Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2780_Библиотеки_им_академика_М_И_Перельмана

Surgical hematoma removal is most effective for subcortical hemorrhage and cerebellar hem­orrhage. In elderly patients with subcortical hemorrhage, however, repeated subcortical hem­orrhage due to amyloid angiopathy may occur, and surgical indication should be carefully con­sidered. For putaminal hemorrhage, which is most common, the indication for surgery is con­sidered according to the amount of hematoma and the degree of consciousness disorder [3].

The main pathogenesis of lacunar infarction is occlusion of the perforating artery which is dam­aged by hypertension-induced arteriolosclerosis. The perforating artery branches off from the ori­gin of the middle cerebral artery or basilar artery and feeds the deep brain. Lacunar infarction is diagnosed when a small infarction of less than 15mm in diameter (Fig.9.6) is found in the terri­tory of the perforating artery on CT/MRI images.

It is estimated that 10–15% of patients develop brain infarction within 90days, but most of them develop within 1 week. In recent years, the risk of occurrence of infarction within 2 days is evalu­ated by the ABCD2 score (Table 9.2). When embolization from the carotid artery or other sources occurs in the ophthalmic artery region,

which is a branch of the internal carotid artery, there may be a transient lack of the unilateral visual eld. The condition is diagnosed as tran­sient monocular blindness (amaurosis fugax) and treated similar to transient ischemic attack.

in providing oral care “feeding function therapy” to patients with brain infarction, and “repetitive saliva swallowing test (RSST)” and “modied water swallowing test (MWST)” are performed as screening. Videoendoscopic evaluation of swallowing (VE) and videouorographic evalua­tion of swallowing (VF) should be considered to examine the swallowing function for planning swallowing training. In cerebrovascular disease with unilateral lesion, which is overwhelmingly common, hemiparalysis is often observed, but dysphagia, dysarthria, and mastication disorders are limited in about 10% of patients. Although there are impairments in the oral preparatory and oral propulsive phases due to paralysis of the oral apparatus, the swallowing reex is theoretically not directly affected because the medulla oblon­gata, the center of the swallowing reex, is not impaired.

In the chronic phase of brain infarction, anti­platelet and anticoagulation therapy (Table 9.1) according to the stroke treatment guidelines [9] are used to prevent recurrence. Therefore, it is important to cooperate with the attending physi­cian when invasive dental procedures, such as periodontal surgery and tooth extraction, are planned. If patients are prescribed with an antico­agulant, warfarin potassium, information about the coagulation status is essential. If the PT-INR [prothrombin time—international normalized ratio: a test to evaluate the function of prothrom­bin (a protein in plasma that functions as a blood clotting agent) with an internationally standard­ized value] is less than 3, it is possible to perform minor oral-maxillofacial surgery such as tooth extraction and periodontal surgery while continu­ing to take warfarin potassium. Since the amount of procedure-related bleeding inevitably increase by anticoagulation therapy, the patient should be treated with caution and cooperation with a higher-order medical institution should be con­sidered. On the other hand, some new anticoagu­lants, such as dabigatran, a direct oral thrombin inhibitors, do not affect PT-INR values. Therefore, it is very important to conrm the medication his­tory and to prepare for and respond to bleeding complications during dental treatment.

In addition, if the patient is to undergo anes­thetic dental and oral-maxillofacial surgical pro­cedures such as tooth extraction, pulpectomy under anesthesia, or periodontal treatment, vital signs should be measured, and the patient should be monitored continuously during the procedure. If the patient of brain infarction is treated accord­ing to the aforementioned guidelines, it is a prin­ciple to continue antiplatelet and anticoagulant medication without discontinuation and to per­form dental and oral-maxillofacial procedures in cooperation with the attending physician. Depending on the content of treatment, the degree of invasion, and the patient’s other complications such as circulatory, respiratory, metabolic, and endocrine conditions, patient’s general status needs to be carefully evaluated in cooperation with the attending physician, and the dental and oral-maxillofacial priority and the cooperation with the higher institute should be planned and indicated.