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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_186_библиотеки_им_акад_М_И_Перельмана

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Digitalsubtractioncatheterangiographyshowingatypicalflame-shapedocclusionoftheinternalcarotid artery.(ReprintedfromCastilloM.NeuroradiologyCompanion.4thed.WoltersKluwer;2011.)
CerebralVenousSinusThrombosis
Thrombosisofthecerebralveinsorduralvenoussinusesisrelativelyrarebutanimportantdo-not-miss diagnosis.Theduralvenoussinuses(alsoreferredtoascerebralvenoussinuses)arevenouschannels locatedwithinthedurathatdrainbothbloodandCSFfromthebrainintotheinternaljugularvein. Consequently,thrombosiscanobstructdrainageofbothblood(predisposingtoischemicandhemorrhagic stroke)andCSF(whichcanresultinelevatedintracranialpressure).
Themajorcerebralveinsandsinuses.
Womenareaffectedmoreoftenthanmen.Riskfactorsincludebothgeneticandacquiredthrombophilia (mostnotablypregnancy-associatedthrombophilia;theriskofcerebralvenoussinusthrombosis(CVST) ismorethantentimeselevatedduringlatepregnancyandtheearlypostpartumperiod),headinjury,and infectioninvolvingtheears,sinuses,mouth,andthroat.
Symptomsvarywidelyandincludeheadache(oftenwithfeaturesofintracranialidiopathic hypertension;seepage115),seizures,encephalopathy,andfocalsymptomsdependentonthelocationof thethrombosedvein.
https://t.me/med1917
CerebralVenousThrombosiswithVaccine-InducedImmuneThrombotic Thrombocytopenia
Theuseoftheadenovirus-basedcoronavirusvaccineswasbrieflysuspendedinthespringof 2021givenreportsofbothcerebralandsplanchnicvenousthrombosisassociatedwith thrombocytopeniaandantibodiesdirectedagainstplateletfactor4(PF4).Currently,onlya handfulofcaseshavebeenreportedamongthetensofmillionsofvaccinatedpatients,and thebenefitsofthevaccineshavebeendeterminedtogreatlyoutweightherisks.However, earlyrecognitionofthesignsandsymptomsofvenousthrombosisinpatientsrecently vaccinatedwiththeadenovirus-basedvaccinesremainscritical,andshouldprompttesting foranti-PF4antibodiesandtreatmentwithnonheparin(argatroban,fondaparinux) anticoagulation.
MRorCTvenogramsarethemostsensitivetechniquesfordiagnosingvenoussinusthrombosis. Occasionally,CTwilldemonstratedirectvisualizationoftheclot.Infarctsduetovenoussinusthrombosis tendtoinvolvemultiplearterialterritories,becausetheydonotrespectthearterialvasculardistributions. Treatmentiswithanticoagulation,whichiscontinuedanywherefromseveralmonths(inthecaseofa provokedthrombosis)tolifelong(inpatientswithseveregeneticthrombophilia).Importantly,the presenceofvenoushemorrhageisnotacontraindicationtoanticoagulation.
(A)The“densetriangle”signonnoncontrastCTscandemonstratingahyperdenseclotwithinthesuperior sagittalsinus.(B)The“emptydelta”signonpostcontrastMRIinthesamepatient,demonstratingafilling defectinthesamelocation.Thereisalsoassociatedleptomeningealenhancementlikelyduetovenous congestion.(ReprintedfromPopeTLJr,HarrisJHJr.Harris&Harris’TheRadiologyofEmergency Medicine.5thed.WoltersKluwer;2012.)
https://t.me/med1917
ReversibleCerebralVasoconstrictionSyndrome(RCVS)
RCVSisasyndromethatischaracterizedbyreversibleandmultifocalconstrictionoftheintracranial cerebralarteries.Itismorecommoninwomenthanmen,andriskfactorsincludepregnancy,migraine, andtheuseofvasoconstrictiveandothermedications(includingtriptans,selectiveserotoninreuptake inhibitorsandvariousimmunosuppressants)andillicitdrugs(cocaineandmethamphetamine).
Recurrent,excruciatingthunderclapheadachesoverthespanofdaystoweeks,withorwithout associatedfocaldeficits(duetoedema,orischemicorhemorrhagicstrokescausedbyvasospasm),are themosttypicalpresentation.
Brainimagingisoftennormalespeciallyearlyon,butcanshowsmallischemicinfarcts(typicallyin watersheddistributions)aswellasintracerebralandsubarachnoidhemorrhage.Thepresenceofdiffuse, segmentalvasoconstrictioncausinga“beaded”appearanceonCTorMRangiographyisclassicand,in therightclinicalcontext,diagnostic,butthesescanscanbenormalearlyonaswell.Iftheinitialscanis negativeandclinicalsuspicionishigh,it’sagoodideatorepeatthescanafewdayslater.
Anangiogramshowingmultifocalarterialnarrowingconsistentwithreversiblecerebralvasoconstriction syndrome(RCVS).(CourtesyofJonathanHoward.)
ThereisnoproventreatmentforRCVS,althoughanecdotalevidencesuggestscalciumchannel blockersmaybehelpful.Steroidshaveactuallybeenshowntoworsenoutcomesandshouldbeavoided. Ifacausativeagentispresent(suchasatriptan,SSRI,orcocaine),itshouldbestopped.Mostpatients recoverspontaneouslywithinweekstomonths.
Vasculitis
https://t.me/med1917
CNSvasculitisreferstodiffuseinflammationandbreakdownofthebloodvesselsinthebrainand/or spinalcord.Theoverwhelmingmajorityofcasesaresecondarytoanotherprocess,suchasasystemic autoimmuneorinflammatorydisease,infectionorneoplasm.Whennosecondaryetiologyisfound,the conditionisreferredtoasprimaryangiitisoftheCNS(PACNS).PACNSisrare,mostoftenseeninolder men,andtypicallylacksthesystemicsymptomsassociatedwithmostothervasculitides(suchasfever andweightloss).
ExamplesofSecondaryCausesofCNSVasculitis
Systemicvasculitides Largevesselvasculitis(giantcellarteritis,takayasuarteritis)
Antineutrophilcytoplasmicantibody(ANCA)-associatedsmallvesselvasculitis(granulomatosiswithpolyangiitis) Immunecomplex-associatedsmallvesselvasculitis(cryoglobulinemicvasculitis)
Autoimmune disease Sjögrensyndrome Infection Viral(HIV,varicella-zostervirus[VZV],cytomegalovirus[CMV])
Bacterial(TB,lyme,syphilis) Fungal(aspergillus,cryptococcus)
Parasitic(cysticercosis,malaria)
DrugInduced Cocaine
Methamphetamines
Neopla stic Lymphoma
Paraneoplastic
Ingeneral,thepresentationofCNSvasculitisisnonspecificandinsidious.Headaches,encephalopathy, andseizuresarecommon.Bothischemicandhemorrhagicstrokescanoccurduetovascularbreakdown. Tip-offsonMRItoanunderlyingvasculiticetiologyincludeacombinationofbothischemicand hemorrhagiclesions,smallembolic-appearingischemicstrokesaffectingbothcorticalanddeepgray matterstructures(duetoinvolvementofthesmallandmediumvessels)andstrokesinoddlocations(e.g., thecorpuscallosum).
Establishingthediagnosisinvolvesconfirmingvasculiticchangesonangiography,whichwillshow segmentalnarrowingwithabeadedappearance.Soundfamiliar?DistinguishingvasculitisfromRCVS canbedifficult,butitiscriticalgiventhevastlydifferenttreatmentprotocols.CSFanalysisisoften crucial:youshouldexpectaninflammatoryprofilewithelevatedproteinandwhitecellsinpatientswith vasculitis,whereasinRCVSnormalCSFistherule.AbatteryofbothserumandCSFstudiesshouldbe senttohelpdeterminethepresenceofasecondaryetiology,includingvariousinflammatory,autoimmune, andneoplasticmarkers.
Treatmentiswithsteroidsandshouldbeinitiatedearly,regardlessofknownorunknownsecondary vasculiticetiology.Evidenceregardingtheoptimaldurationoftherapyislimited,anddecisionsaremost oftenmadeonacase-by-casebasis.
https://t.me/med1917
https://t.me/med1917
Follow-uponYourPatient:Laura’sdeficitsaresubtlebutultimatelydeemeddisablingand,
intheabsenceofanycontraindications,sheisgiventPA.HerCTangiogramisnormal, withoutevidenceofanintervenableLVOoranysignificantstenosis.Herexamination improvespost-tPA,andseveralhourslateronlyverymildwristweaknesspersists.HerMRI showsanembolic-appearingright-sidedfrontoparietalinfarct.Givenherageandlackof cardiovascularriskfactors,youorderatransesophagealecho,whichrevealsalargepatent foramenovale(PFO).5LowerextremityDopplers(tolookfordeepveinthrombosis)are negative,butherhypercoagulabilitypanelreturnspositiveforfactorVLeiden.Sheisstarted onanticoagulationanddischargedhome,andafteronlyaweekortwoofphysicaltherapy, she’sbackonthecourt.
Younowknow:
The basics of cerebrovascular anatomy and can localize many of the most common stroke syndromes. HowtoclassifyischemicstrokesubtypesviatheTOASTclassification. Whentogiveand—justasimportant—whennottogivetPAforacuteischemicstroke. Whentoconsiderendovascularthrombectomyforacuteischemicstroke. Howtomanageacuteintracerebralandsubarachnoidhemorrhage. How to recognize and treat several other important cerebrovascular disorders, including cervicocephalicarterialdissection,RCVS,cerebralvenoussinusthrombosis,andCNSvasculitis.
Citedstatisticsherearefrom:
ViraniSS,AlonsoA,BenjaminEJ.Heartdiseaseandstrokestatistics–2020update:areportfromthe AmericanHeartAssociation.Circulation.2020;141:e139-e596.
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000757TheNationalInstituteofNeurological
DisordersandStrokert-PAStrokeStudyGroup.Tissueplasminogenactivatorforacuteischemicstroke. NEnglJMed.1995;333:1581-1588.
1
ThisnumberisforadultsintheUnitedStates,anditchangesbasedongeographiclocationandage;inchildren,forinstance,hemorrhagic
strokeismuchmorecommonthanischemicstroke.
2
Wewillnotbetalkinganymoreabouttheexternalcarotidartery,butincaseyouareinterested,itsuppliesbloodtothefaceandneck,notthe
brain.Externalcarotidarterydiseasedoesnotcausestroke.
3
Thisistrueasofthiswriting,butongoingresearchiscurrentlyinvestigatingtherisksandbenefitsofgivingtPApriortothrombectomy.
4
Tenecteplase(TNK)isanotherthrombolyticthatcanbeused.ItissimilartotPAbuthasahigherfibrinspecificityandalongerhalf-life;its
timewindowandcontraindicationsarethesame.Ongoingresearchisevaluatingitsefficacyforacutestroke.
5
TherecentpublicationofseverallargeclinicaltrialshasresultedinfurtherexpansionofthetPAwindowincarefullyselectedpatient populationswithspecificimagingcharacteristicssuggestiveofsignificantsalvageablebraintissue.Perhapsmostexcitingly,patientswith “wake-up”strokes(i.e.,patientswhofallasleep“normal”andwakeupthefollowingmorningwithneurologicdeficits)arenowpotentialtPA candidatesiftheirimagingmeetsspecificcriteria.
5
Thisisbeyondthescopeofthisbook,butincaseyouareinterested,theliteraturehasgonebackandforthonthebenefitsandrisksofPFO
https://t.me/med1917
closureinpatientswithstroke.Differentphysiciansandinstitutionshavedifferentpreferences,butinthecaseofourpatient,mostwouldlikely deferclosure;becausesheispositiveforfactorVLeidenandnowhasahistoryofthromboembolism,shewillbeonlifelonganticoagulation regardless,thusobviatingtheneedforclosure.
https://t.me/med1917
3Headache
Inthischapter,youwilllearn:
1. Howtorecognizeandtreatcommonheadachedisorders
2. Whentoworry(andwhattodo)aboutpotentiallyalarmingheadacheetiologies
3. Thedifferentialdiagnosisofthunderclapheadaches
4. Howtomanageacutemigraineinanurgentsetting
5. Howtomanageheadacheduringpregnancy
CASE3
https://t.me/med1917
YourPatient:Anna,anotherwisehealthy28-year-oldfirst-yearsurgicalresident,comesto
seeyoubecauseofworseningheadaches.Shedescribesalonghistoryofpredominantly right-sided,throbbingheadachesthatusedtooccuraboutonceamonthandresolvedwith nonsteroidalanti-inflammatorydrugs(NSAIDs).Butinthepastfewmonths,shehasbeen gettingtheseheadachesmuchmorefrequently,experiencingthreethispastweekalone. NSAIDstaketheedgeoffbutnolongerfullyrelievethepain.Shehasahardtimeworking whenshehasaheadache;justlookingatacomputerscreenhurtshereyes,andtryingto thinkfeelslike“runninginaswimmingpool,”slowandexceedinglyeffortful.What’sthenext
https://t.me/med1917
stepinyourmanagement?
Headacheisoneofthemostcommonreasonswhichsendpeopletoseekmedicalattention.Primary headachedisorders,suchasmigraine,tension-type,andclusterheadaches,arebyfarthemostfrequently
encountered.MorethanonemillionpatientsvisitemergencyroomsintheUnitedStateseveryyearfor migrainesalone.However,secondaryheadachedisorders—headachescausedbyotherunderlying, sometimesworrisome,occasionallylife-threateningpathologiessuchasinfections,bleeds,andtumors— compriseasignificantminority.Distinguishingbetweenprimaryandsecondaryheadachesisthemost importantandoftenthemostchallengingstepinmanagingpatientswithheadache,solet’sstartthere.
HeadacheRedFlags
Primaryheadachedisorderscanbesevereandevendisabling,buttheyarenotfatal,unlikesome secondaryheadachedisorders.Sowhendoweworry?Whatsetsoffalarmbellsforapotentialsecondary etiology?ThemnemonicSNOOPishelpfulhere.Asourknowledgebasehasincreased,thismnemonic hasgonethroughmultipleiterations(mostrecentlySNNOOPPPPPPPPPP—wearenotkidding),butfor thesakeofsanity(yoursandours)andsimplicity,wewilluseSNOOP2.
https://t.me/med1917
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