ATUALIZAO E PERSPECTIVAS

Definies
Leso cerebral por interrupo abrupta do fluxo sanguneo Isqumico ou hemorrgico Arterial ou venoso AVC x AVE x Stroke

Definio da OMS
Um dficit neurolgico: De instalao sbita Com disfuno focal e no global No qual, aps investigao adequada, os sintomas so considerados como de origem vascular no-traumtica Que duram por >24 horas

Epidemiologia
Annually, 15 million people worldwide suffer a stroke. Of these, 5 million die and another 5 million are left permanently disabled, placing immense burdens on family and community. In 2005, it accounted for approximately 10% of all deaths worldwide. Globally, stroke is the second leading cause of death [3].

Epidemiologia
AVCI corresponde a 87% dos avcs nos EUA. ICH and SAH account for approximately 10% and 3% of all strokes, respectively. About 36% to 69% of ICH is deep in location, 15% to 32% is lobar, 7% to 11% is cerebellar, and 4% to 9% is in the brain stem [11].

Epidemiologia risco de recurrncia

The risk for recurrent ischemic stroke is 2% at 7 days, 4% at 30 days, 12% at 1 year, and 29% at 5 years after initial cerebral ischemia Risk for recurrent stroke at 30 days on the basis of stroke subtype is 18.5% for largeartery cervical or intracranial atherosclerosis with stenosis, 5.3% for cardioembolism, 1.4% for lacunar infarction, and 3.3% for infarct of uncertain cause

Epidemiologia - mortalidade

The overall mortality for stroke in the United States in 2004 was 50 per 100,000. About 70% to 80% of all stroke deaths are ischemic. Hemorrhagic strokes are less prevalent but more likely to be fatal. Globally, the average 30-day case fatality following first ischemic stroke is about 22.9% with the exception of Japan (17%) and Italy (33%) According to the Rochester Epidemiologic Project, the risk for death after first ischemic stroke was 7% at 7 days, 14% at 30 days, 27% at 1 year, and 53% at 5 years

FATORES DE RISCO
Hipertenso arterial (7x) Doenas cardacas (isqumicas) (2x) Fibrilao atrial (5x) + valv. (17x) Diabetes (2x) snd. Metablica. Tabaco (1,5x AVC e 1,9x AVCI) Hiperlipidemia (esp. em jovens) Fatores hematolgicos (fibrinognio e homocistena) Apnia obstrutiva do sono Doena carotdea

ABCD2 e AIT de alto risco

Symptom
Age > 60 years Blood pressure > 140/80 Clinical (neurological deficit) 1 point 1 point 2 points for hemiparesis 1 point for speech problem without weakness

Score

Duration
Diabetes
Maximal score is 7.

2 points for >60 minutes 1 point for 10-60 min

1 point

Rothwell et al,

Lancet. 2007;369:283-92

ABCD2 Stroke Risk

48 hours 0-3 Low risk 4-5 Mod. risk 5-7 High Risk 1% 4% 8% 1 week 1% 6% 12% 3 months 3% 10% 18%

AITs com escore de 5 ou maior devem ser admitidos para investiao e tratamento imediatos.

Fibrilao atrial e CHADS2

The CHADS2 criterion offers a risk stratification scheme for individual stroke risk factors in patients who have atrial fibrillation. The CHADS2 acronym stands for congestive heart failure, hypertension, age older than 75 years, diabetes mellitus, and prior stroke or TIA. Individuals receive 1 point for each risk factor except prior stroke or TIA, which receives 2 points The stroke rate increases by 1.5 with each 1-point increase on the CHADS2 score. Subsequent studies have validated this risk scheme and the studys ability to correctly identify those at high or low risk

Fontes de embolismo cerebral

Cardacas: fibrilao atrial, outras arritmias, trombo mural (IAM, hipocinesias, cardiomiopatia), endocardite bacteriana, vlvulas prostticas, vegetaes nobacterianas, mixoma atrial Grandes artrias: aorta e cartidas Paradoxal: shunt direito-esquerdo (FOP)

Fisiopatologia

ISQUEMIA CEREBRAL

AVC HEMORRGICO

Hemorragia Subaracnide

CLASSIFICAO dos AVCIs

Aterosclerose de grandes artrias. (~30%) Embolismo cardiognico (~30%) Doena vascular oclusiva de pequenos vasos (~20%) AVC de outras causas determinadas (~10%) AVC criptognico TOAST

Diagnstico do AVC agudo

Time is Brain Deteco precoce Descartar diferenciais Verificar critrios de incluso Afastar critrios de excluso

Circulao Cerebral

Circulao Cerebral

Classificao de Bamford para o AVC agudo

Sndromes lacunares LACS Snd. da Circul. Anterior Total TACS Snd. Da Circulao Ant. Parcial PACS Snd. Circulao Posterios - POCS

LACS
Sind Motora Pura Sind. Sensitiva Pura Disartria Clumsy Hand Hemiparesia Atxica Dficits proporcionados

TACS
Hemiplegia Hemianopsia Disfuno cortical superior (linguagem, funo visuoespacial, nvel de conscincia)

PACS
Dficti S/M + hemianopsia Dficit S/M + disfuno cortical Disfx cortical + hemianopsia Disfx cortical + motor puro (monoparesia) Disfx cortical isolada

POCS

Paralisia de par craniano (nica ou mltipla) ipsilateral + dficit S/M contralateral Dficit S/M bilateral Alterao dos movimentos conjugados dos olhos Disfuno cerebelar sem dficit de trato longo ipsilateral Hemianopsia isolada ou cegueira cortical.

Time is Brain
Um pedao de crebro do tamanho de uma ervilha morre para cada 12 minutos de atraso no tratamento Cada minuto que se espera, voc perde cerca de 2 milhes de clulas cerebrais

26

The Cincinnati Prehospital Stroke Scale

Facial Droop (have patient show teeth or smile):

Normalboth sides of face move equally Abnormalone side of face does not move as well as the other side

Arm Drift (patient closes eyes and holds both arms straight out for 10 seconds):
Normalboth arms move the same or both arms do not move at all (other findings, such as pronator drift, may be helpful) Abnormalone arm does not move or one arm drifts down compared with the other

Abnormal Speech (have the patient say you cant teach an old dog new tricks):
Normalpatient uses correct words with no slurring Abnormalpatient slurs words, uses the wrong words, or is unable to speak

Interpretation: If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%.

NIH Stroke Scale (NIHSS)

1a. Nvel de conscincia (NC}
O = Alerta 1= No alerta, mas acorda aos pequenos estmulos, com resposta adequada 2= No alerta, responde somente com estmulos repetidos, ou com estmulos vigorosos (dor) para realizar movimentos (no esteriotipados) 3 = Responde somente com reflexo motor ou autonmico, ou totalmente irresponsivo, flcido ou arreflexo 0 = Responde as duas questes corretamente 1 = Responde uma questo corretamente 2 = No responde a nenhuma questo corretamente

1b. NC Questes

1c. NC Comandos

0 = Realiza dois comandos 1 = Realiza um comando 2 = No realiza nenhum comando

NIH Stroke Scale (NIHSS)

2. Olhar conjugado
0 = Normal 1 = Paralisia parcial 2 = Desvio do olhar conjugado, ou paralisia total no modificada com manobra oculoceflica 0= Normal 1= Hemianopsia parcial 2= Hemianopsia completa 3= Hemianopsia bilateral (cequeira cortical, ou cequeira por outra causa). 0= Normal 1= Leve (assimetria no sorrir, apagamento sulco nasolabial) 2= Parcial (paralisia total ou quase total da poro inferior da face) 3= Completa (de um ou dos dois lados)

3. Campo Visual

4. Paralisia facial

NIH Stroke Scale (NIHSS)

5. Resposta Motora (MMSS)
0= Sem queda a 45 (90) por 10 seg 1= Queda (no total) antes de completar 10 seg 2= Queda (at a cama) antes de 10 seg, com dificuldade de vencer a gravidade 3= Discreto movimento, mas sem vencer a gravidade 4= Sem movimento X= Amputao/fuso articular explicao:________________________________ 5a. MSE 5b. MSD 0 = Sem queda a 30 por 5 seg 1 = Queda (no total) antes de completar 5 seg 2 =Queda (at a cama) antes de completar 5 seg com dificuldade de vencer a gravidade 3 = Discreto movimento, mas sem vencer a gravidade 4 = Sem movimento X = Amputao/fuso articular explicao:__________ 6a. MIE 6b. MID

6. Resposta Motora (MMII)

NIH Stroke Scale (NIHSS)

7. Ataxia apendicular 8. Sensibilidade
0 = Ausente 1 = Presente em um membro 2 = Presente em dois membros 0 = Normal 1 = Leve a moderado dficit da sensibilidade do lado afetado, mas o paciente tem conscincia de estar sendo tocado 2 = Severo ou total dficit da sensibilidade (face/ MS/MI) 0 = Normal 1 = Afasia leve a moderada, perda da fluncia ou facilidade da compreenso, sem significante limitao nas ideias expressas. Reduo na fala ou compreenso 2 = Afasia severa, toda a comunicao atravs de expresses fragmentadas. Grande necessidade de inferir, adivinhar e questionar por parte do examinador 3 = Mutismo, afasia global

9. Linguagem

NIH Stroke Scale (NIHSS)

10. Disartria
0 = Ausente 1 = Leve a moderada (paciente pode ser compreendido com certa dificuldade) 2 = Severa / Mutismo / Anartria X = Entubado ou outra barreira explique:_____________ 0 = Normal 1 = Visual, ttil, auditiva, espacial ou extino aos estmulos simultneos sensoriais, em uma das modalidades sensoriais 2 = Hemi-inateno severa ou em mais de uma modalidade

11. Extino /Inateno

Total:

4< elegvel < 22

Atendimento agudo ao AVC

TIME IS BRAIN A Penumbra isqumica

Atendimento agudo ao AVC

Atendimento agudo ao AVC

Atendimento agudo ao AVC

Checklist para rTPA

Inclusion Criteria (all Yes boxes in this section must be checked): Yes Age 18 years or older? Clinical diagnosis of ischemic stroke with a measurable neurologic deficit?

Time of symptom onset (when patient was last seen normal) well established as 180 minutes (3 hours) before treatment would begin?

Checklist para rTPA

Contraindications:
Evidence of intracranial hemorrhage on pretreatment noncontrast head CT? Clinical presentation suggestive of subarachnoid hemorrhage even with normal CT? CT shows multi-lobar infarction (hypodensity greater than one third cerebral hemisphere)? History of intracranial hemorrhage? Uncontrolled hypertension: At the time treatment should begin, systolic pressure remains 185 mm Hg or diastolic pressure remains 110 mm Hg despite repeated measurements? Known arteriovenous malformation, neoplasm, or aneurysm? Witnessed seizure at stroke onset? Active internal bleeding or acute trauma (fracture)? Acute bleeding diathesis, including but not limited to Platelet count 100 000/mm3? Heparin received within 48 hours, resulting in an activated partial thromboplastin time (aPTT) that is greater than upper limit of normal for laboratory? Current use of anticoagulant (eg, warfarin sodium) that has produced an elevated international normalized ratio (INR) 1.7 or prothrombin time (PT) 15 seconds?* Within 3 months of intracranial or intraspinal surgery, serious head trauma, or previous stroke? Arterial puncture at a noncompressible site within past 7 days?

Checklist para rTPA

Relative Contraindications/Precautions:
Recent experience suggests that under some circumstanceswith careful consideration and weighing of risk-to-benefit ratiopatients may receive fibrinolytic therapy despite one or more relative contraindications. Consider the pros and cons of tPA administration carefully if any of these relative contraindications is present:
Only minor or rapidly improving stroke symptoms (clearing spontaneously) Within 14 days of major surgery or serious trauma Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days) Recent acute myocardial infarction (within previous 3 months) Postmyocardial infarction pericarditis Abnormal blood glucose level (50 or 400 mg/dL 2.8 or 22.2 mmol/L)

*In patients without recent use of oral anticoagulants or heparin, treatment with tPA can be initiated before availability of coagulation study results but should be discontinued if the INR is 1.7 or the partial thromboplastin time is elevated by local laboratory standards.

TOMOGRAFIA COMPUTADORIZADA

CT x RNM

Multimodal Diffusion-Perfusion MRI

DWI PWI MRA

Tissue Status

Perfusion Status

Vessel Status

Bioenergetic Compromise
UCLA Stroke Center

Hemodynamic Compromise

Occlusions or Stenoses

Evoluo radiolgica