Silvestrini Mauro. Cefalea e dissecazione arteriosa. ASMaD 2011

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  • 1. Cefalea e Malattia Cerebrovascolare Roma, 25 marzo 2011 CEFALEA E DISSECAZIONE ARTERIOSA M. Silvestrini Clinica Neurologica – Dip. di Neuroscienze Università Politecnica delle Marche
  • 2.  
  • 3. Cefalea Cefalea associata Relazione tra Cefalea e Ictus dissecazione arteriosa
  • 4. Quali Cefalee possono essere “ PERICOLOSE “
    • EMORRAGIA SUBARACNOIDEA
    • EMORRAGIA CEREBRALE
    • DISSECAZIONE CAROTIDEA
    • TROMBOSI DEI SENI
    • ENCEFALOPATIA IPERTENSIVA
    • PATOLOGIA INFETTIVA
    “ EMERGENZA”
    • CEFALEA TUMORALE
    • CEFALEA DA SFORZO
    • ARTERITE TEMPORALE
    • CEFALEA IN EMATOMA
    • SOTTODURALE
    • EMICRANIA con AURA ?
    “ URGENZA “ - Cefalea ed emicrania già nota e diagnosticata ma trasformata “ PROGRAMMABILE? “
  • 5. Migraine as a predisposing condition for sCADs?
    • EPIDEMIOLOGICAL EVIDENCES
    • Case-control studies:
    • migraine twice as common in patients with sCAD than in patients whose
    • ischemic stroke was not related to sCAD
    • J. D’Anglejan-Chatillon 1989; C. Tzourio 2002; A Pezzini 2005
    • Hospital-based case-control study:
    • higher prevalence of migraine with aura among sCAD patients as compared to controls
    • V. Artto 2010
    • A common generalized vascular disorder?
  • 6. The mechanism by which migraine may affect the risk of sCAD is unknown
    • Increased activity of serum elastase
    • possible extracellular matrix degradation ( C Tzourio 2000 )
    • altered common carotid artery distensibility ( B. Guillon 2000; C. Lucas 2004)
  • 7. DISSEZIONE CAROTIDEA ematoma subintimale - ematoma subavventiziale Risk factors : mechanical injury (e.g., trauma involving the neck) during vigorous neck turning in previously diseased carotid arteries, the chance of a dissection is increased collagenopathies
  • 8.
    • Familial structural abnormalities related to sCAD (autosomal dominant pattern of inheritance)
    • … ..this implicates that genetically determined alterations of the extracellular matrix may play a crucial pathogenic role and that candidate genes involved in the regulation of the endothelial and the vessel wall functions, might increase susceptibility to both conditions .
    • (A. Pezzini, 2011)
  • 9. SCENARIO: cefalea recente da dissecazione carotidea Recenti studi che si avvalgono della ecografia in fase acuta suggeriscono che questa patologia è piu’ frequente di quanto si pensasse
  • 10. EPIDEMIOLOGIA 0.4-2.5% STROKE (< 40 anni ) INCIDENZA MEDIA: 2-3% per 100.000 (ICA) 1-1.5% per 100.000 (VA) PRESENTAZIONE: CLASSICA TRIADE: CEFALEA OMOLATERALE DOLORE FACCIALE O CERVICALE Sindrome di Horner parziale (miosi-ptosi da interruzione fibre simpatiche post-gangliari) TIA/STROKE Compressione locale IX, X, XII n.c. ESA (più comune nella dissezione vertebrale intracranica)
  • 11. ..once you suspect cerebral artery dissection, there is a way to make an accurate diagnosis with the helps of MRI, MRA, and three-dimensional CT to demonstrate pathognomonic findings such as irregular narrowing, pearl and string sign, intramural hematoma, or a double lumen of the affected cerebral vessel. McCombe J, 2006 Median time from onset of headache to neurological symptoms: 4 days for carotid dissection 14.5 hours for VA dissection
  • 12.
    • Cervical artery dissection
    • Headache reported by 60-95% of patients with carotid artery dissection and 70% of patients with vertebral artery dissection
    • Most commonly associated with a headache of subacute onset
    • 20% of patients present with a thunderclap headache
    • Headache generally ipsilateral to the dissection and involves the face, jaw, ears, periorbital, frontal and temporal regions; with neck pain in 25-50% of patients
  • 13. FISIOPATOLOGIA DELLE COMPLICANZE ISCHEMICHE CEREBRALI Tia/ictus DISTURBO EMODINAMICO (stenosi)? EMBOLIA? TRATTAMENTO?
  • 14. TRATTAMENTO
  • 15. E’ sempre la stessa malattia? Cosa influenza la prognosi?
  • 16. Distribution of the number of patent collateral vessels by mRS score. Silvestrini M et al. 2011 EARLY ACTIVATION OF INTRACRANIAL COLLATERAL VESSELS INFLUENCES THE OUTCOME OF SPONTANEOUS INTERNAL CAROTID ARTERY DISSECTION …… the possibility of selecting those patients at highest risk of an unfavorable outcome could contribute to identifying those who might benefit most from endovascular recanalization procedures.