Neurovascular Emergencies - PowerPoint PPT Presentation

Loading...

PPT – Neurovascular Emergencies PowerPoint presentation | free to download - id: 691e2e-NDFlO



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Neurovascular Emergencies

Description:

Neurovascular Emergencies Victor Politi, M.D., FACP Medical Director, SVCMC, School of Allied Health, Physician Assistant Program – PowerPoint PPT presentation

Number of Views:13
Avg rating:3.0/5.0
Slides: 69
Provided by: VictorP156
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Neurovascular Emergencies


1
Neurovascular Emergencies
  • Victor Politi, M.D., FACP
  • Medical Director, SVCMC, School of Allied Health,
    Physician Assistant Program

2
Brain Injury - Hypoxia
  • Ischemia
  • mismatch between needed cerebral blood flow and
    the amount of perfusion supplied
  • Injury
  • After a period of ischemia, the brain becomes
    damaged
  • Infarction
  • Irreversible death of brain tissue

3
Neurological Changes
  • Reasons for increased ICP (pressure)
  • Bleeding
  • Edema
  • Inflammation
  • Tumor

4
Neurological Changes - Bleeding
  • Bleeding
  • aneurysm
  • trauma
  • CVA
  • subdural (SDH) - bleeding below the Dura
  • Epidural- bleeding above the Dura
  • Subarachnoid (SAH)
  • Intracerebral- bleeding within the brain

5
Neurological Changes-EDEMA
  • Edema -
  • general swelling of brain tissue in response to
  • trauma (injury)
  • hypoxia (cellular death)

6
Neurological Changes -
  • Inflammation -
  • infection of brain tissue
  • Tumor -
  • cancer
  • arteriovenous malformation (AVM)

7
Assessment of Neurological Function
  • Level of consciousness
  • Glasgow Coma Scale (GCS) the standard measure
    used to quantify level of consciousness in head
    injury patients
  • Widely used in scoring systems, treatment
    protocols and general clinical decision-making in
    critically ill patients

8
Glasgow Coma Score
  • The GCS is scored between 3 and 15, 3 being the
    worst, 15 the best
  • GCS is composed of 3 parameters Best Eye
    Response, Best Verbal Response, Best Motor
    Response
  • A GCS of 13 or higher correlates with a mild
    brain injury, 9-12 is moderate injury and 8 or
    less a severe brain injury

9
Glasgow Coma Scale
  • E (eye) M (motor) V (verbal) 3 to 15
  • 90 less than or equal to 8 are in coma
  • Greater than or equal to 9 not in coma
  • 8 is the critical score
  • Less than or equal to 8 at 6 hours - 50 die
  • 9-11 moderate severity
  • Greater than or equal to 12 minor injury
  • Coma is defined as (1) not opening eyes, (2) not
    obeying commands, and (3) not uttering
    understandable words.

10
Glasgow Coma Scale (GCS)
  • Measures best response
  • Eyes scaled 1-4
  • Verbal scaled 1-5
  • Motor scaled 1-6
  • Total 3-15

11
Glasgow Coma Scale (GCS)- Eyes
12
Glasgow Coma Scale (GCS)-Verbal
13
Glasgow Coma Scale (GCS)-Motor
14
Assessment of Neurological Function Decorticate
Posturing
  • Seen when there is lesion of corticospinal tract
    superior to level of brainstem
  • indicated in comatose patient who responds to
    sternal rub by full flexion of the elbows,
    wrists, fingers, as well as plantar flexion of
    feet with extension and internal rotation of legs

15
Assessment of Neurological Function - Decerebrate
posturing
  • Seen in patients with lesions of brainstem
  • patients exhibit extension of the arms, flexion
    of the wrists, jaw-clenching, back-arching,
    plantar flexion, neck extension, either
    spontaneously or in response to sternal rub

16
Cushing Triad
  • Increased BP Decreased HR
  • Irregular Respirations

17
Cushing Triad
  • Increase in BP to overcome the increase of
    pressure inside the skull
  • Brain trying to prevent infarct
  • Decreased HR to allow the heart to pump more
    effectively and increase BP
  • Cheyne-Stokes respirations to try to blow off CO2
  • CO2 is a potent vasodilator

18
(No Transcript)
19
Cushing Triad
  • CO2 is a potent vasodilator
  • Increase of CO2 in the blood
  • Causes increase in blood volume intracranially
  • Decrease in CO2 in the blood
  • Causes decrease in blood volume intracranially

20
Herniation
  • The increased ICP is forcing the brain through
    the Foramen Magnum
  • Signs and Symptoms
  • worsening GCS
  • sudden change in pupil response (dilation or no
    responsiveness)
  • Change in VS indicating Cushing's response
  • General demise of patient

21
Treatment
  • Airway
  • Increased ICP may diminish or paralyze the gag
    reflex
  • - allowing aspiration
  • Suction
  • Positioning
  • - C Spine ?

22
Treatment
  • Breathing
  • severe brain injury may interfere with breathing
    center of the brain
  • be ready to BVM patient if necessary
  • High flow oxygen (10-15 lpm)

23
Treatment
  • Circulation
  • Treat for shock
  • prevent hypotension - hypoxia and infarct of
    brain tissue
  • IV initiate
  • assist with BP control
  • med line if seizure

24
Treatment
  • Positioning
  • What can be done to assist flow into the skull
  • maintain blood pressure
  • What can be done to assist flow out of the skull
  • HOB elevated to 30
  • C-collar removed

25
Treatment
  • Communicate with the patient
  • whether they respond or not
  • They may be awake and cannot communicate

26
Neurovascular Emergencies
  • TIA (transient ischemic attack)
  • Stroke
  • Hemorrhage
  • Aneurysm
  • Headache (worst of life)

27
Headache
28
Danger signals
  • First or worst headaches
  • Headache on exertion, early morning, or nocturnal
  • Progressive headache
  • New onset headache in adult gt50 years old
  • Abnormal physical or neurological findings
    (fever, stiff neck)

29
Secondary Headache DDx
  • Subarachnoid Hemorrhage (SAH)
  • first or worst headache
  • physicians consistently misdiagnose SAH
  • pts with the greatest potential tx benefits are
    most often misdiagnosed
  • early complications develop in patients with an
    incorrect dx
  • Meningitis
  • associated with fever, neck stiffness, confusion

30
Secondary Headache DDx
  • Subdural hematoma
  • recent trauma (/-)
  • Stroke (Ischemic or Hemorrhagic)
  • occurs with focal neurologic sx
  • Cervicocephalic arterial dissection
  • trauma hx (/-), neck pain, ipsilateral Horners
  • Giant cell arteritis
  • gt 50 yrs, visual loss, temporal pain, ? ESR

31
Secondary Headache DDx
  • Dental abscesses/TMJ
  • oral or jaw pain initially
  • Sinusitis
  • overdiagnosed, dx more likely with fever/purulent
    nasal discharge
  • Trigeminal neuralgia
  • sharp unilateral pain usually over maxillary
    distribution
  • Low CSF pressure headache
  • sx resolve in supine position and recur when
    upright
  • Acute Glaucoma
  • periorbital pain, conjuntival injection, lens
    clouding

32
Subhyaloid hemorrhage
33
CT versus MRI
  • Preferred in SAH ICH
  • Posterior fossa lesions
  • CVT
  • Meningeal disease
  • Cerebritis and abscess
  • Pituitary pathology

34
SAH
35
L.P in evaluation of headache
  • Suspected SAH if CT is negative
  • (Deterioration after LP in patients with clots
    on CT or a dilated pupil)
  • Start antibiotics in patients with suspected
    meningitis, while waiting for CT
  • CSF pressure should be measured
  • Distinguish traumatic tap from true hemorrhage

36
Probability of detecting xanthochromia in CSF
with spectrophotometry after SAH
  • 12 hours 100
  • 1 week 100
  • 2 weeks 100
  • 3 weeks gt70
  • 4 weeks gt40

37
Angiography
  • In proven SAH- 4 vessel angio to identify source
    and r/o multiple aneurysms
  • Initial arteriogram negative in up to 16 of SAH
  • MRA detects 90 of saccular aneurysms of gt5mm
  • Spiral CT angio detects 85 of saccular aneurysms

38
Cerebral Aneurysm
39
Cerebral aneurysm
  • The brain has many arterial blood vessels that
    supply blood pumped by the heart. When the wall
    of a blood vessel becomes weak and/or thin, it
    forms a bulge or a bubble. This bulge or bubble
    is called an aneurysm.
  • Aneurysms may also rupture, causing bleeding in
    the brain. This bleeding results in Subarachnoid
    Hemorrhage

40
(No Transcript)
41
Causes
  • Genetic predisposition in persons with polycystic
    kidney disease or coarctation of the aorta
  • Cause often unknown

42
Treatment
  • Unruptured aneurysms
  • Large Aneurysms are surgically clipped at their
    bases to prevent rupture.
  • Small (less than 1/2 centimeter) ones without
    symptoms are usually followed with repeated
    cerebral angiographies

43
Treatment
  • Ruptured aneurysms
  • Surgical clip placed at the base of the aneurysm
  • Aminocaproic acid may be considered, but has
    complications
  • Calcium channel blockers such as Nimodipine may
    prevent spasm of the artery where the aneurysm
    ruptured

44
STROKE
45
Stroke
  • 3rd Leading cause of death in the United States
  • The mortality from the acute event is about 20
  • Leading cause of disability

46
Three Types of Stroke
  • Temporary or partially occluded blood flow (TIA)
  • Hemorrhagic stroke
  • Ischemic (infarct) stroke

47
Stroke - Type 1
  • Temporary partial occlusion of blood flow
  • TIA or Transient ischemic attack
  • nonpermanent deficits
  • 30 will have a stroke

48
Management of TIA
  • ASA
  • Dipyridamole (Persantine)
  • Ticlid
  • Plavix
  • Carotid Endarterectomy

49
Stroke - Type 2
  • Hemorrhage Stroke
  • bleeding in skull or brain (subarachnoid or
    intracerebral)
  • blood must be removed
  • burst aneurysm
  • (the worst headache of my life)

50
Hemorrhagic Stroke
  • Only 1 out of every 5 strokes
  • 30-day mortality of 30-50
  • Occur in younger patient population
  • Two major categories -
  • intracerebral
  • subarachnoid hemorrhage

51
(No Transcript)
52
ICH
  • Majority of hemorrhagic strokes
  • Leading risk factors - increasing age,hx of prior
    stroke
  • Associated with
  • Chronic HTN
  • Amyloidosis
  • Other causes -
  • bleeding diathesis due to iatrogenic
    anticoagulation, vascular malformation and
    cocaine use

53
SAH
  • Half as common as ICH
  • Half of all SAH due to berry aneurysm rupture
    most commonly occurring at arterial bifurcations
    or branchings
  • Arteriovenous malformations make up another 6 of
    all SAH

54
Stroke - Type 3
  • Ischemic (infarct) stroke
  • 70-80 of all strokes
  • can be reversed with clot busters
  • occlusion or blockage
  • embolization (primarily from the carotid artery
    or the heart)
  • thrombosis
  • low flow state

55
Ischemic Stroke
  • Three Major Categories
  • Thrombotic
  • Embolic
  • Hypoperfusion

56
(No Transcript)
57
Ischemic Stroke
58
Stroke
  • Arteriosclerosis -
  • what occurs in the heart can occur in the brain
    as well...

59
(No Transcript)
60
T.P.A. - Thrombolytics for CVA
  • When to Use
  • Time to Drug From Onset of Symptoms
  • Exclusion Criteria

61
(No Transcript)
62
Tissue Plasminogen Activator (TPA)
  • Medication approved by FDA for acute treatment of
    stroke
  • Must be given within 3 hours of neurologic
    symptoms(numbness, tingling, weakness, speech
    problems, language difficulties), while awake

63
Tissue Plasminogen Activator (TPA)
  • IV r-TPA given in a dose of 0.9mg/kg up to a
    maximum of 90mg - 10 of the dose in a bolus and
    the remainder infused over one hour
  • improves outcome after stroke when given very
    early and within 3 hours on onset of stroke in
    carefully selected persons.
  • The benefit persists over the long term (3
    months)

64
Tissue Plasminogen Activator (TPA)
Contraindications
  • Patient selection and timing of symptoms are
    critical!
  • Symptoms not rapidly improving or resolved
  • No currently active internal bleeding
  • No illness predisposing to an increased risk of
    bleed

65
Tissue Plasminogen Activator (TPA)
Contraindications
  • No history of prior brain hemorrhage
  • No significant GI or GU bleeding in past 3 months
  • No known stroke, serious head trauma, or brain
    surgery in past 3 months
  • No lumbar puncture or arterial puncture in past
    week

66
Tissue Plasminogen Activator (TPA) -
Contraindications
  • No pregnancy
  • Diastolic BP lt or 110 and systolic BP of lt or
    185
  • Platelet count less than 100,000/mm3
  • No Major surgery within preceding 14 days
  • Blood glucose lt50mg/dl or gt 400mg/dl
  • recent MI

67
(No Transcript)
68
QUESTIONS ??
About PowerShow.com