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Boala vasculara cerebrala

Sistemul arterial cerebral

INCIDENTA: toate tipurile de AVC


I ncidenta primului AVC, orice tip, pe grupe de
varsta si sex, in Europa
45
40

in ra t e s p e r 1 0 0 0

35
30
25
20
15
10
5
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:
Incidenta medie 75 + :

8.72 / 1 000 ambe sexe


17.31 / 1 000 ambe sexe

Subtipuri de AVC (CT, RMN)


AVC
15%
85%

Hemoragic
. Intraparenchimatos
. Subarahnoidian

Ischemic
20%

25%

20%

Boala aterosclerotica Artere penetrante


vas mare
(Lacunar)

Embolie
cardiogena
.
.
.
.

30%

5%

AVC
criptogenic

FIA
Valvulopatii
Trombi intraventriculari
Altele

Cauze rare

.
.
.
.
.
.

Stari protrombotice
Disectii arteriale
Arterite
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

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
ACA: pareza crurala
controlaterala
ACM: hemipareza predominant
facio-brahiala controlaterala,
hipoestezie cl, hemianopsie
homonima cl, afazie,
ACP: hemianopsie homonima
cl
A vert: vestibular + cerebelos
A bazilara: sd altern + coma

Ocluzia de vas mic (perforant): AVC


lacunar

Hemipareza ataxica
Hemihipoestezie izolata
Pareza faciala / faciobrahiala
!! Semnele se remit in 3-7
zile

Diagnostic paraclinic

CT / IRM
examen ultrasonografic vascular / cardiac
profil lipidic
profil biologic
teste hematologice

CT: hipodensitate

Diagnostic diferential
Criza epileptica / deficitul postcritic
rezidual
Proces expansiv intracerebral cu debut
clinic pseudoictal
Encefalopatii metabolice: hipoglicemica,
hepatica, uremica
Encefalite

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

Tratament faza acuta


Antiedematos: Manitol
simptomatic: hidratare IV (NU GLUCOZA)
Tratamentul HTA (valori peste 200/110 mmHg,
glicemiei peste 140 mg/dl, febrei
profilaxia complicatiilor:
edem cerebral (HIC) -> decompresie terapeutica de
necesitate
TVP TEP: heparine GMM
complicatii decubit,
aspiratie (bronhopneumonie)

Profilaxia secundara
Medical:
antitrombotic:
Antiagregant: aspirina, clopidogrel, dipiridamol + aspirina
Aspirina in primele 7 zile: 150 320 mg / zi
Si in AVC tranzitor urgenta majora

Anticoagulant: numai AVC cardioembolice confirmate


Antivit K: dicumarinic
Non-antivit k: numai FIA non valvulara

tratamentul factorilor de risc: IEC/ sartani, statine

Proceduri:
Chirurgical: endarterectomie
Endovascular: stent