Stroke/ PGS

Introduction
Circulatory failure is the second to third largest cause of death in most industrialized countries. The incidence of strokes (ischemic and hemorrhagic together) in the Czech Republic is twice as high as in other medically developed countries, it is around  300 cases per 100 000 inhabitants per year. Ischemic strokes account for  80–85 % of all cerebrovascular accidents (CVA). Hemorrhage, regardless of the cause, accounts for about 20% of total CVA, 10–15 % for spontaneous intracerebral hemorrhage and the remaining 5% is due to spontaneous subarachnoid or intraventricular hemorrhage. Therapeutic options for CMP are currently undergoing significant changes, which, due to the acute nature of the condition, must be constantly monitored and supplemented according to the latest findings. In addition to the diagnostic progress given mainly by neurological applications of new imaging methods, the possibilities of timely and effective treatment have also significantly expanded. náhled|vpravo|150px|Akutní CMP

Definition
The following division is possible in most cases only with the knowledge of the subsequent development of the state. We start treatment at a time when we often cannot categorize the stroke.

Completed stroke:

rapidly developing clinical signs of focal brain disease lasting more than 24 hours or leading to death, unless clinical, laboratory and basic imaging tests suggest another cause of neurological deficit.

Transient ischemic attack (TIA):

rapidly developing clinical signs of focal brain disease or monocular vision impairment, which typically last less than 1 hour, but not more than 24 hours, unless clinical, laboratory and imaging tests suggest another cause of neurological deficit.

Clinical picture
Sudden development of focal neurological symptoms of central origin manifested according to the territory of the affected cerebral artery (weakness to paralysis and / or sensitivity of the body, symbolic function, deviation of the head and eyeballs, visual paresis, visual field loss, diplopia, sudden dizziness or sudden fall in conjunction with previous central neurological symptoms, amaurosis, incoordination, or other symptoms depending on the location of the lesion.)

Lacunar infarcts are manifested mainly by isolated motor and / or sensitive deficits, atactic hemiparesis, dysarthria, "clumsy hand". Rarely, ischemic stroke is manifested by headache, initial vomiting, impaired consciousness, even more rarely, epileptic paroxysm is the initial symptom.

Small and large symptoms of stroke

Causes
A number of diseases can etiologically contribute to the occlusion or narrowing of a cerebral vessel with a reduction in blood flow and subsequent ischemia of a part of the brain tissue (Table 1).

Definition
Blood penetration into the leptomeningeal space, ie the intermeningeal space between the pia mater and the arachnoid. It can be combined with parenchymal, which either secondarily penetrated into the cerebral sheaths, or, conversely, was formed secondarily by blood penetration into the cerebral parenchyma.

Clinical picture
Sudden headache (in seconds to minutes) is the only sign of subarachnoid hemorrhage in 20%. There are also nausea and vomiting, focal neurological deficit with the possibility of rapid progression of qualitative and quantitative disorders of consciousness, meningeal syndrome (often up to about 6 hours after the event). Bleeding often occurs during increased physical exertion. In clinical practice, the classification according to WFNS (World Federation of Neurological Surgeons) or Hunt and Hesse is used (Table 6).

Examination procedure and treatment
The same algorithm as in any acute neurological patient (Chapter 2) or in a patient with impaired consciousness (Chapter 3) or as patients with intracranial hypertension syndrome (Chapter 4?), With emphasis on early brain CT, which has up to 98% sensitivity in during the first 12 hours, for older bleeding,  brain MR is recommended. If the CT finding is negative but subarachnoid hemorrhage is suspected from the clinical picture,lumbar puncture is required.

Positivity of CT (MR) findings or positivity of lumbar puncture examination are indications for consultation of the neurosurgical department, because causal treatment and prevention of rebleeding is possible only through neurosurgery or interventional neuroradiological procedures. For this reason, the next examination procedure (DSA) should only be performed at a workplace capable of these procedures. Therefore, it is necessary to ensure the transport of the patient by ambulance accompanied by a doctor. Depending on the overall condition, depending on the GCS, patient transport is indicated in some cases only after the intensivist has previously secured and stabilized vital functions.

Causal treatment is fully within the competence of neurosurgery and / or interventional neuroradiology by performing open surgery (clipping) and / or endovascular techniques (coiling).

Further prevention of complications of subarachnoid hemorrhage - can take place in the department of neurointensive care. (3H therapy, transcranial doppler monitoring, prevention and treatment of vasospasms (nimodipine iv / po, papaverine iv), laxatives, antitussives).

Related articles

 * Brain ischemia

Links and literature

 * European Stroke Initiative, Recommendations 2008, Ischaemic Stroke,Prophylaxis and Treatment
 * Doporučený postup pro diagnostiku a léčbu pacientů s mozkovým infarktem, TIA, Cerebrovaskulární sekce České neurologické společnosti.