КУТОВОЙ ИГОРЬ АЛЕКСАНДРОВИЧ: +38 050 300-25-50; +38 098 447-26-32 город Харьков, ул. Акад. Павлова, 46 Государственное учреждение "Институт неврологии, психиатрии и наркологии НАМН Украины"
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mail: igorKutovoy@gmail.com

Class 5

Class 5

Methodological recommendations on the theme:

The vascular diseases of the brain requiring surgery. Classification, clinical course, diagnostics of hemorrhagic and ischemic insults. Treatment. Arterial aneurysms, arterio-venous malformations of vessels of the brain. Clinical course. Methods of investigation. Treatment. Endovascular and intracranial vascular neurosurgery.

1. Importance of the theme

Acute of disorders of brain blood circulation constitute about 30% of all cases of death from cardiovascular diseases; for last 10 years in Ukraine the rate of vascular diseases of the brain and death rate from them have increased considerably, in 1997 death rate from cerebrovascular diseases reached 8.41 on 10000 population which made about 20% of total death; parameters death rate from vascular diseases of the brain in Ukraine the is 2-5 times higher in comparison with the West-European countries and the USA (Kukushka J.A., 1998; Vinichuk S.M., 1998; Tsimejko O.A., 1998).

Acute of disorders of brain blood circulation constitute about 30% of all cases of death from cardiovascular diseases; for last 10 years in Ukraine the rate of vascular diseases of the brain and death rate from them have increased considerably, in 1997 death rate from cerebrovascular diseases reached 8.41 on 10000 population which made about 20% of total death; parameters death rate from vascular diseases of the brain in Ukraine the is 2-5 times higher in comparison with the West-European countries and the USA (Kukushka J.A., 1998; Vinichuk S.M., 1998; Tsimejko O.A., 1998).

Subarachnoidal haemorrhages (SAH) due to ruptures of arterial aneurysm (АА) of vessels of the brain result annually in death or disablement about 18000 individuals in Northern America (Kassell N.F., et all., 1990). It is known, that in the former USSR there were annually examined about 28000 patients with spontaneous SAH, half of them have been caused by rupture of АА, and the surgery was made only in 500 patients per year (Konovalov A.N., 1990). Intracranial АА are observed in 4 % of the population, every fifth of them is the cause of SAH with high death rate and disablement (Duros J. et all., 1991). In the USA during one month after the first haemorrhage up to 46 % of patients die (Broderick J.P. et all., 1993), in Sweden 21% of patients with ruptures of АА of the brain die before examination of the neurosurgeon (Edner G., Ronne-Engstrom E., 1991). Factors which determine results of treatment in the acute the period of haemorrhage are severity of the condition and age of the patients, terms of surgery, spreading of haemorrhage, the size of aneurysms and their quantity (Kassell N.F. et all., 1990; Brouwers P.J.A.M. et all., 1993; Findlay J.M. et all., 1993; Guber C.J. et all., 1993; Serbinenko F.A. et all., 1990; Solomon R.A. et all., 1991).

 

2. The practical aims

The STUDENT SHOULD KNOW (α =1) modern principles of classification, etiopathogenesis, clinical course and treatment of cerebrovascular diseases.

THE STUDENT SHOULD KNOW: (α =2)

  • Modern classification of cerebrovascular diseases.
  • Etiopathogenesis of acute haemorrhages in the brain.
  • Clinical course of acute haemorrhages in the brain.
  • Clinical course of compression of the brain.
  • Principles of diagnostics in definition of a kind of haemorrhages in the brain.
  • General brain and focal manifestation of haemorrhages in the brain
  • Modern methods of examination of the patient with clinical picture of acute haemorrhages in the brain.
  • The basic kinds of conservative and operative treatment.
  • Principles of rehabilitation of the patients who have had haemorrhage in the brain.

THE STUDENT SHOULD BE ABLE: (α =3)

  • To render the urgent aid to the patient with acute haemorrhages in the brain.
  • To define a kind of acute haemorrhages.
  • To examine these patients with application of auxiliary methods of diagnostics.
  • To estimate results of the received data.
  • To make a final diagnosis, to ground necessity, to determine terms and a method of surgery.
  • To determine volume of conservative treatment at acute of haemorrhages in the brain.
  • To fill in the medical documentation.

 

3. The educational aims

To observe principles of ethics and deontology on examination of patients with acute disorders of the brain blood circulation.

 

4. Interdisciplinary integration

Disciplines

To know

to be able

The previous disciplines

 

 

 

Anatomy and physiology of the vascular system of the brain.

 

 

Clinical manifestations of ADCC by hemorrhagic type

 

 

Clinical manifestations of ADCC by ischemic type

 

 

Diagnostics of ADCC

 

Intradisciplinary integration

 

 

 

5. The contents of the theme of the class

Ischemic disease of the brain. It is known, that 50-60 % of all ischemic disorders of brain blood circulation arise due to occlusive and stenosis affections of vessels of the brain. Ischemic disease of the brain includes ADCC by ischemic type (infarction brain, insults), TIA (TIA), discirculatory encephalopathy (ХСМН). Occlusive affections include occlusions, stenoses, a pathological tortuosity (a looping, excesses), extravasal compression. These affections are based on fibromuscular dysplasia, osteochondrosis, the atherosclerosis, hypertinsion, etc. All these affections result in deterioration of the brain bloodstream and ischemia of the brain. Occlusive affection develop more often the extracranial part of brain vessels (carotid and vertebral arteries) in the ratio to intracranial as 4/1. Extracranial arteries of the brain are rather easily accessible to surgical correction.

The history of surgery of ischemic disease of the brain is rather short. Attempts of interventions on carotid arteries go back to the end of the last century when the first messages on operations concerning syphilitic an aneurysm of the carotids on the neck have been published, all these operations finished unsuccessfully, therefore there was an opinion on impossibility of reconstruction of the carotids. The first successful reconstructive operation on the internal carotid artery – a carotid endarterectomy – was performed in 1953 by M.De Bakkey. In 1958 eastcott successfully performed a resection of pathologically twisted internal carotid artery. In 1967 Yasargil and Donaghy suggested and practically performed a bypass. In the USSR Petrovsky, Pokrovsky, Zlotnik, in Ukraine –Peleh, Zozulja, Voronin were the first to operate on carotids.

Clinical manifestations of occlusive affections of vessels of the brain include neurologic and local symptoms. Neurologic symptoms are studied in the course of nervous diseases. The local symptoms include palpable – reduction, absence of pulse on brachycephalic arteries; auscultatory – systolic noise on brachycephalic arteries, dull of tones on them.

Diagnostics: US Dopplerography, CT-SCAN, angiography, CT-scan-angiography, MRI-ANGIOGRAPHY.

Surgery. Indications: TIA, ADCC, ХСМН. Terms: – the first day after ADCC or in a month after it. Most important preventive direction of surgery of ischemia of the brain is at the stage of TIA and asymptomatic. The following operations are performed: a carotid and vertebral endarterectomy, a carotid and vertebral resection the end in the end and the end inside, redressment and decompression of these arteries, every possible shunting operations, including a bypass.

Preoperative and postoperative therapy: antiagregants (aspirin, Trentalum), anticoagulants (Heparinum) single dose of 5000 units during operation before temporary occlusion, hemodilution – Rheopolygluci, antiagregants are given within 2-6 months after operation.

Results of surgery: НМК does not recur in 85% of patients with ADCC and in 95 % of patients with TIA; the condition improves in 60-65% of patients with ADCC and ХСМН.

Hemorrhagic insult. A hemorrhagic insult is on the second place among cerebrovascular diseases. The cause of hemorrhagic disorder of brain blood circulation – hypertonic disease and atherosclerosis. Most often haemorrhage occurs from thalamostrial arteries in which the muscular layer is very much feebly marked and under influence of the arterial hypertension microaneurysms are formed which result in haemorrhage.

The first who stated an idea on an opportunity of surgery of hemorrhagic insult was Cushing in 20th years, he the first who performed successful operations of this disease. In Ukraine the pioneers were Arutyunov, Zozulja, Pedachenko.

Clinical signs: the onset of the disease in acute, in anamnesis there is long hypertonic disease, long disturbance consciousness of a various degree developing directly after haemorrhage, a focal manifestation is rough, develops directly after haemorrhage, the meningeal syndrome can be absent, especial in the first days.

Diagnostics: CT-SCAN, AG.

The surgery consists of removal of haematomas, there are different methods – open, puncture, stereotaxic, CT-scan-guided, open microsurgical. Indications to operation – surgical intervention is only removal of a massive blood clot. Damage due to crush and edema of tissues of the brain cannot be eliminated during operation. Thus, in haemorrhages without compression and dislocations of the brain, there are no indications to operation. Indications to operative intervention do not exist in «typical senile brain haemorrhages», involving internal capsule when gradual improvement comes after an insult; the consciousness of the patient clears up, and focal symptoms smooth out. If after disappearance of rough symptoms of haemorrhage the condition temporarily improves, and then deterioration gradually develops, then it is necessary to find out whether there is the extensive haematoma squeezing the brain. On the whole operative intervention does not result in improvement of the condition in patients over 60 years with sharply marked atherosclerosis (especially in a combination with expressed IHD), the expressed arterial hypertension, in coma and exhausted patients are more senior. With the help of operative intervention it is possible to achieve the best results in comparison with medicamentous treatment, if:

1)    operation is performed in a week after insult;

2)    the patient is not in coma;

3)    haematoma squeezing the brain is located more lateral then internal capsule.

Haematoma in the cerebellum occurs seldom though according to some authors about 10% of hypertonic haemorrhages have cerebellar localization. As a rule, in some days after not severe insult there are symptoms of increase of the intracranial pressure without signs specifying the side of affection.

Results of a surgery in careful estimation of indications to it is better than conservative – the mortality makes about 20%.

Arterial aneurysm (АА) of vessels of the brain is a limited or diffuse expansion of the lumen of the artery or a diverticulum of its wall. Usually it is a thin-walled bag in which there are a neck, a body and a bottom. Diffuse expansions – fusiform aneurysms are met less often.

As a rule, in the aneurysm wall there is no muscular layer, the endothelium is absent or underdeveloped. The wall represents a plate of various thickness from a cicatricial connective tissue which is sharply thinned in the area of the bottom. Ruptures of АА, as a rule, are located in the area of the bottom, rarer in the body, practically never in the neck. In АА cavity there can be blood clots of different remotedness.

АА of vessels of the brain are found in 0.5-5 % of all died of other reasons, however all of them are not always manifested clinically. It is known, that more than half of all not traumatic subarachnoidal haemorrhages (SAH) result from rupture of АА. It is known, that annually in Northern America SAH due to rupture of АА result in death or disability of 18000 individuals. Epidemiological research in Ukraine was not made, but it is known, that annually in the former USSR 25000 patients with non traumatic SAH were registered, about half of them had been caused by ruptures of АА of which no more than 500 have been operated mainly in the cold period, that is in a month after SAH. Thus, it is known, that 50-80 % of none operate patients die within a month after the first rupture from repeated bleedings from АА, ischemia of the brain, acute hydrocephaly, intracranial hypertension and other causes. The rate of aneurysmal SAH is from 4 up to 12 on 100000 population per year. In the general structure of cerebrovascular diseases it is about 5%.

АА occurs in women more often in the ratio to men as 3/2. Ruptures of АА occur at any age, but more often at the age 30 - 60 it, is rare at children's and senile age. Multiple АА make 10-20%.

Etiology. Many authors associate development of АА with incomplete reverse development of the embryologic vascular plexus. It is known, that practically all АА are formed in places of division and connection of the arteries of Willis circle where there are often defects of the muscular layer. Significance of congenital inferiority of the arterial wall proves to be true by freequent combination of АА with other developmental anomalies (anomalies of Willis circle, cystic kidney, congenital heart diseases, coarctation of the aorta). A certain role in occurrence of АА is played by degenerate changes of the vascular wall – atherosclerosis, collagenosis. Some authors explain by non-uniform pressure of the blood stream upon different sites of walls of arteries selective localization of АА. There is an opinion on the traumatic nature of АА development. A certain role in occurrence of АА is played by inflammatory diseases of the vessels, it is known, that in septic endocarditis there are microaneurysms.

The historical information. The first known mention in the literature is described by Morgagni in 18-th century. The first known operation was performed by Horsley in 1890 – at operation for a tumour of the middle cranial fossa, the pulsing cyst has been found, operation has been completed by bandaging of the internal carotid artery on the neck. The first purposeful operation in the patient with АА, diagnosed before the operation, was performed in 1933 by Scottish neurosurgeon Dott – he shrouded АА. There is an opinion that the first purposeful operation was performed Cushing in 20th years. In 1938 Dandy first suggested and performed clipping of АА, and already in 1944 published a monography which generalized 100 operations. In the USSR the first operations have been made by Zlotnik, Konovalov, in Ukraine - Arutyunov, Zozulja, Pedachenko. The Soviet and Ukrainian neurosurgeons posess a priority of endovascular operations in АА (Serbinenko, Scheglov).

Clinical course. Two types of АА course are distinguished – apoplexy and pseudotumoral (paralytic). Paralytic course occurs extremely seldom and typical of huge АА which cause compression of the brain, cranial nerves and vessels of the brain that is manifested as various symptoms of syndromes (focal, convulsive, endocrine and others).

In connection with that majority of АА are in subarachnoidal space of tanks of the basis of the brain, the most frequent manifestation of АА is SAH. The physical or emotional overstrain, sometimes a trauma of the head can precede a rupture, but more often there is no visible cause.

Clinical signs:

  1. Sharply, suddenly arisen headache, feeling of hot flow on the head;
  2. Nausea, vomitting, quite often repeated;
  3. Photophobia;
  4. Loss of consciousness, more often short-term, in half of patients up to 10-20 minutes, but in severe cases for many hours and days;
  5. There may be seizures;
  6. Meningeal symptoms (Kernig, Brudzynsky, rigidity of the occipital muscles) which may be absent in the first day of SAH and in severe cases due to oppression of reflex activity;
  7. Mental disorders – confusion, disorientation, excitation;
  8. Hyperthermia, is more often subfebrile;
  9. Leukocytosis with deviation to the left;
  10. Arterial hypertension, lability of the AP, a medicamentous rigidity of the AP;
  11. Disorder of cardiac and respiratory activity in severe cases;
  12. Oculomotor symptoms depend on localization of АА and are considered pathognomonic for АА;
  13. Hemisyndrome – depends on depends on localization of АА and haemorrhage, and also development of the ischemia;
  14. Haemorrhages on the eye fundus, there can be a reduction of sight;
  15. In absence of loss of consciousness its level can gradually go down.

In haemorrhage in the parenchyma of the brain or ventricles of the brain clinical signs are more general brain and focal symptoms are more expressed.

The differential diagnosis.

  1. Migraine. The family anamnesis, no meningeal syndrome.
  2. Occipital neuralgia. This diagnosis can be made, if more dangerous causes are excluded.
  3. Fresh CCT.
  4. Hypertonic crisis.
  5. Hemorrhagic or ischemic insult.
  6. Meningitis.

 

Evaluation of patients’ condition:

Classification of severity of the condition of patients with aneurysmal SAH according to surgical risk (W.Hunt, R.Hess, 1967):

I degree –insignificant or moderate headache, insignificant meningeal syndrome.

II degree – a moderate or severe headache, moderate or expressed meningeal syndrome, there may be oculomotor disorders.

III degree – deafening, a headache of different intensity, focal symptoms.

IV degree – sopor, a meningeal syndrome, various focal symptoms or no focal symptoms.

V degree –coma, a decerebration rigidity, there may be vegetative inpairments.

In presence of concomitant severe somatic pathology (hypertonic disease, IHD, diabetes mellitus, pneumonia, etc.) the degree of severe increases by a unit.

Glasgow Coma Scale:

  1. Opening of the eyes.
  2. Verbal reactions.

 

3. Motor reactions.

 

  • spontaneous - 4 points
  • to speech - 3
  • to a pain - 2
  • no - 1
  • focused - 5
  • confused - 4
  • inappropriate - 3
  • illegible sounds – 2
  • no - 1
  • carries out commands - 6
  • locates pain - 5
  • bending to pain - 4
  • abnormal bending - 3
  • extension to pain - 2
  • no -1
   

 

Emergency actions in rupture of АА.

  1. In unconsciousness – restoration of function of external respiration.
  2. Antispastic therapy – in patients with spasms.
  3. To lieve a pain, morphines are undesirable since oppressing respiration, they aggravate hypoxia.
  4. Antagonists of calcium.

Intensive care supervision.

During loss of consciousness, confusion or disorientation the following parameter are evaluated every 15 minutes: a level of consciousness, pupillary reactions, a pulse rate, AP, RM and rhythm, bodies. Monitoring of these parameters is desirable. In gaining consciousness they are evaluated hourly. Aggravation of consciousness, impairment development or grooving of neurologic deficiency (hemisyndrome, mydriasis, etc.), change of pulse, AP, breathing the nurse immediately reports about it to the doctor on duty.

Principles of treatment.

  1. No hemostatics.
  2. Antagonists of Са.
  3. Arterial normotension, and after operation –hypertension.
  4. Moderate hemodilution.
  5. Inhibitors of proteolysis.
  6. Antihypoxants, antioxidants.
  7. Early operation in the first three day.

Diagnostics. CT-SCAN, angiography, MRI-angiography, CT-scan-angiography, dopplerography, LP.

Course and prognosis. 20-30% of patient die before rendering aid. 50% of none operated have repeated SAH, only a few survive the third haemorrhage. Repeated SAH is more severe, death rate is 2 times higher, usually it happens in 1-2 years, sometimes in many years (A.Mironov). Without surgery 50-60% of patients die within 6-8 weeks, half of the survived are disabled, 20 % of the survived die from repeated SAH within 5 years.

Surgery. Microsurgical and endovascular methods.

Mortality in the acute period up to 20 %, in not severe SAH – 4-6%, to work – 60%. In the cold period mortality is the tenth and 100-th shares of %.

 

  1. 1.                Arteriovenous malformations of the brain (AVMS) - arteriovenous angiomas, aneurysms - represent malformation of the vascular system of congenital genesis in which there is a ball of pathological generated vessels of different calibers between hypertrophied adducting arteries and sharply expanded draining veins which cannot be differentiated morphologically in to arteries and veins and through which there is an arteriovenous drainage. In the embryologic period in the vascular system of the surface of the brain bubbles arteries and veins are directly connected among themselves by arterio-venous anastomoses. Further these anastomoses are atrophied on the surface of the brain. But in some cases arterio-venous anastomoses are preserved and AVM are formed on their place.

Clinical symptoms of AVMS are manifested at the age of 20-30 predominantly as intracranial haemorrhages. Death rate after the first haemorrhage reaches 10 %, the rate of repeated haemorrhages is 25-30 %, but a new haemorrhage develops in longer time, than in АА. Death rate in repeated haemorrhages 12-20 %.

A severe paroxysmal and located headache is revealed in the anamnesis of half of patients; in one third of patients seizures are observed, more often of focal character.

In rupture of AVMS not only SAH develops, but also intracerebral haematoma, usually of small size is formed in a significant part of the patients (40-50 %). Due to close location to the cortex – haematomas are more often lobar. Quite often the cause of focal symptoms are only haematoma and edema of the surrounding brain. In some cases the focal manifestation arises without haemorrhage – on a basis hypoxia.

Diagnostics. CT-SCAN, angiography, MRI, ТКДГ.

Treatment. Only surgical or symptomatic. Operation is indicated in bleeding from AVMS, can be delayed before stabilization and improvement of the condition of the patient. In case of the convulsive syndrome which does not respond in to medicamentous treatment, and in increase of neurologic symptoms, the indications to the operation are emphasized by constant threat of bleeding. The essence of operation consists in microsurgical deenergizing the vessels having AVM, but the most effective is removal of all AVMS. If there is a haematoma it is removed simultaneously with AVMS. The postoperative mortality reaches 15 % that is much lower than mortality in conservative treatment (40-45 %). After the operation the focal convulsive syndrome usually does not disappear completely, but the rate of attacks is reduced, and antispastic therapy becomes more effective. In last years the intravascular surgery of AVMS is developing rapidly which consists in artificial embolization or balonization.

Carotid-cavernous co-opening (CCF) arises in a craniocerebral trauma or in rupture of АА of the intracavernous part of the internal carotid artery in connection with that a cavernous sinus – is the only place where the large artery passes inside the vein. If there is a rupture of the artery at this place arterial blood under great pressure rushes into a cavernous sinus. It causes symptoms: a pulsing exophthalm, hyperemia of the sclera and chemosis, deterioration of sight and ophtalmoparesis. Sometimes hemispheric symptoms are observed associated with deprivation of the brain through the arterio-venous shunt. Headaches are often observed. Subjectively and objectively pulsing noise is auscultated which usually disappears in squeezing internal carotid artery on the neck. Because of presence of anastomoses between the cavernous sinuses unilateral co-opening can cause bilateral symptoms. Angiography is a reliable method of diagnostics of CCF.

Treatment is surgical: ligation of the internal carotid artery on the neck and its clipping in the supraclinoid part; direct opening and a clipping co-opening; embolization by various emboli; balonization by a controlled balloon-catheter.

 

6. Materials of methodological maintenance of the class

 

  • What basic kinds of cerebrovascular diseases do you know?
  • The basic kinds of haemorrhages in the brain
  • What are clinical signs of haemorrhage in the brain?
  • What data indicate compression of the brain?
  • What auxiliary methods of investigation are applied in haemorrhages in the brain?
  • What can cause compression of the brain?
  • Optimum terms of surgery of haemorrhages in the brain.
  • Rehabilitation and readaptation of patients.
  • Indications and contra-indications to application of paraclinical methods of examination?
  • Indications and contra-indications to surgery of ADCC.
  • Methods of surgery of ADCC.
  • Principles of intensive therapy in ruptures of ADCC.
  • What are basic symptoms of rupture of arterial aneurysm of the brain?
  • What are basic symptoms in rupture of arterial aneurysm of the internal carotid artery?
  • What are basic symptoms in rupture of arterial aneurysm of the middle cerebral artery?
  • What are basic symptoms in rupture of arterial aneurysm of the anterior cerebral artery?
  • What are basic symptoms in rupture of arterial aneurysm of the basilar artery?
  • What are pathogenetic mechanisms of development of the delayed ischemia in ruptures of arterial aneurysm of the brain?
  • What are pathogenetic mechanisms of development of hydrocephaly in ruptures of arterial aneurysm of the brain?
  • What diagnostic methods are applied to diagnostics of haemorrhage in ruptures of arterial aneurysm of the brain?
  • Name tomographic signs of rupture of arterial aneurysm of the brain.
  • What diagnostic methods are applied to diagnostics of arterial aneurysm of the brain?
  • What are indications and contra-indications to application of paraclinical methods of examination?
  • Indications and contra-indications to surgery of arterial aneurysm of the brain.
  • Methods of surgery of arterial aneurysm of the brain.
  • Principles of intensive therapy in ruptures of arterial aneurysm of the brain.

 

SITUATIONAL TASKS FOR CHECKING OF THE LEVEL OF KNOWLEDGE OF STUDENTS WITH STANDARD ANSWERS.

 

№1. The patient of 34 years old suddenly developed severe headache, short-term loss of consciousness. He was brought to a neurosurgical department with complaints of a severe headache, nausea, there was a repeated vomiting. On examination consciousness was 13 by a scale of comas of Glasgow; there were the expressed rigidity of occipital muscles, paresis of the oculomotor nerve on the left. Make the preliminary diagnosis, estimate a condition of the patient by classification of W.Hunt–R.Hess, and determine the plan of examination.

ANSWER. The preliminary diagnosis: a rupture of arterial aneurysm of a supraclinoid part of the left internal carotid artery. A condition of the patient by classification of W.Hunt-R.Hess is II degree. For specification of the diagnosis CT-SCAN of the brain, left-side carotid angiography are indicated.

 

№2. The patient of 40 years old suddenly developed the headache, short-term loss of consciousness, there was vomiting. On the fourth day weakness in the left extremities developed, he was brought to neurosurgical department. On examination complaints of a headache, nausea, weakness in the left extremities. Objectively: consciousness was 13 by a scale of comas of Glasgow, rigidity of the occipital muscles, anisoreflexia S>D, strength in the left extremities was 3 points, symptoms of Babinsky on the left. Make the preliminary diagnosis, estimate a condition of the patient by classification W. Hunt–R.Hess, determine the plan of inspection. What pathogenetic mechanisms have led to the development of weakness in the left extremities?

ANSWER. The preliminary diagnosis: a rupture of arterial aneurysms of the anterior part of the arterial circle of the brain. The condition of the patient by classification W.Hunt–R.Hess - III degree. For specification of the diagnosis: CT-SCAN of the brain, a right-hand side carotid angiography, ТКДГ are indicated. Development of weakness in the left extremities resulted from arterial vascular spasm of the right middle cerebral artery.

 

№3. The patient, of 20 years old suddenly developed a severe, headache, loss of consciousness, there was vomiting. He was admitted to a neurosurgical department. On examination – consciousness 7 by a scale of comas of Glasgow, AP of 200/120 mm Hg, bradycardia 48 per 1 minute, hormeotonic spasms, Chaine-Stocks resration. Make the preliminary diagnosis, estimate the condition of the patient by classification W.Hunt–R.Hess, determine the plan of inspection. What pathogenetic mechanisms have led to the hormeotonic spasms?

ANSWER. The preliminary diagnosis: rupture of arterial aneurysms of the brain. The condition of the patient by classification of W.Hunt–R.Hess is V degree. For specification of the diagnosis: CT-SCAN of the brain, a total cerebral angiography are indicated. Hormeotonic spasms has resulted from blood in the cerebral ventricles.

 

№4. The patient, aged 39 suddenly developed a severe headache, weakness in the left extremities, short-term loss of consciousness, there was vomiting. He was admitted to a neurosurgical department. On examination: complaints of a headache, nausea, weakness in the left extremities. Objectively – consciousness was 13 by of Glasgow coma scale, there were rigidity of the occipital muscles, anisoreflexia S>D, strength in the left extremities 2 points, a symptom of Babinsky on the left. Make the preliminary diagnosis, estimate the condition of the patient by classification W.Hunt–R.Hess, determine the plan of examination. What pathogenetic mechanisms have led to development of weakness in the left extremities?

ANSWER. The preliminary diagnosis: a rupture of arterial aneurysms of the right middle cerebral artery. The condition of the patient by classification of W.Hunt–R.Hess is III degree. For specification of the diagnosis CT-SCAN of the brain, a right-hand side carotid angiography, ТКДГ are indicated. Weakness in the left extremities has resulted from formation of a haematoma in the lateral fossa of the brain on the right.        

 

№5. The patient, aged 35 suddenly developed a severe headache, short-term loss of consciousness has suddenly appeared, there was vomiting. He was admitted to infectious hospital on suspicion of meningitis. On examination: consciousness 13 by of Glasgow coma scale, there was rigidity of the occipital muscles. At lumbar puncture liquor pressure was 300 mm H2O, liquor is intensively painted by blood. During the puncture the condition has sharply worsened – loss of consciousness up to 8 by of Glasgow coma scale, hormeotonic spasms, increase of AP up to 220/120 mm Hg, bradycardia 40 per minute. Make the preliminary diagnosis, estimate a condition of the patient by classification of W.Hunt–R.Hess on admission and after deterioration of the condition, determine the plan of examination. What pathogenetic mechanisms have led to deterioration of the condition?

ANSWER. The preliminary diagnosis: a rupture of arterial aneurysms of the anterior part of the arterial circle of the brain. The condition of the patient by classification of W.Hunt–R.Hess is III degree, after deterioration – V degree. For specification of the diagnosis CT-SCAN of the brain, a total cerebral angiography are indicated. Deterioration of the condition has resulted from reduction in intracranial pressure during a lumbar puncture.

 

№6. The patient, aged 34 suddenly developed a severe headache, short-term loss of consciousness, has fallen and hit his head. He was brought to a neurosurgical department with complaints of a severe headache, nausea, there was a repeated vomiting. On examination consciousness was 13 by of Glasgow coma scale, there were rigidity of the occipital muscles, paresis of the oculomotor nerve on the left, a wound of 5 cm – the is intact bone is in the occipital area of the head. Make the preliminary diagnosis, determine the plan of examination.

ANSWER. The preliminary diagnosis: a rupture of arterial aneurysms of the supraclinoid part of the left internal carotid artery, a secondary craniocerebral trauma. For specification of the diagnosis CT-SCAN of the brain, a left-hand side carotid angiography are indicated.

 

7. The literature

The main literature:

  1. И.М.Иргер «Нейрохирургия» М., «Медицина», 1982
  2. Бротман Н.К. и соавт., Ранние проявления нейрохирургических заболеваний, К., Здоров’я, 1984
  3. Ромоданов А.П. и соавт., Оперативные вмешательства при заболеваниях головного мозга, К., Здоров’я, 1987

The additional literature:

  1. Зозуля Ю.А., Педаченко Г.И., Орлов Ю.А. Хирургическое лечение внутричерепных гематом после разрыва аневризм сосудов мозга.- В кн.: Диагностика и хирургическое лечение сосудистых заболеваний головного мозга. Л.,1974, с. 163-165
  2. Коновалов А.Н. Хирургическое лечение артериальных аневризм головного мозга. - Дисс. докт., М.,1970.