Docstoc

STROKE amphetamine Intoxication

Document Sample
STROKE amphetamine Intoxication Powered By Docstoc
					CEREBROVASCULAR
    ACCIDENT
CLASSIFICATION

   Complete stroke
   T.I.A
   R.I.N.D
   Stroke in evolution
Acute neurological injury which occurs as a
  result of ;


   1—Embolism
   2---Thrombosis
   3---Haemorrhage
   4---Demyelation
   5---SOL { Space occupying lesion}
RISK FACTORS

   Age—advanced age
   Sex—males more than females
   Hypertension
   DM
   Hyperlipidemia
   Smoking
   Excess alcohol consumption
   Polycythemia
   O.C. pills
   Vasculitis
   Thrombophillia
   Anticardiolipin antibody
   Homocysteinurea
         MANAGEMENT
HISTORY

May be helpful
Headache + vomiting ---favour the Dx
 of IC hge or SAH

Abrupt onset of impaired cerebral
 function without focal symptoms
 suggest SAH
EXAMINATION
 BP

 Breathing

 Fever----meningitis

            subdural haematoma
            brain abcess
            infective endocarditis
 Neck---for bruits

 Pulses----in neck and arms
   CVS---valvular heart disease ,AF
   Skin---signs of cholesterol
    embolism+IE
   Fundus
INVESTIGATIONS

   CBC , ESR
   U+E, RBS
   LFT, PT, PTT
   CT scan brain or MRI
   Doppler U.S of carotids
   Echo
   Hypercoagguable screen
   Screen for connective tissue disease
   Toxicology screen
D/D
--Migraine
--Head trauma
--Brain tumour
--Systemic infections
--Toxic metabolic disturbance
         hypoglycemia
         acute renal+ hepatic failure
         drug intoxication
Todd,s paralysis
HAEMORRHAGE
Intracranial hge can be caused by—
 Intracerebral hge {ICH}

  also called parenchymal hge which
  involves bleeding directly into brain tissue.
 SAH
  involves bleeding into the CSF that
  surrounds the brain and the spinal cord
 Trauma

  causing subdural or extradural
  haematomas
COMMON CAUSES
 Hypertension

 Trauma

 Bleeding diathesis
 Amyloid angiopathy

 Illicit drug abuse {amphetamine ,
  cocaine}
 Vascular malformation

 Rupture of aneurysm

 Vasculitis
SUBARACHANOID HAEMORRHAGE
1--Bleeding from aneurysm typically located
  in the anterior half of circle of willis at the
  base of the brain.
2—2nd commonest causes
         A/V malformation
         bleeding diathesis
         drugs
         amyloid angiopathy
COMPLICATION OF SAH DUE TO
  ANEURYSM
 Rebleeding within 10 days

 Vasospasm

 Systemic complications

  --hyponatremia
  --MI
  --CNS disturbance
TREATMENT
 Identify cause

 Prevent rebleeding

 Prevent brain damage due to delayed
  ischaemia related to
  vasoconstrictionof IC arteries
  --surgical removal
  --Calcium channel blocker -
  Nimodipine
PROGNOSIS
 SAH from intra cranial aneurysm has a

  mortality of 50%
 Prognosis is closely related to pts

  neurological condition on hospital arrival
 Pts who are alert and have no major focal

  defecit have a 70-80% chances of survival
 Those who are comatosed have

  90%mortality
INTRACERBRAL HAOMORRHAGE
Strongly associated with hypertension
Hypertension leads to fibrinoid necrosis of arterioles
                        +
Long standing hypertension leads to hyaline
  changes in the muscular and elastic arterial
  layer-----leads to microaneurysim-----liable to
  rupture
Middle cerbral artery and the lenticular branches
  are prone to develop these aneurysms
Majority of ICH occur in the region of the internal
  capsule
FIVE COMMON AREAS OF
  HAEMORRHAGE
 Putamen

 White matter or lobe

 Thalamous

 Pons

 Cerebellum
   ICH usually presents abruptly when
    the pt. is awake
   Severe headache
   ½ of pts. Present with LOC and fits
   Since internal capsule is involved so
    there is hemiplegia
   Massive bleeding---increase
    intracranial pressure---papilloedema-
    ---deep coma
GENERAL RULE
 If the bleeding is greater than 80 mls
  as estimated by CT scan, and is
  associated with deep coma------
  chances of survival are very poor
 ICH of moderate size >1.5 cm in
  diameter, surgical evacuation may
  be life saving
 Bleeding forms localized haematoma
---spreads along the white matter
---haematoma enlarges and continues
  to grow
---pressure surrounding it increases to
  limit its spread
                  OR
Decompresses itself into the
  ventricular system CSF
   Any patient with sudden onset of severe
    headache should be considered to have
    SAH.
   Headache with global impairement of
    conciousness is typical
   Focal neurological signs are rare
   Diplopia + cranial nerve lesion may occur
   Neck stiffness
   Subhyloid hge
PUTAMEN
 Majority of hgic strokes occur in this
  area
 Hemiparesis or hemiplegia

 Sensory loss

 Aphasia if on dominant side

 Surgery of questionable value
PONS
 Rapid loss of conciousness

 Pin point pupils

 Periodic respiration

 Quadriparesis

Surgery of no value
   WHITE MATTER OR LOBE

   Same as putamin hge signs
   Distinguished only by neuroimaging

   Surgical evacuation, if suitable
EMBOLIC STROKE

   Usually occur abruptly
   Occasionally present with
    stuttering fluctuating symptoms
   Either the anterior (carotid) or
    posterior (vertibobasilar )
    circulation may be involved
CLASSIFCATION ACCORDING TO
 LOBES

FRONTAL LOBE
Personality and emotional disorders
Expressive dysphasia
Contralateral hemiparesis
Primitive reflexes
PARITAL LOBE
-Spatial disorientation
-Apraxia +acalculia +agraphia +alexia
-Sensory inattention,neglect of non
  dominant side
-Contralateral hemisensory loss
-Lower quadrantonopia
TEMPORAL LOBE

-Receptive dysphasia
-De ja vu phenomena
-Hallucination of taste and smell
-Excessive lip smacking
-Micropsia
-Upper quandrantonopia
OCCIPITAL LOBE
-Homonymous hemianopia with
  sparing of the macula
-Thalamic syndrome
LOCALIZING FEATURES OF
 MOTOR LESIONS

CEREBRAL CORTEX

   Flaccid weakness---
    flexors+extensors equally
    affected (global weakness)
   INTERNAL CAPSULE
   Spastic weakness
   Extensors more than flexors
   Distal muscles affected more than
    proximal
   Patient looks away from the lesion
    (paralysis of head and eye
    movement )
BRAIN STEM
--crossed hemiplegia i.e ipsilateral cranial
  nerve palsy with contralateral
  limb palsy
ROOT AND PERIPHERAL LESION

--peripheral nerve lesions usually affect both
  motor and sensory function in muscles
  and skin supplied by the nerve
                    l
LOCALIZING ACCORDING TO BLOOD SUPPly
MIDDLE CEREBRAL ARTERY
Supplies majority of the internal capsule,
  larger part of frontal , parietal and
  temporal lobe)
 Contralateral spastic weakness

 Hemianopia

 May have signs of frontal , temporal or

  parietal lobes
ANTRIOR CEREBRAL ARTERY
(Supplies the frontal lobe , superior
  portion of cerebral cortex and
  anterior portion of internal capsule)
--Motor dysphasia
--Cortical flaccid weakness of the
  opposite leg
--Cortical sensory loss in opposite leg
--Frontal lobe signs
POSTERIOR CEREBRAL ARTERY
(supplies occipital lobe, branch to thalamous
  and mid brain)
--homonomous hemianopia with sparing of
  the macula
--thalamic syndrome
--if both cerebral arteries are occluded—
  cortical blindness (pt is blind but all the
  pupillary reflexes are intact
 CNS LOCALIZATION
 HEMIPLEGIA

 CORTICAL

         speech disturbances
         UMNL 7th N palsy
SUBCORTICAL
             multiple cranial nerve
             palsy
   SPINAL CORD
   Bilateral pyramidal signs
   Higher function intact
   No cranial nerve palsy apart from
    occasional 11th nerve palsy
WEAKNESS OF LOWER LIMBS
 With pyramidal signs

      cord lesion
      MND
 Without pyramidal signs

      neuropathy either sensory or
      motor
      muscle disease
CRANIAL NERVES
 Single

       DM or Bell,s palsy
 Multiple

        brain stem , with or without
        long tract signs----SOL
                        ----vascular
EXTRAPYRAMIDAL

   With pyramidal signs
      vascular like atherosclerosis
   Without pyramidal signs
      degenarative group
CEREBELLAR
 Wings

      look for pes cavus
 Tract signs

           SOL (acoustic neuroma)
           PICA
MUSCLES
           Dystrophies
CEREBELLUM
 Headache

 Vertigo

 Atxia

 Lethargy

 No focal weakness

Surgical evacuation for all except small
haemorrhages
CLASSIFICATION
Within the cavernous sinus
  (infraclinoid)
 It may compress structures like

  3,4,5 and 6th nerve palsy
----dilated pupil
----facial pain
----variable loss of facial sensation
Above the cavernous sinus
  (supraclinoid)
 Most frequently compress the

  occulomotor nerve , optic tracts and
  chiasm
 May extend into the frontal lobe
   6th year

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:14
posted:7/3/2011
language:English
pages:66