Boala vasculara cerebrala

Sistemul arterial cerebral

 INCIDENTA: toate tipurile de AVC

Incidenta primului AVC, orice tip, pe grupe de

varsta si sex, in Europa

45

40

35

30
in rates per 1000

25

20

15

10

0
55-59 60-64 65-69 70-74 75-79 80-84 85-89 90+
Age ranges
Males Females

6 statistici, ambulatori si institutionalizati

Incidenta medie 65 - 84: 8.72 / 1 000 ambe sexe

Incidenta medie 75 + : 17.31 / 1 000 ambe sexe
 Subtipuri de AVC (CT, RMN)

AVC

15% Hemoragic
. Intraparenchimatos
. Subarahnoidian
85%

Ischemic

20% 25% 20% 30% 5%

Boala aterosclerotica Artere penetrante Embolie AVC Cauze rare
vas mare (« Lacunar ») cardiogena criptogenic
. FIA . Stari protrombotice
. Valvulopatii . Disectii arteriale
. Trombi intraventriculari . Arterite
. Altele
. Migrena/Vasospasm
. Abuz droguri
. Altele
 Ischemia cerebrala
• Accident vascular cerebral constituit
- durata peste 3 ore
- leziune teritoriu arterial superficial / profund
- invaliditate / deces
• Accident vascular cerebral tranzitor
- durata sub 3 ore
- leziune nedecelabila imagistic (+/-)
- recuperare integrala
 Etiopatogenie
• Boala aterosclerotica
– Extracerebrala: aorta
– Cerebrala:
• Vas mare: tromboza in situ,
embolie arterio-arteriala
• Vas mic: lipohialinoza, necroza->
tromboza in situ / hemoragie
• Boala cardiaca
– FIA
– Boala mitrala (stenoza)
– Anevrism sept, ventricul
– IMA
 Mecanisme:
• Aterotrombotic – prin
– Tromboza in situ: pe o stenoza preexistenta ->
ocluzie la aelasi nivel
– Embolie arterio-arteriala: emboli migrati de la
nivelul unei placi de aterom trombozate
• Cardioembolic: emboli din sursa cardiaca
(atriala / ventriculara)
• Hemodinamic : hipoperfuzie sistemica +
stenoza a unui vas cerebral
Mecanisme de “salvare” a zonei
ischemice
- Deschiderea anastomozelor
- Saltul tensional
 Fiziopatologie
• Necroza ischemica
– Central
– Perfuzie < 10 ml/100g/min
– Ireversibila
• Penumbra
– Perfuzie < 30 ml/100g/min
– Recuperabila
– Pseudo-apoptoza
– Metab anaerob: acidoza
• Edem vasogenic -> metab
anaerob -> edem citotoxic
 Diagnostic clinic
• Debut brusc
• Deficit neurologic focal: motor, senzitiv,
vizual, limbaj / modificare a starii de
constienta
• salt tensional asociat (compensator!)
• +/- cefalee
 Manifestare clinica
Ocluzie vas mare Ocluzia de vas mic
(perforant): AVC lacunar
• ACA: pareza crurala
controlaterala • Hemipareza ataxica
• ACM: hemipareza • Hemihipoestezie izolata
predominant facio-brahiala • Pareza faciala / facio-
controlaterala, hipoestezie brahiala
cl, hemianopsie homonima
cl, afazie, • !! Semnele se remit in 3-7
• ACP: hemianopsie zile
homonima cl
• A vert: vestibular +
cerebelos
• A bazilara: sd altern + coma
 Diagnostic paraclinic
• CT / IRM
• examen ultrasonografic vascular / cardiac
• profil lipidic
• profil biologic
• teste hematologice
CT: hipodensitate
Angiografie + RMN
AVC cardioembolice
Microangiopatie cerebrala
 Prognostic
Functie de:
– Dimensiunea AVC
– Aria afectata
– Statusul cognitiv anterior
– +/- afazie
– Complicatii

• Recuperare: totala / partial / absenta

• Tulburare neurocognitiva: dementa asociata bolii vasculare
cerebrale
• Deces
 Complicatii
Locale Generale
•Transformare •Infectii pulmonare
hemoragica (aspiratie, imobilizare
•Edem cerebral masiv prelungita)
•Sd HIC •Leziuni cutanate –
sepsis
•Tromboze - TEP
Tratament
 Profilaxia primara
= Tratamentul factorilor de risc:
• HTA
• dislipidemie
• diabet
• boli cardiace

• fumat, alcool, droguri

 Tratamentul fazei acute
Recanalizare:

• tromboliza IV, IA -> r-TPA

• Proceduri endovasculare:
– Trombectomie
– Dilatatie cu stent
 Tratament faza acuta
• Antiedematos: Manitol 20%

• Simptomatic: combaterea febrei, hiperglicemiei, trat TA

daca > 210/120 mmHg

• profilaxia complicatiilor:
– edem cerebral (HIC) -> decompresie terapeutica de necesitate
– TVP – TEP: heparine GMM
– complicatii decubit
– aspiratie (bronhopneumonie)
 După primul AVC riscul de recurenţă a
evenimentelor CV este mare
20 AVC recurent

IM sau eveniment cardiac fatal

Pacienţi cu evenimente (%)

15
(n=655)

10

0
30 zile 1 an 5 ani
Momentul monitorizării
IM = infarct miocardic.

Adapted from Dhamoon MS et al. Presented at the 57th Annual Meeting of the American Academy of Neurology;
Miami Beach, FL. April 9-16, 2005. S38.005.
 Profilaxia secundara
• Medical:
– antitrombotic:
• Antiagregant: aspirina – din prima zi a AVC acut 150 –
300 mg/zi
– clopidogrel, dipiridamol + aspirina
• Anticoagulant: numai in AVC cardioembolice confirmate
– Antivit K: dicumarinic
– Non-antivit k: numai FIA non valvulara
– tratamentul factorilor de risc: HTA (IEC/ sartani), dislipidemie,
ateromatoza a vaselor cerebrale (statine)

• Proceduri:
– Chirurgical: endarterectomie
– Endovascular: stent