiting' estibular

nucleus – orners syn!rome )miosis" tosis" !ecrease! s$eating,' 'escending

sympathetic tract

– Dyshagia" hoarseness" aralysis of alate" aralysis of vocal cor!"!iminishe! gag re&e' %ssuing bers ninth and tenth nerves

– 7oss of taste' *ucleus and tractus solitarius

– umbness of isilateral arm" trun(" or leg' Cuneate and gracile nuclei – ;ea(ness of lo$er face' +enuected upper motor neuron bers to

ipsilateral facial nucleus

• On si!e oosite lesion – maire! ain an! thermal sense over half the bo!y" sometimes face'

Spinothalamic tract


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• E- .otal unilateral me!ullary syn!rome )occlusion ofvertebral artery,' Combination of me!ial an! lateralsyn!romes

•

4- 7ateral ontome!ullary syn!rome )occlusion ofvertebral artery,' Combination of lateral me!ullary an!lateral inferior ontine syn!rome

• 5- 6asilar artery syn!rome )the syn!rome of the lonevertebral artery is e%uivalent,' * combination of the

various brainstem syn!romes lus those arising in theosterior cerebral artery !istribution-

• 6ilateral long tract signs )sensory an! motor< cerebellaran! eriheral cranial nerve abnormalities,' -ilaterallong tract; cerebellar and peripheral cranial nerves

• Paralysis or $ea(ness of all etremities" lus all bulbarmusculature' Corticobulbar and corticospinal tractsbilaterally


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• Signs and symptoms:Structures involved

• :- +e!ial inferior ontine syn!rome )occlusion of

arame!ian branch of basilar artery, – On si!e of lesion

– Paralysis of con=ugate gae to si!e of lesion )reservationof convergence,' Center for con.ugate lateral ga"e

– ystagmus' estibular nucleus

– *taia of limbs an! gait' 7i(ely middle cerebellar peduncle

– Diloia on lateral gae' Abducens nerve

• On si!e oosite lesion – Paralysis of face" arm" an! leg' Corticobulbar and

corticospinal tract in lo&er pons – maire! tactile an! roriocetive sense over half of the

bo!y' Medial lemniscus


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• 2- 7ateral inferior ontine syn!rome )occlusion ofanterior inferior cerebellar artery,

• On si!e of lesion

– oriontal an! vertical nystagmus" vertigo" nausea"vomiting" oscilloia' estibular nerve or nucleus

– Facial aralysis' Seventh nerve

– Paralysis of con=ugate gae to si!e of lesion' Center forcon.ugate lateral ga"e

– Deafness" tinnitus' Auditory nerve or cochlear nucleus

– *taia' Middle cerebellar peduncle and cerebellarhemisphere

– maire! sensation over face' 'escending tract and

nucleus fth nerve• On si!e oosite lesion

– maire! ain an! thermal sense over half the bo!y

)may inclu!e face,' Spinothalamic tract


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Clinical Presentations of Stro(e

• Focal ischemia )85A, – /mbolism

– .hrombosis

• emorrhage ):5A, – /i!ural – Sub!ural

– ntraarenchymal


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Cerebral schemia

/mbolism

• *brut onset

• Small vascular area

• Focal !ecit – Pure ahasia

– Pure hemianoia

• *cute C. normal

• igh recurrenceris(

.hrombosis

• Prece!e! by .*s

• *brut onset• 7arge vascular area• +ore comle

symtoms

• *cute C. normal


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Cerebral emorrhage

/i!uralhemorrhage

•

Smooth onset• *rterial origin

• +ass eGectcauses comaover hours

• Similar )butslo$er in

evolution, to

Sub!ural hemorrhage

• Smooth onset• Venous origin

• +ay be recurrent

• Fluctuating" falselylocaliing signs


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/mbolic infarction

• .he most common cause of stro(e

• /mbolic materials consist of a fragment that hasbro(en a$ay from a thrombus $ithin the heartHcar!ioembolicI

• *trial brilation re!isose to this tye of stro(e

• .he infarction is ale" hemorrhagic" or mie!

• 7arge embolic clots can bloc( large vessel

• /mbolic material more often it brea(s intofragment that enter smaller vessels revealtheir nal location


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Causes of cerebralembolism

• Car!iac origin – *trial brilation

– +yocar!ial

infarction – *cute an! subacute

bacterialen!ocar!itis

–

eart !isease – Comlication of

car!iac surgery

– Valve rostheses

• on car!iac origin – *therosclerotis of

aorta an! caroti!

arteries – .hrombus in

ulmonary veins

– Fat"tumor" air

– Comlication ofnec( an! thoracicsurgery


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Clinical syn!rome ofembolic stro(e

• Develo most rai!ly Hli(e a bolt out ofthe blueI

• Deen! on the artery involve! an! the

site of obstruction in the vessel – 7arge embolus !istal internal caroti! artery

• Full blo$n syn!romes

– 6ranches of the mi!le cerebral artery• +otor or sensory ahasia

• +onolegia

• 6rachiofacial $ea(ness $ith !ysarthria


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– Posterior cerebral artery• omonymous emianoias

–

6asilar artery• er basilar bifurcation coma

– +e!ial temoral lobe of thalamus an!subthalamus• Comle !isor!ers of memory" sensation"

movement

– 7ateral me!ullary• *taia


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.reatment an! revention

• .hree hases of theray

:- +easures !irecte! to restoringciirculation

:- .hrombolysis2- embolectomy

2- Prevent recurrent embolus

:- 7ong terms of anticoagulants

2- *ntiarrhytmic !rugs

E- Physical theray an! rehabilitation


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Presentation of 7acunar Stro(e

• 1is( factors – Diabetes

–

yertension – Polycythemia

• Variable course rogressing over !ays – Fluctuating< rogressing in stes< or

remitting

– Prece!e! by .*s in 25A

– ;ithout hea!ache or vomiting


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7acunar Stro(e Syn!romes

• ;ell3!ene! syn!romes – Pure motor hemiaresis )$ith

!ysarthria, – Pure sensory stro(e )loss or

aresthesias,

– Dysarthria3clumsy han! )$ithcontralateral face an! tongue$ea(ness,

– *taia3hemiaresis )contralateral face

an! leg $ea(ness,


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7acunar Stro(e Outcome

• +anagement – 7ong3term bloo! ressure control

– /miric anti3latelet theray – Omega3E oil : gm .D to imrove

viscosity

• Prognosis – >oo! recovery of function

–

Other lacunes !evelo


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Prevention Pearls


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1e!ucing Primary 1is( 3 :

• Obstructive slee anea

• omocysteine folate" 6J" 6:2

• yertension K morning 6P surge

• Smo(ing 50A ris( re!uction in : yr

• yerlii!emia statins

•

+igraine

tritans• Drugs K cocaine" ehe!ra" PP*


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1e!ucing Primary 1is( 3 2

• *symtomatic caroti! stenosis – /n!arterectomy for L J0A stenosis

– 1is( re!uction for EA to :A er year – 6enet relate! to surgical ris(

• onvalvular atrial brillation

– *sirin for atients M J5 years"healthy

– ;arfarin for atients L J5 years orhaving other stro(e ris( factors


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1e!ucing Secon!ary 1is(

1e!ucing ris( of recurrence

• .* $ith isilateral caroti! stenosis en!arterectomy for L @0Astenosis

• Car!iogenic embolism $arfarin

• 7acunar infarcts asirin"!iyri!amole

• Crytogenic infarcts )40A embolic,


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1e!ucing 1is( in Chil!ren

• Sic(le cell !isease – Screen $ith transcranial !oler % J

mo – .ransfusion theray for 2 abnormal

stu!ies

•

Congenital heart !isease• *rterial !issections )trauma,

• Prothrombotic !isor!ers

•

+itochon!ria !isor!ers )+/7*S,


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Decreasing Salt nta(e

• 1e!ucing salt inta(e by E g er !aylo$ers bloo! ressure< the eGect is!ouble! $ith a J gm#!ay re!uction

an! trile! $ith a 9 gm#! re!uction-

• 1e!uction in stro(e ris( arallels

re!uction in salt inta(e-


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sing Statins

• Poole! results after 5 years

• Pravastatin or Simvastatin 40 mg#!ay

• Changes in cholesterol levels – .otal cholesterol decreased 20A

– 7D7 cholesterol decreased 28A

– D7 cholesterol increased 5A

– .riglyceri!es decreased :EA


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sing Statins

• 1e!ucing 7D7 cholesterol by :mmol#7 – 22A stro(e re!uction in atients $ith

(no$n vascular !isease

– JA stro(e re!uction in atients $ithout

(no$n vascular !isease

– 28A re!uction in thromboembolic stro(e

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