Cerebrovascular Disorders- Clinical Features, Investigations And Treatment

Subarachnoid Hemorrhage (SAH)

• It is the second most common type of intracranial hemorrhage. The first and most common is cerebral or parenchymal hemorrhage. The most common cause of SAH is trauma. The most common cause of spontaneous or non-traumatic SAH is Berry aneurysm rupture.

Q.What is the most common cause of spontaneous, non-traumatic SAH?

 Ans. Berry aneurysm

Clinical Features

• Headache also known as thunder clap, worst headache of life or very severe headache, Loss of consciousness (LOC), Neck rigidity , Vomiting 

Investigation Of Choice

• The primary investigation of choice is an NCCT scan (which will show us the location of the bleed). If NCCT is equivocal then lumbar puncture to detect “xanthochromia” can be used for confirmation. Lumbar puncture in SAH needs to be differentiated from traumatic tap. Traumatic tap is the presence of blood due to procedure.

Difference Between Traumatic Lumbar Puncture (LP) And Sah

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• In traumatic LP RBCs count declines as CSF (cerebrospinal fluid) drains, while in SAH, it remains constant. Supernatant fluid (residual fluid after the clot settles down)  is clear in traumatic LP while in SAH it is xanthochromic. In traumatic LP the blood is fresh and usually clots, while in SAH there is no clotting. Opening pressure (initial pressure) is usually normal or low in traumatic LP ,while in SAH it is high.

Investigation of choice

• Primarily is  NCCT (site of bleed). Definitive – CT angiography , DSA (Digital subtraction angiography)-  Diagnostic, Therapeutic. MR angiography

Treatment

• Traumatic SAH mostly is conservative management. Spontaneous -above investigations is negative then manage conservatively. If aneurysm is found then treat accordingly either by endovascular coiling or surgical clipping of aneurysm. Always remember 4 vessels intra arterial-DSA is the gold standard for identification of aneurysm.

Intracranial Aneurysm

• It is the most common cause of spontaneous SAH. The location or most common site of an intracranial aneurysm is-      The most common age group found is 50 to 60 years old. The most common site in anterior circulation is at the Junction of anterior cerebral artery (ACA) and anterior communicating artery . The second most common site is the posterior communicating artery and internal carotid artery (ICA)junction. Middle cerebral artery (MCA) bifurcation is third most common site.

Clinical Features

• Anterior circulation aneurysm
  • Visual field defects
  • Hypothalamic dysfunction 
  • Diabetes insipidus (DI)
• Carotid aneurysm
  • Cavernous sinus involvement
  • Carotico-cavernous fistula 
  • Multiple cranial nerve involvement
• Basilar vertebral aneurysm
  • Third nerve palsy 
  • Brain stem syndrome

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Classification Systems

1. WFNS grading stands for World Federation of Neurological Surgeons-It is based on GCS and deficits .
2. HUNT and HESS scale: clinical based scale.
3. FISHER GRADING: CT-based grading.

Type Of Aneurysm

• Saccular: It characteristically arises from the wall and has neck and dome.
• Fusiform: It is the enlargement of the vessels and no neck or dome.
• Dissecting / false: It is due to a defect in the wall, which creates flow of blood leading to double lumen sign (ultrasound).

Risk Factors

• Smoking 
• Hypertension 
• Alcohol 
• Cocaine  etc 

Associated Conditions 

• Fibro-muscular dysplasia, Ehlers Danlos syndrome, Neurofibromatosis 1, Marfan’s syndrome, Autosomal dominant polycystic kidney disease  (ADPKD) etc
• The most common site of rupture of an aneurysm is dome. Dome is the thinnest part and the blood flow is most directed in this region. Giant aneurysm- It is more than 2.5 cm. They are present with mass effect and thromboembolic phenomena.

Treatment

• Endovascular coiling options- Stenting,Glue . Surgical options-Clipping,Bypassing aneurysm,Muscle wrapping

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Cerebrovascular Accidents (CVA)

1. ISCHEMIC CVA-It is the most common cause of CVA contributing 85%.- Embolic phenomena (75%) , Thrombosis (25%)

2. HEMORRHAGIC CVA (15%)

1. Parenchymal is most common about 66.6%
2. SAH: Subarachnoid hemorrhage
3. EDH: Epidural hematomas
4. SDH: Subdural hematomas

Intra Cerebral Hemorrhage (ICH)

• ICH is the second most common cause of stroke. The most common type of intracranial hemorrhage is intra cerebral hemorrhage. It is also the deadliest cause of stroke. The most common cause of ICH is hypertension. The most common site is Basal ganglia (putamen).

Clinical Features

• Headache, Loss of consciousness, Focal neurological deficit, Raised ICP

Investigation Of Choice (IOC)

• NCCT head is the investigation of choice in ICH.

Treatment

• In the majority of cases, it is conservative management. The surgical indications are as follows: If Hematoma is > 50 cc. If it is causing a midline shift >5mm. Deteriorating consciousness is not attributable to another cause. Anisocoria

Vein Of Galen Malformation (VOG)

• VOG is classically formed by Joining two internal cerebral veins and basal vein of Rosenthal. VOG is a rare entity. Clinical features of VOG are: - New born baby with a bulging anterior fontanelle, it has the features of cardiac failure and failure to thrive.

Q. How is VOG formed?

Ans. VOG it is classically formed by Joining two internal cerebral veins and basal vein of Rosenthal 

Q. What are the clinical features of VOG?

Ans. Newborn baby, bulging anti neural fontanelle, features of cardiac failure, failure to thrive.

Investigations

• Trans cranial ultrasound which will show a midline hypo-echoic structure. MR Angio or DSA can also be done and sometimes even DSA can be therapeutic.

Treatment

• Ideally embolization of feeding vessels. Generally, it has a poor prognosis.

Brain Abscess

Causes Includes

• Direct spread ,it can be from:-

1. Paranasal sinuses
2. Mastoid infections (most common)

• Hematogenous ,it can be from :-

1. Respiratory tract 
2. Cardiac infections 
3. Dental infections etc

Most Common Sites

• In otitis media or mastoiditis, the temporal lobe is the most common site, followed by the cerebellum.  In pilonidal sinus (PNS) or dental infections, frontal lobe is the most commonly involved. The parietal lobe is the most common site in hematogenous spread. The most common organism responsible for brain abscess is Streptococcus.

Clinical Features

• Signs of raised intracranial pressure ICP which are due to mass effect, Fever, Neck rigidity, Focal neurological deficit (FND. In infants patients general present with: Increased head circumference, Failure to thrive 

Investigation Of Choice

• The contrast MRI is the investigation of choice in which characteristic sign is ring enhancing lesion.

Treatment

• Firstly, it is a surgical aspiration. If abscess reoccur either redo surgical aspiration or excision of the abscess. In case of Multiple abscess, conservative treatment with antibiotics is recommended. Antibiotic protocol: IV antibiotics for at least 6 to 8 weeks followed by 4 to 8 weeks of oral antibiotics. In steroids specific indication in patients with abscess is as follows: Tubercular abscess, Severe edema in deteriorating patients. Seizure prevention is necessary and hence anti- epileptics are given along with the other drugs.