Hospital

Carlos Van Buren

V A L P A R A I S O

NEUROCIRUGA

ENFERMEDAD CEREBROVASCULAR
ENFOQUE NEUROQUIRRGICO

Dr. Rodrigo Riveros Pintone

Residente de Neurociruga Hospital Carlos Van Buren Escuela de Medicina UV

14 de Octubre de 2010
jueves 14 de octubre de 2010

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Hospital Carlos Van Buren
V A L P A R A I S O

jueves 14 de octubre de 2010

posterior inferior cerebellar a. vertebral a. anterior spinal a.

NEUROCIRUGA
Hospital Carlos Van Buren
V A L P A R A I S O

lenticulostriate aa. middle cerebral a. anterior cerebral a. anterior choroidal a.

carotid circulation

thalamic aa. posterior cerebral a. superior cerebellar a. anterior inferior cerebellar a. posterior inferior cerebellar a. vertebral aa./ basilar a. vertebrobasilar circulation

Fig. 6.11 Territories supplied by the individual arteries of the brain.

Blubber Blubber

jueves 14 de octubre de 2010

Mumenthaler / Mattle, Fundamentals of Neurology 2006 Thieme All rights reserved. Usage subject to terms and conditions of license.

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Hospital Carlos Van Buren
V A L P A R A I S O

Enfermedad Cerebrovascular
Infarto 80% 23% Hemorragia Intraparenquimatosa 10% 50% Hemorragia Subaracnodea 7% 33%

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Hospital Carlos Van Buren
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jueves 14 de octubre de 2010

Perfiles Temporales
Ictal Clnica Vascular Segundos
jueves 14 de octubre de 2010

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Hospital Carlos Van Buren
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Minutos Tiempo

Horas

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Hospital Carlos Van Buren
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Infarto Cerebral

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Infarto Maligno ACM

Infarto extenso territorio ACM Hipertensin endocraneana

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Hospital Carlos Van Buren
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territory is a ected. Other authors predict a malignant course with development of severe oedema if more than NEUROCIRUGA Hospital Carlos Van ganglia 50% of the rostral MCA territory and the basal Buren V A P A R A I S O show ischaemic alterations.12,37 Additionally,L infarctions of
Intracranial blood CSF

Intracranial pressure

Change in intracranial pressure Brain tissue Change in volume

Intracranial volume

Figure : Brain oedema formation Schematic diagram of cerebral compliance. An increase in oedematous brain tissue requires a compensatory decrease in the other jueves 14 de octubre de 2010two physiological compartments contained in the skull: intravascular blood and CSF. If these

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Hospital Carlos Van Buren
V A L P A R A I S O

jueves 14 de octubre de 2010

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Hospital Carlos Van Buren
V A L P A R A I S O

Hemorragia Intracerebral

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Hospital Carlos Van Buren
V A L P A R A I S O

Hemorragia Intraparenquimatosa
Traumtica Espontnea Primaria 87% Secundaria 13%
Malformacin Vascular Tumor Cerebral Trombosis Seno Venoso Transformacin Hemorgica Coagulopata Vasculitis Drogas

Hipertensiva Angiopata Amilodea

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Hospital Carlos Van Buren
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MEDICAL PROGRESS

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Hospital Carlos Van Buren
V A L P A R A I S O

jueves 14 de

Figure 2. Most Common Sites and Sources of Intracerebral Hemorrhage. Intracerebral hemorrhages most commonly involve cerebral lobes, originating from penetrating cortical branches of the anterior, middle, or posterior cerebral arteries (A); basal ganglia, originating from ascending lenticulostriate branches of the middle cerebral artery (B); the octubre de 2010thalamus, originating from ascending thalmogeniculate branches of the posterior cerebral artery (C); the pons, originating from paramedian branches of the basilar artery (D); and the cerebellum, originating from penetrating branches of the pos-

 Paciente Edad HTA Aspectos tomogrficos Localizacin HSA asociada Edema asociado
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Estudio Etiolgico

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Hospital Carlos Van Buren
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Hospital Carlos Van Buren
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Hemorragia Subaracnodea

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Hospital Carlos Van Buren
V A L P A R A I S O

Hemorragia Subaracnodea
Traumtica Espontnea
85% Aneurisma roto 10% Perimesenceflica 5% Otras (diseccin, MAVS, Fstula dural, Lesiones vasculares medulares, Micticos, Apopleja hipofisiaria, Drogas, Trauma)

jueves 14 de octubre de 2010

is in persons 55 to 60 years old.11 An estimated 5 to 15 percent of cases of stroke are related to ruptured intracranial aneurysms.12 Aneurysmal subarachnoid hemorrhage, a form of hemorrhagic stroke, has a 30-day mortality rate of 45 percent. An estimated 30 percent of survivors will have moderate-to-severe disability.13 Little is known about the cause of intracranial aneurysms or the process by which they form,

grow, and rupture, although hypertension and smoking-induced vascular changes are thought to have a major role.3 The most common histologic finding is a decrease in the tunica media, the middle muscular layer of the artery, causing structural defects. These defects, combined with hemodynamic factors, lead to aneurysmal outpouchings at arterial branch points in the subarachnoid space at the base of the brain (Fig. 1).3

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Hospital Carlos Van Buren
V A L P A R A I S O

Pericallosal artery, 4%

Additional miscellaneous aneurysm locations not shown: 3.5%

Anterior communicating artery, 30% Internal carotid artery bifurcation, 7.5% Middle cerebral artery, 20% Posterior communicating artery, 25% Basilar tip, 7%

Posterior inferior cerebellar artery, 3%

jueves 14 de octubre de 2010 Figure 1. The Intracranial Vasculature, Showing the Most Frequent Locations of Intracranial Aneurysms.

Clnica
Anamnesis
cualitativo)

NEUROCIRUGA
Hospital Carlos Van Buren
V A L P A R A I S O

Cefalea Compromiso de conciencia (cuantitativo y Vmitos Convulsiones Amaurosis monocular TEC asociado
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Clnica
Examen

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Hospital Carlos Van Buren
V A L P A R A I S O

III par VI par Hemiparesia Meningismo Hemorragia subhialodea

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Hospital Carlos Van Buren
V A L P A R A I S O

Cuadro Clnico Sugerente TAC

HSA Angiografa 3D AngioTAC

Sin HSA Puncin Lumbar

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Hospital Carlos Van Buren
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Sensibilidad
100

TAC

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Hospital Carlos Van Buren
V A L P A R A I S O

75 Porcentaje 50 25 2 5 0 21

7 Das de Evolucin HSA

14

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Puncin Lumbar
Seminar

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Hospital Carlos Van Buren
V A L P A R A I S O

Idealmente 6 - 12 h Presin de apertura Xantocroma Bilirrubina Crenados 3 tubos

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w an ad tr

Figure : Xanthochromia of cerebrospinal uid Haemorrhagic cerebrospinal uid after centrifugation shows a yellow colour (right) compared with water (left), which proves that blood was not introduced during puncture.

If the cerebrospinal uid seems clear, the pressure should be measured, since sudden headache can be a rst manifestation of intracranial venous thrombosis.50 Conversely, low cerebrospinal uid pressure can signify spontaneous intracranial hypotension. Clear cerebrospinal

Th co ab ne as an gr pr w an re te ra of pe pr ne

Aneurisma Roto

Hemorragia Subaracnodea

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Hospital Carlos Van Buren
V A L P A R A I S O

Complicaciones
Neurolgicas Resangrado Vasoespasmo Hidrocefalia Convulsiones Edema Cerebral HTEC
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Extraneurolgicas Cardiovasculares Respiratorias Hidroelectrolticas TVP Infecciones

Plazos
24 h
Confirmacin HSA

NEUROCIRUGA
Hospital Carlos Van Buren
V A L P A R A I S O

48 h
Confirmacin Aneurisma

24 h
Tratamiento

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Hospital Carlos Van Buren
V A L P A R A I S O

jueves 14 de octubre de 2010