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

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YourPatient’sFollow-up:Haileypresentedwithaheadachethathadbeenworseningover
severaldaysandisnowmuchimprovedafterreceivingpainmedication.Yourattendinghas askedyouifshecangohome,butyoufeeluneasy.Youwereonlyabletospendafew minuteswithherbecauseyouhadtoprioritizeothermoreacutelyillpatients.Youtellyour attendingtogiveyoufivemoreminutes,andyoureturntoHailey’sbedside.
Onfurtherquestioning,shetellsyouthatthisheadachewasright-sided(unlikehertypical headaches,whicharebilateral)butdeniesanyotherassociatedsymptomssuchasnausea, vomiting,orlightorsoundsensitivity.Yourepeataquickneurologicexaminationandthistime noticejusttheslightestdownwarddriftandpronationofherlefthandwhenyoutestpronator
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drift.Youdothetestagain,andyetathirdtime,andconvinceyourself:it’ssubtle,butit’s there.Shehasnoticednoweaknessbutsheisrighthanded,andyouwonderifshemaynot havebeenawareofthissubtlechange.Giventhisnewinformation(anewheadachefeature inthesettingofafocalfindingonexamination)youorderaCToftheheadwhichis suggestiveofarightfrontalmass,followedbyanMRItobetterevaluatethelesion.TheMRI isshownonthenextpage,andthemomentyouseeityouknowthatthoseextra5minutes youtooktotalktoherandthoroughlyexaminehermayhavesavedherlife.
Haileyisultimatelydiagnosedwithalow-gradegliomaandisquicklyscheduledforsurgery.
Younowknow:
Basicneuroanatomy.There’smoretocomebut,believeitornot,youhavenowlearnedthebulkof it.Haveyoumemorizeditall?Ofcoursenot,butyoucankeepcomingbacktothesepagestorefresh yourlearning. Howtotakeafocusedandusefulneurologichistory. Howtoperformacomprehensiveneurologicexamination. Howtodistinguishneurologicdiseasesfromnon-neurologicdiseases.Thisisn’talwayseasy,even forexperiencedneurologists. Thebasicprinciplesofthediagnostictoolsatourdisposal:imagingtests,LP,EEG,andEMG/NCS.
Younowhaveallthetoolsthatyouwillneedtounderstand,diagnose,andevaluatevirtuallyallofthe neurologicdisordersyouwillencounterinthechapterstofollow.Wewillmakeyouthispromise:itgets alotmoreinterestingfromhere!
1
Theanswer,bytheway,isthatthelesionismostlikelylocatedinthesubcorticalwhitematterofthebrain.Becausethemotorpathways convergeastheydescend(seethepictureabove),itismucheasierto“knockout”theface,arm,andlegalltogetherbyasinglelesioninthe internalcapsule,forinstance,thanitisinthecortex,wheretheface,arm,andlegmotorfibersaremuchmorespreadout.Ifthisdoesn’tmake anysensetoyoujustyet,don’tworry:itwillsoon!
2
SeeChapter2,page59foracomprehensivereviewonlanguagecomponentsandlocalization.
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2StrokeandCerebrovascularDisease
Inthischapter,youwilllearn:
1. Themanycausesofischemicstroke,andhowtodivvythemupintoamanageablehandful ofcategories
2. Howtorecognizethemostcommonischemicstrokesyndromes
3. Theevaluationandtreatmentofacuteischemicandhemorrhagicstrokes
4. The presentation, management, and complications associated with subarachnoid hemorrhage(SAH)
5. The most clinically relevant and useful essentials of other important cerebrovascular disorders, including arterial dissection, reversible cerebral vasoconstriction syndrome (RCVS),cerebralvenoussinusthrombosis,andcentralnervoussystem(CNS)vasculitis
CASE2
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YourPatient:Laura,a27-year-oldprofessionaltennisplayer,presentstotheemergency
department2hoursafterexperiencingthesuddenonsetofleftfaceandarmnumbnessand weakness.Thetriagenurseactivatesastrokecode,andyoumeetLauraassheisbeing takenforaCTscan.Shetellsyouthatshehasnopastmedicalhistoryandtakesno medications.Onexamination,youfindmildsensorylossinvolvingherleftfaceandarmwith extinctiontodoublesimultaneousstimulationontheleft(seepage31),leftnasolabialfold flattening,subtleweaknessofherleftwristextensorsandleft-handclumsiness.HerNIH
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strokescale(NIHSS)is3.ACTofherheadisnormal.Whatisthenextstepinyour management?
BadNewsButGoodNewsToo
SomeoneintheUnitedStateshasastrokeevery40seconds.Every4minutes,someonediesfromstroke. ItisthefifthleadingcauseofdeathintheUnitedStatesandissecondonlytocardiacdiseaseworldwide. Itisalsoaleadingcauseofseriouslong-termdisability.Conservatively,strokecoststheUnitedStates over30billiondollarseachyear.
So,yes,cerebrovasculardiseaseiscommonandcanbedevastating,butthepaceofscientific discoveryandclinicaladvancesoverthepastfewdecades—andespeciallyoverthepastfewyears—has beenbreathtaking.Thisisnowheremoreevidentthaninourrapidlyescalatingabilitytohaltandreverse theeffectsofstrokewhileitisinprogress,therebypreventingdisabilityandsavinglives.Inaddition, globalawarenesseffortsandaggressiveriskfactorcontrolhaveledtosignificantreductionsinboththe incidenceofandmortalityfromstroke.
TheBasics
Ascomplicatedasstrokecarehasbecome,therearetwo(onlytwo!)majorcategoriesofstroke,and— fromanetiologicstandpoint—theyarediametricallyoppositeconditions:
ischemia,whichiscausedbyblockedorseverelynarrowedbloodvesselsresultingininadequate tissueperfusion,and hemorrhage,duetoextravasationofbloodfromadamagedvessel.
Inotherwords,toolittleversustoomuchblood.About85%ofallstrokesareischemic.
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Examplesofacute(A)hemorrhagicand(B)ischemicstrokes.Acutebloodisbrightwhite,or “hyperdense,”oncomputerizedtomography(CT),andeasytorecognize.Acuteischemiaismoresubtle, characterizedbythelossorblurringofgray/whitedifferentiation(seeimageB,star)andeffacementofthe sulci.Sometimesyoumaybeabletovisualizetheclotitselfasahyperdensesegmentofavessel:(C) showsaclotintherightmiddlecerebralartery(MCA,knownasthe“denseMCA”sign).(A,reprintedfrom LouisED,MayerSA,RowlandLP.Merritt’sNeurology.13thed.WoltersKluwer;2015.B,reprintedfrom DaffnerRH,HartmanM.ClinicalRadiology.WoltersKluwer;2013.C,reprintedfromPopeTLJr,HarrisJH Jr.Harris&Harris’TheRadiologyofEmergencyMedicine.5thed.WoltersKluwer;2012.)
Strokeis,firstandforemost,aclinicaldiagnosis,definedastheacuteonsetoffocalneurologic symptomscausedbybrain,spinalcord,orretinalcelldeath.
Box2.1TransientIschemicAttack(TIA)
TIAsare“almost-strokes,”morepreciselydefinedasbriefepisodesofneurologic dysfunctionduetofocalbrain,spinalcord,orretinalischemiawithoutpermanenttissue infarction.MostTIAslastlessthan1hour.Theyareimportanttorecognizebecause approximately10%ofpatientswithaTIAwillgoontohaveastrokewithinthenextfew months.Theriskishighestintheimmediate24hoursfollowingtheTIA,andmostpatients shouldbehospitalizedforevaluationandcarefulmonitoringeventhoughtheirneurologic symptomshaveresolved.
Beforewegoanydeeperintodetail,aquickreviewofcerebrovascularanatomyiscrucial.Onlyby knowingthevascularanatomyofthecentralnervoussystem(CNS)willyoubeabletorecognizespecific strokesyndromes,conceptualizetheunderlyingstrokeetiology,andunderstandthesubsequent management.Wepromisetomakethisasconcise,clinicallyrelevant,andpainlessareviewaspossible.
CerebrovascularAnatomy
Thecerebralbloodsupplyisdividedintotwocomponents:
Theanteriorcirculation suppliesapproximately75%ofthe brain.Itoriginates from thecommon
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carotid arteries (leftand right),whichbifurcateintothe internal and external carotid2 arteries at approximatelythelevel ofthe C4 vertebrae. Theinternalcarotid arteries then travel up the neck, entertheskullatthepetrouspartofthetemporalbone,passthroughthecavernoussinus,giveoffthe ophthalmic arteries (whichsupply theeyeball andocular muscles), andthensplitinto the anterior andmiddlecerebralarteries.
The anterior cerebral arteries (ACAs) supply the majority of the frontal lobe, the anterior limb of the internal capsule, the anteriorbasalganglia,andmostofthecorpuscallosum. Themiddlecerebral arteries(MCAs)supplythe majorityofthelateral surfaceofthehemispheres,includingbothBroca and Wernicke’sareas,whichareresponsiblefortheproductionandcomprehensionofspeech,respectively(seepage59).Theyalso giveoffcountlessmicroscopicarteriescalledlenticulostriatesthatsupplytheinternalcapsuleandthebasalganglia.
Theanteriorcirculationtothebrain.
The posterior circulation supplies the remaining ∼25% of the brain. It originates from the vertebral arteries (again, there are two—left and right; the vertebral arteries arise from the subclavianarteries), which travel superiorly, looping inandoutof the transverse foramina ofthe vertebrae,entertheskullthroughtheforamenmagnum,andthenmergeatthepontomedullaryjunction to form the basilar artery. The basilar artery runs up the pons then splits into the two posterior cerebralarteries(PCAs)atthejunctionoftheponsandthemidbrain.
Thevertebralarteries eachgiveoffthree important branches: theposteriorandanterior spinal arteries (which supply the spinal cord), andtheposterior inferior cerebellar artery (PICA, which supplies the posterior inferior cerebellum and lateral medulla). Thebasilararteryalsogivesoffthreeimportantbranches:theanteriorinferiorandsuperiorcerebellararteries (AICAand superiorcerebellarartery[SCA],whichtogethersupplytherestofthecerebellum)andthePCAs(seethenextparagraph).The basilararteryalsogivesoffmanymicroscopicpontineperforatorbranches,whichsupplythepons. Theposteriorcerebralarteries(PCAs)supplytheoccipital lobe,medialtemporal lobe,thalamus,midbrain,andposteriorlimbof theinternalcapsule.
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Theposteriorcirculationtothebrain.Notetheproximityoftheposteriorcommunicatingarterytothethird nerve;thisiswhyposteriorcommunicatingarteryaneurysmscancausethirdnervepalsies!
Anteriorcerebralartery(ACA),middlecerebralartery(MCA),andposteriorcerebralartery(PCA)territory distributions.
ThecircleofWillisisananastomoticarterialringformedatthebaseofthebrainthattiestogetherthe anteriorandposteriorcirculations.Theanteriorcommunicatingartery(Acomm)joinsthetwoACAs, andtheposteriorcommunicatingarteries(Pcomm;therearetwoofthem)connecttheinternalcarotid
https://t.me/med1917
arteries(ICAs)tothePCAs.
Theimportanceofthiscirclecannotbeoverstated,becauseitcanmaintaincerebralperfusiondespite majorvesselblockages.Foranextremeexample,therearepeoplewholiveasymptomaticallydespite twoblockedinternalcarotidarteries;theircerebralbloodflowisderivedentirelyfromtheposterior circulationwhich,viathetwoPcommarteries,isabletosupplytheentirebrain.
https://t.me/med1917
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