(Cerebral ischemia, stroke, apoplexy)

Strokes affect the arteries of the brain (brain arteries.), Either the front coverage area (branches of the internal carotid artery) or the rear supply area (branches of the Aa. Vertebral and basilar).

The term “stroke” comprises a heterogeneous group of diseases, is defined as a sudden interruption of the focal cerebral blood flow, which causes a neurological deficit. Stroke can be ischemic (80%), typically as a result of hemorrhagic of thrombosis or embolization, or (20%) as a result of vascular rupture (z. B. subarachnoid or intracerebral hemorrhage). Transitory stroke symptoms (h take usually <1) indicates (based on diffusionsgewichtetem MRI) as a transient ischemic attack (TIA) without evidence of acute cerebral infarction. In the United States, stroke is the fourth leading cause of death and the leading cause of neurological disability in adults. Strokes affect the arteries of the brain (brain arteries.), Either the front coverage area (branches of the internal carotid artery) or the rear supply area (branches of the Aa. Vertebral and basilar). Brain arteries. The anterior cerebral artery supplies the medial parts of the frontal and parietal lobe and the corpus callosum. The middle cerebral artery supplies large parts of the surface of the frontal, parietal and temporal lobes. Branches of the anterior cerebral artery and the middle cerebral artery (arteries lentikulostriäre) supply the basal ganglia and the front limb of the internal capsule. The Aa. and vertebral basilar artery supplying the brain stem, cerebellum, cerebral cortex, the rear and the medial temporal lobe. The Aa. cerebri posterior formed by bifurcation of the basilar artery and supply the medial temporal lobe (incl. the hippocampus), the occipital lobe, the thalamus, the mammillary bodies and the geniculate bodies. Front and rear circulation communicate in the circle of Willis. Risk Factors The following are the modifiable factors that appear most contribute to an increased risk of stroke: hypertension cigarette smoking dyslipidemia Diabetes Abdominal obesity alcohol consumption lack of physical activity high-risk diet (eg, high in saturated fats, trans fats and calories.) Psychosocial stress (eg., depression) heart disease (especially diseases that predispose to embolisms, such as acute myocardial infarction, infective endocarditis, and atrial fibrillation) hypercoagulable state (only thrombotic stroke) Intracranial aneurysms (only subarachnoid hemorrhage) drug use (eg. as cocaine, amphetamines) vasculitis straight to the änderlichen risk factors include previous stroke Seniority stroke Family history of male sexual symptoms and complaints The initial symptoms occur suddenly. These include i. Gen. Deafness, paresis or plegia of the contralateral limbs and face; Aphasia; Confusion; Blurred vision in one or both eyes (. Eg transient monocular blindness); Dizziness or loss of balance and coordination; A headache. The neurological deficits reflect the affected area of ??the brain resist (see Table: Selected Stroke Syndrome). Infarcts in front basin typically cause unilateral symptoms. Infarcts in the back basin can include or cause bilateral deficits and affect more awareness, especially when the basilar artery is involved. Selected Stroke Syndrome symptoms and discomfort syndrome contralateral hemiparesis (maximum in the leg), urinary incontinence, apathy, confusion, poor judgment, mutism, griffons Flex, Gangapraxie anterior cerebral artery (rare) contralateral hemiparesis (worse in the arm and face when in the leg), dysarthria hemianesthesia, contralateral homonymous hemianopia, aphasia (if the dominant hemisphere is affected) or apraxia and sensory neglect (when the non-dominant hemisphere is affected) middle cerebral artery (common) Contralateral homonymous hemianopia, unilateral cortical blindness, memory loss, unilateral paralysis of the III. Cranial nerves, hemiballism posterior cerebral artery monocular vision loss (amaurosis) ophthalmic artery (a branch of the middle cerebral artery) Unilateral or bilateral cranial nerve deficits (z. B. nystagmus, dizziness, dysphagia, dysarthria, diplopia, blindness), ataxia in hull or limbs, spasticity, crossed sensory and motor deficits *, disturbances of consciousness, coma, death (with complete occlusion of the basilar artery), tachycardia, blood pressure fluctuations Vertebrobasiläres system No cortical deficits plus one of the following manifestations: pure motor Hemipare se pure sensory hemianesthesia atactic hemiparesis Dysarthria-clumsy-hand syndrome Lacunar infarction * ipsilateral sensory disturbances in the face or motor weakness with contralateral body hemianesthesia or -Hemiparese show a lesion in the pons or medulla of. Systemic or vegetative disorders (eg. As hypertension, fever) are uncommon. Other manifestations more conclusively than neurological deficits on the stroke type. Sudden severe headache have z. As a subarachnoid hemorrhage out. Impaired consciousness or coma, often accompanied by headache, nausea and vomiting, speak for an increased intracranial pressure (overview of intracranial tumors: symptoms and complaints) may occur after prolonged ischemic stroke and even earlier in hemorrhagic insults, the h 48-72; a fatal entrapment can result (pathophysiology). Complications of a stroke may include: insomnia, confusion, depression, incontinence, atelectasis, pneumonia and swallowing disorders that can lead to aspiration, dehydration or malnutrition. Immobility can lead to thromboembolism, deconditioning, sarcopenia, urinary tract infections, pressure sores and contractures. Everyday functions (to go including the ability to see, to feel, to remember, to think and to speak) may be reduced. Assessment evaluation aims to establish the following: whether stroke occurred Whether stroke is ischemic or hemorrhagic whether emergency treatment is required what the best strategies for prevention of secondary strokes are whether and how the rehabilitation continues The suspected. Stroke, patients with one of the following characteristics: Sudden neurological deficits that fit to a brain injury in an arterial supply area Sudden, exceptionally strong headache sudden, inexplicable coma sudden impairment of consciousness glucose is measured at the bedside to eliminate hypoglycaemia. If a stroke still is suspected, immediate brain imaging is necessary to differentiate between hemorrhagic and ischemic stroke and for references to find an increased intracranial pressure. A CT is sensitive to intracranial blood; but it may turn out normal or show only slight changes in the first few hours with symptoms of ischemic stroke in the front stattgehabtem coverage area. In the CT also some minor insults of the rear service area and up to 3% of subarachnoid bleeding can not be detected. An MRI is sensitive to intracranial blood, and can show signs of ischemic stroke, which are not covered with the CT; However, a CT may be performed usually faster. If the CT the clinical suspected. not confirmed stroke, diffusion-weighted MRI can ischemic stroke usually recognize (ischemic stroke). If consciousness is disturbed and missing lateralizing characters or are ambiguous, more tests will be on the review of other causes performed (coma and impaired consciousness). After the stroke has been identified as ischemic or hemorrhagic, tests are performed to determine the cause. The patients are also tested for in addition existing acute underlying diseases (eg. As infection, dehydration, hypoxia, hyperglycemia, hypertension). Patients will be asked about depression that often occur after a stroke. Dysphagia team assesses swallowing; sometimes a barium Breischluck-examination is necessary. Treatment stabilization reperfusion in some ischemic strokes Supportive care and treatment of complications strategies to prevent further strokes Sometimes the vital stabilizing the patient's full investigation must precede. Comatose or dazed patients (z. B. Glasgow Coma Score ?8) to a breathing assistance need (mechanical ventilation at a glance). In V. a. and measures to reduce the cerebral edema (head injury: Increased intracranial pressure): to increased intracranial pressure intracranial pressure (intracranial pressure monitoring and its monitoring and investigation of intensive care patients) may be necessary. The acute specific treatment varies depending on the type of stroke. They may include (acute treatment) reperfusion (eg. B. recombinant tissue plasminogen activator, thrombolytic, mechanical thrombectomy) in some ischemic stroke. Clinical computer: Glasgow coma scale strategies for the prevention and treatment of complications of stroke application of elastic support stockings in combination with intermittent pneumatic compression and frequent implementation of active and passive leg exercises Frequent rotating bed-ridden patients, with particular attention to pressure points passive movement of limbs, which are kontrakturgefährdet, and establishing appropriate rest positions, if necessary, with rails Safe set of adequate hydration and nutrition, screening patients for swallowing and support in the diet if necessary Unless contraindicated, Gabe small Enoxaparindosen 40 mg s.c. every 24 h or heparin 5000 U s.c. every 12 hours, if not contraindicated to deep vein thrombosis and pulmonary embolism prevent encouragement early to go back (once the vital signs are normal), (with close monitoring maximizing lung function z. B. smoking cessation, deep breathing exercises, respiratory therapy, prevention measures Early aspiration in patients with dysphagia) search for and treatment of infections, v. a. Pneumonia, urinary tract infections and skin infections dealing with bladder problems in bedridden patients, preferably without the use of an indwelling catheter promote changes in risk factors (eg. As smoking cessation, weight loss, healthy diet) Regulation of early rehabilitation (z. B. active and passive exercises, exercises the range of motion) Empathic talks with patients about the preserved functions, the prognosis for recovery and strategies to compensate for the functional deficits För alteration of maximum independence through rehabilitation encouragement of the patient and his relatives, contact with stroke support groups for social and psychological support to include the provision of supportive care, the correction of concurrent disorders (eg. As fever, hypoxia, dehydration, hyperglycemia, sometimes hypertension) as well as the prevention and treatment of complications during the acute phase of convalescence critical (see table: strategies for the prevention and treatment of complications of stroke); these measures can significantly improve the clinical results. During convalescence measures to prevent aspiration, deep vein thrombosis, urinary tract infections, pressure sores and malnutrition may be necessary. Passive exercise treatment, especially of paralyzed limbs, and breathing exercises are started early to prevent contractures, atelectasis and pneumonia. Most patients require occupational therapy and physical therapy (s. Rehabilitation after stroke) to the maximum functional recovery. Some need additional therapies (eg. As speech therapy, diets). Depression after a stroke can make antidepressant treatment required; many patients benefit from psychological counseling. Rehabilitation, an interdisciplinary approach is best. The modification of risk factors by changes in lifestyle (eg. As smoking cessation) and through drug therapy (eg. For example, for treatment of hypertension) can help to delay or prevent further strokes. Other stroke prevention strategies are chosen based on patient risk factors. In ischemic stroke prevention, strategies may include interventions (eg. As carotid endarterectomy, stenting), antiplatelet and anticoagulation.

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