A. 16 - 16. Emergency in cerebrovascular disorders

Question 1

how long does it take for the symptoms to deteriorate after acute cerebrovascular disorder?

Answer 1

within the first 24-48h

Question 2

whatis is necessary if there is altered consciousness or if focal symptoms are severe/worsening?

Answer 2

ICU

Question 3

when is it necessary to intubate?

Answer 3

Intubation is necessary if bulbar reflexes are absent/patient is in coma

Question 4

what are the general complications in case of Emergency in cerebrovascular disorders?

Answer 4

Fever

AMI

Hypertension

Blood glucose level increase

Dysphagia

Urosepsis risk increases (in case of catheter use)

DVT

Question 5

fever as General complication in cerebrovascular disorders emergency?

Answer 5

○ In most cases a sign of pneumonia

○ Give broad spectrum antibiotics and antipyretic tx ASAP

○ Increases the metabolic demand of the brain, leading to enlargement of infarct

Question 6

AMI as General complication in cerebrovascular disorders emergency?

Answer 6

mainly increased risk in right hemispheric lesions:
○ Probably due to increased release of catecholamines from brain → arrhythmias
(both depolarizing and repolarizing changes can be seen)

Question 7

Hypertension as General complication in cerebrovascular disorders emergency?

Answer 7

○ Most important risk factor of cerebrovascular disorders

○ Reducing blood pressure in the acute phase of ischemic vascular events may be harmful, as the elevation is a compensatory mechanism for maintaining perfusion to the brain.
After stabilization of general condition the blood pressure decrease is spontaneous in
most cases.

○ In some cases a spontaneous lowering is not expected (hypertensive encephalopathy, AMI, ARF, aortic dissection), and anti-HTN tx is needed:
■ Oral ACE inhibitors, i.v. labetalol (or i.v. sodium-nitroprusside)

Question 8

Hyperglycemia as General complication in cerebrovascular disorders emergency?

Answer 8

○ Cerebral ischemia in diabetic patients are associated with very high blood glucose levels.
Also usually increased in non-diabetic patients

○ Mechanism: in anaerobic conditions glucose is transformed to lactate → damage to BBB → cerebral edema.

○ Glucose is contraindicated in cerebral ischemia (except in hypoglycemia).

○ Insulin should be given if glucose levels > 15 mmol/L (target: 7,8-10 mmol/L)

Question 9

Dysphagia as General complication in cerebrovascular disorders emergency?

Answer 9

○ In large hemispheric infarctions, brainstem disorders, vascular pseudobulbar paralysis and in diseases affecting nucleus ambiguus
→ increased risk of aspiration pneumonia.
→ malnutrition

○ Nasogastric/nasoduodenal tube should be inserted

○ H2 blockers are recommended

Question 10

DVT as General complication in cerebrovascular disorders emergency?

Answer 10

○ Immobilisation secondary to cerebrovascular disorders results in DVT in 50% of cases, whereas PE is the cause of death in 10% of stroke patients.

○ Standard heparin or LMWH is given as prophylactic therapy:
■ Started 1st day in case of ischemic stroke
■ Started 3rd day in case of hemorrhagic stroke

○ If heparin is CI compression stockings and/or oral aspirin is given

Question 11

Neural complications in cerebrovascular disorders emergency?

Answer 11

○ Ischemia → cerebral edema, maximum at 3rd day
■ Reduced by osmodiuretics like mannitol or glycerol
■ Loop diuretics reduce production of CSF
■ In severe cases:
1. Controlled hyperventilation (decreased pCO2 will reduce ICP)
2. Barbiturate narcosis (EEG/plasma level monitoring)
3. Last solution is decompressive craniectomy

○ In occlusive hydrocephalus, e.g. blockage of the 4th ventricle, temporary drainage of CSF is indicated