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Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
Cerebrovascular Disease
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Cerebrovascular Disease

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  • 1. Cerebrovascular disease & Strokes Dr. Osman Sadig Bukhari
  • 2. <ul><li>Stroke is: </li></ul><ul><li>- is za 3 rd commonest cause of death </li></ul><ul><li>- 2/1000/year </li></ul><ul><li>- male > females </li></ul><ul><li>- uncommon before 40years except with: </li></ul><ul><li>- trauma </li></ul><ul><li>- cardiac diseases e.g RHD </li></ul><ul><li>- congenital vascular abn </li></ul><ul><li>- inflammatory arteritis </li></ul><ul><li>- vascular disease </li></ul><ul><li>- SS anaemia </li></ul>
  • 3. <ul><li>Cerebral circulation </li></ul><ul><li>Cerebral vascular diseases comprise: </li></ul><ul><li>1- Thromboembolic infarction ( thrombosis and </li></ul><ul><li>embolism) </li></ul><ul><li>2- Intracerebral haemorrhage (ICH) </li></ul><ul><li>3- Subarachnoid haemorrhage (SAH) </li></ul><ul><li>4- Extradural hage & subdural haematoma </li></ul><ul><li>5- Cortical venous & dural venous sinus thromb </li></ul>
  • 4.  
  • 5.  
  • 6. <ul><li>Stroke is either due to: </li></ul><ul><li>1- Infarction (ischemic) (80-85%) </li></ul><ul><li>- thrombosis </li></ul><ul><li>- embolism </li></ul><ul><li>2- Haemorrhage (15-20%): </li></ul><ul><li>- intracerebral </li></ul><ul><li>- subarachnoid </li></ul><ul><li>Site of stroke </li></ul><ul><li>- internal capsule - brainstem </li></ul><ul><li>- cerebral cortex - basal ganglia </li></ul><ul><li>- cerebellum </li></ul>
  • 7. <ul><li>Mechanism of stroke: </li></ul><ul><li>1- Cerebral infarction (Ischemic) </li></ul><ul><li>- thrombosis at za site of atheroma </li></ul><ul><li>- embolism to a cerebral artery from </li></ul><ul><li>- extracranial vessels </li></ul><ul><li>- heart </li></ul><ul><li>* cerebral oedema may complicate infarction </li></ul><ul><li>and impair blood supply & cause further </li></ul><ul><li>damage </li></ul>
  • 8. <ul><li>2- Cerebral haemorrhage </li></ul><ul><li>- subarachnoid haemorrhage </li></ul><ul><li>- ruptured beri aneurysm </li></ul><ul><li>- ruptured AVM </li></ul><ul><li>- intracerebral haemorrhage </li></ul><ul><li>- rupture of perforating vessels weakened </li></ul><ul><li>by HT or atheromatous degeneration </li></ul><ul><li>( micro aneurysm= 0.8-1.0 mm) </li></ul><ul><li>- rupture of aneurysms or AVM </li></ul><ul><li>* SAH arterial spasm & cerebral infarction </li></ul><ul><li>* ICH may extend to subarachnoid space. </li></ul>
  • 9. <ul><li>* Disability from stroke depends on the </li></ul><ul><li>site & extent of damage </li></ul><ul><li>* Cerebellar hage can be fatal if there is </li></ul><ul><li>compression of brain stem. </li></ul>
  • 10. <ul><li>Clinical classification of stroke </li></ul><ul><li>1- Completed stroke </li></ul><ul><li>focal neurological episodes with sympto </li></ul><ul><li>lasting > 24hrs. </li></ul><ul><li>- Major stroke </li></ul><ul><li>- Minor stroke ( recovery in 1-2Ws) </li></ul><ul><li>2- Evolving stroke </li></ul><ul><li>symptoms worsening gradually or in </li></ul><ul><li>stepwise fashion over hrs or days </li></ul><ul><li>( DD= tumour, SDH) </li></ul><ul><li>3- Transient ischemic attack (TIA) </li></ul><ul><li>symptoms lasting < 24hrs. </li></ul>
  • 11. <ul><li>Disorders causing stroke </li></ul><ul><li>comprises:- </li></ul><ul><li>1- Thromboembolic disease (infarction </li></ul><ul><li>- atherosclerosis </li></ul><ul><li>- arteriosclerosis (HT, degenerative) </li></ul><ul><li>- embolism (20%) </li></ul><ul><li>- arteritis (syph, TA, PAN, SLE) </li></ul><ul><li>- dissection (spontaneous, traumatic) </li></ul><ul><li>- Vasospasm (migraine, SAH, angiogr) </li></ul><ul><li>- hyper viscosity (PRV) </li></ul><ul><li>- anti phospholipid syndrome </li></ul><ul><li>- SS disease - hypotension - OCPs </li></ul>
  • 12. <ul><li>2- Haemorrhage </li></ul><ul><li>- intracerebral 50% </li></ul><ul><li>- sub arachnoid 50% </li></ul><ul><li>- AVM </li></ul><ul><li>- Beri aneurysms </li></ul><ul><li>- Degenerative aneurysms </li></ul><ul><li>- HT arteriolar aneurysms </li></ul><ul><li>- Mycotic aneurysms </li></ul><ul><li>- Anticoagulants, thrombolytic therapy </li></ul><ul><li>- Bleeding disorders (ITP, DIC, haemop </li></ul><ul><li>- Alcohol, cocaine, amphetamine) </li></ul>
  • 13. <ul><li>Risk factors for stroke </li></ul><ul><li>1- Non modifiable factors </li></ul><ul><li>- age - gender </li></ul><ul><li>- race - hereditary </li></ul><ul><li>2- Modifiable factors </li></ul><ul><li>- arterial HT - cardiac diseases </li></ul><ul><li>- DM - cigarette smoking </li></ul><ul><li>- Hyperlipidaemia - Thrombocythemia </li></ul><ul><li>- polycythemia - Physical inactivity </li></ul><ul><li>- Obesity - OCPs </li></ul><ul><li>- High alcohol intake - trauma </li></ul><ul><li>- Peripheral vascular disease </li></ul>
  • 14. <ul><li>Transient ischemic attacks TIA </li></ul><ul><li>Definition : focal neurological symptoms </li></ul><ul><li>(due to cerebral ischemia) wz symptoms </li></ul><ul><li>lasting < 24hrs. </li></ul><ul><li>Causes : </li></ul><ul><li>- emboli or PL material from extracranial </li></ul><ul><li>arteries </li></ul><ul><li>- cardiac emboli </li></ul><ul><li>- severe stenosis of a major artery + </li></ul><ul><li>haemdynamic disturbance ( e.g V/basilar </li></ul><ul><li>- small infarcts, hage, brainstem tumours and SDH can cause TIA </li></ul>
  • 15. <ul><li>Clinical features: </li></ul><ul><li>Carotid system Vertebrobasilar syst </li></ul><ul><li>- amaurosis fugax - diplopia, vertigo, vomiting </li></ul><ul><li>- aphasia -dysphagia, dysarthria </li></ul><ul><li>- hemiparesis - facial numb & weakness </li></ul><ul><li>- hemisensory loss - ataxia, nystagmus </li></ul><ul><li>- hemianopic visual - hemisensory loss </li></ul><ul><li>loss - hemianopic visual </li></ul><ul><li>loss </li></ul><ul><li>- transient global </li></ul><ul><li>amnesia & confusion </li></ul><ul><li>- tetraparesis, coma, and </li></ul><ul><li>cortical blindness. </li></ul>+ evidence of underlying disease
  • 16. <ul><li>* TIAs may herald completed stroke and </li></ul><ul><li>25% of pts wz completed stroke recall </li></ul><ul><li>previous TIA </li></ul><ul><li>* TIAs require to investigate za underlying </li></ul><ul><li>cause & prevent to reduce za completed </li></ul><ul><li>stroke </li></ul><ul><li>* 40% of pts wz TIAs suffer completed </li></ul><ul><li>stroke in 5 years. </li></ul><ul><li>* 25% of pts wz TIAs die from stroke or </li></ul><ul><li>coronary heart disease. </li></ul>
  • 17. <ul><li>* management of TIAs </li></ul><ul><li>- identify risk factors & correct </li></ul><ul><li>- antiplatelets reduce za risk of stroke </li></ul><ul><li>by 25%. </li></ul><ul><li>- anticoagulants for definite cardiac </li></ul><ul><li>source of thromboembolism. </li></ul><ul><li>- carotid endarterectomy reduce za risk </li></ul><ul><li>of stroke by 75%. </li></ul>
  • 18. <ul><li>Clinical features of stroke </li></ul><ul><li>Depends on za site & extent </li></ul><ul><li>1- Acute focal neurological deficit : </li></ul><ul><li>- Hemiparesis +/- dysphasia is the </li></ul><ul><li>commonest presentation. Weakness 1 st </li></ul><ul><li>and recovery takes place over days, Ws </li></ul><ul><li>or months. </li></ul><ul><li>- Hypotonia, depressed reflexes and </li></ul><ul><li>extensor reflex occur initially, followed </li></ul><ul><li>later by hypertonia & hyper reflexia. </li></ul><ul><li>- Monoparesis or dysphasia occur wz cortical </li></ul><ul><li>lesions </li></ul><ul><li>- Hemianaethesia & visual fields defects </li></ul>
  • 19. <ul><li>- With brain stem lesions C/f depends on </li></ul><ul><li>the structures involved and leads to </li></ul><ul><li>coma due to damage to reticular </li></ul><ul><li>activating system. The cardinal feature </li></ul><ul><li>is ipsilateral nuclear signs and </li></ul><ul><li>contralateral signs of pyramidal & S/T </li></ul><ul><li>tract lesions signs ( crossed ). </li></ul><ul><li>- With severe strokes flaccid paralysis is </li></ul><ul><li>accompanied by HA, vomiting, seizures </li></ul><ul><li>gaze paresis, impaired consciousness </li></ul><ul><li>+/- papilloedema 2ndry to cerebral </li></ul><ul><li>oedema </li></ul><ul><li>- Ataxia & hemisensory loss occur with deeply </li></ul><ul><li>seated lacunar infarcts. </li></ul>
  • 20. <ul><li>2- Dementia : </li></ul><ul><li>gradual decline in intellectual fn, sp </li></ul><ul><li>in ischemic strokes, with or without </li></ul><ul><li>sensorimotor limb deficit or gait disord </li></ul><ul><li>3- SAH: </li></ul><ul><li>- HA. Neck stiffness & vomiting </li></ul><ul><li>- with or without focal neurological defi </li></ul><ul><li>4- Diseases of cerebral circulation </li></ul><ul><li>** General med ex wz PR & rhythm, BP, </li></ul><ul><li>peripheral vessels, carotid bruits, heart </li></ul><ul><li>ex & complete neurological ex leads to </li></ul><ul><li>correct diagnosis. </li></ul>
  • 21. <ul><li>Differential diag of acute stroke </li></ul><ul><li>1- cerebral tumours </li></ul><ul><li>2- subdural haematoma </li></ul><ul><li>3- cerebral abscess, cysts </li></ul><ul><li>4- Todd's paralysis </li></ul><ul><li>5- demyelinating disorders </li></ul><ul><li>6- hypoglycemia </li></ul><ul><li>7- encephalitis </li></ul><ul><li>8- hysterical conversion </li></ul>
  • 22. <ul><li>Investigation of stroke </li></ul><ul><li>1- Investigations to confirm the diagnosis </li></ul><ul><li>( ? Ischemic, ? Hagic)= CT brain, MRI, </li></ul><ul><li>and L puncture. </li></ul><ul><li>2-Investigations to establish za underlying </li></ul><ul><li>disease = ECG, Echo, CXR, MRA, Doppler US, </li></ul><ul><li>carotid angiography. </li></ul><ul><li>3- Investigations to identify risk factors = </li></ul><ul><li>CBC, blood sugar, lipid profile, serology </li></ul><ul><li>for syphilis, clotting studies, serology for </li></ul><ul><li>collagen diseases, blood cultures for </li></ul><ul><li>SBE is suspected, sickling test, tests for </li></ul><ul><li>thrombophilia (protein C & S, anti thrombin 3 </li></ul>
  • 23. <ul><li>Management of stroke </li></ul><ul><li>The aim is :- </li></ul><ul><li>1- To minimize brain damage </li></ul><ul><li>2- To reduce disability through rehabilitati </li></ul><ul><li>3- Tom prevent complications </li></ul><ul><li>4- To treat za underlying cause. </li></ul><ul><li>5-To prevent za recurrence of stroke </li></ul><ul><li>6- To refer pts wz SAH to neurosurgery. </li></ul><ul><li>** To admit or not depends on za clinical </li></ul><ul><li>state & facilities at home ( TIAs & min </li></ul><ul><li>stroke at home) </li></ul>
  • 24. <ul><li>** General measures: </li></ul><ul><li>- ABC </li></ul><ul><li>- nursing care </li></ul><ul><li>- fluid balance & nutrition </li></ul><ul><li>- urinary cath if not continent </li></ul><ul><li>- physiotherapy, occupational, speech </li></ul><ul><li>and psychotherapy </li></ul><ul><li>** Specific therapy: </li></ul><ul><li>1- Med treatment </li></ul><ul><li>- anti hypertensives not given at the </li></ul><ul><li>start unless very high (> 180/110) </li></ul><ul><li>as some pts show reactive increase in BP. </li></ul><ul><li>It is gradually lowered after za 1 st week </li></ul>
  • 25. <ul><li>- Anti platelets reduce za incidence of </li></ul><ul><li>stroke by 25% e.g. aspirin 75-300mg </li></ul><ul><li>dipyridamol 75 tds, clopidogrel </li></ul><ul><li>- Anti coagulants only if there is a </li></ul><ul><li>source of emboli & avoided in za 1 st </li></ul><ul><li>2Ws following infarction. It may be </li></ul><ul><li>used in evolving stroke, but C/I in </li></ul><ul><li>intra cranial hage & cerebral tumours </li></ul><ul><li>which should be rouled out by CT </li></ul><ul><li>- Thrombolysis (tpA) in USA given </li></ul><ul><li>within 3hrs. </li></ul><ul><li>- Manitol 200ml 20% & dexamethazone </li></ul><ul><li>reduce mortality in pts with brain oedema </li></ul><ul><li>2ndry to severe stroke. </li></ul><ul><li>- Baclofe n (GABA antagonist) for spasticity </li></ul>
  • 26. <ul><li>2- Surgical treatment </li></ul><ul><li>- carotid endarterectomy in TIAs and </li></ul><ul><li>minor stroke when stenosis is > 70% </li></ul><ul><li>reduce incidence of stroke by 75%. </li></ul><ul><li>Avoided over 65 years. </li></ul><ul><li>- surgical evacuation of haematoma if </li></ul><ul><li>accessible & if pat continue to deteriorate e.g cerebellar hage to prevent brainstem compression. </li></ul><ul><li>3- Rehabilitation </li></ul><ul><li>- identify risk factors & treat </li></ul><ul><li>- TR 2ndry depression </li></ul>
  • 27. <ul><li>Prognosis </li></ul><ul><li>- 25% die as a direct result of stroke. </li></ul><ul><li>More in hagic stroke. </li></ul><ul><li>- 50-75% who survive stroke achieve fnal </li></ul><ul><li>independency in 3Ms </li></ul><ul><li>- poor outcome in pts wz deep coma and </li></ul><ul><li>dense hemiplegia </li></ul><ul><li>- recurrent stroke in5-10%/ year </li></ul><ul><li>- patient may die of cardiovascular dis. </li></ul>
  • 28. <ul><li>Complications of acute stroke </li></ul><ul><li>- pneumonia - dehydration </li></ul><ul><li>- hyponatraemia - hypoxaemia </li></ul><ul><li>- hypoglycemia - DVT </li></ul><ul><li>- seizures - subluxation of joints </li></ul><ul><li>- frozen shoulder - pressure sores </li></ul><ul><li>- UTI - constipation </li></ul>
  • 29. <ul><li>Lateral medullary syndrome </li></ul><ul><li>- due to occlusion of PICA or vertebral art. </li></ul><ul><li>- there is ipsilateral ataxia, nystagmus, </li></ul><ul><li>facial numbness, palatal palsy, diplopia </li></ul><ul><li>(6 th CN) & Horners </li></ul><ul><li>- contralateral S/T signs. Hemiparesis rare </li></ul><ul><li>- often vertigo. </li></ul><ul><li>Weber syndrome </li></ul><ul><li>- ipsilateral 3 rd cranial N palsy </li></ul><ul><li>- contralateral pyramidal </li></ul>
  • 30. <ul><li>Pontine hage </li></ul><ul><li>- impaired consciousness </li></ul><ul><li>- hyperpyrexia </li></ul><ul><li>- pinpoint pupils </li></ul><ul><li>- paresis </li></ul><ul><li>Visual cortical infarcts </li></ul><ul><li>- cortical blindness </li></ul><ul><li>- hemianopia </li></ul><ul><li>Lacunar infarcts </li></ul><ul><li>- <1.5 cm </li></ul><ul><li>- commonly HT </li></ul><ul><li>- pure motor, sensory or cerebellar </li></ul>
  • 31. <ul><li>Multi infarct dementia </li></ul><ul><li>- stepwise gradual intellectual loss </li></ul><ul><li>- pseudobulbar palsy </li></ul><ul><li>- Parkinsonian gait. </li></ul><ul><li>Water shed infarcts </li></ul><ul><li>- multiple infarcts at border zones betwee </li></ul><ul><li>areas supplied by cerebral arteries </li></ul><ul><li>following prolonged periods of cerebral </li></ul><ul><li>ischemia </li></ul><ul><li>- cortical blindness </li></ul><ul><li>- amnesia </li></ul><ul><li>- intellectual impairment. </li></ul>
  • 32. <ul><li>Cerebellar hage </li></ul><ul><li>- headache is severe & occipital </li></ul><ul><li>- brainstem symptoms may occur e.g </li></ul><ul><li>diplopia, vertigo wz rapid deterioration of </li></ul><ul><li>conswciousness </li></ul><ul><li>- may cause acute hydrocephalus </li></ul><ul><li>- immediate surgical evacuation of haemat </li></ul>
  • 33. <ul><li>Subarachnoid hage (SAH) </li></ul><ul><li>- 10% of strokes </li></ul><ul><li>- Causes : </li></ul><ul><li>- Berry aneurysm 70% </li></ul><ul><li>- AVM 10% </li></ul><ul><li>- rare causes </li></ul><ul><li>- extension of I/C hage - anticoagul </li></ul><ul><li>- rupture of atheromatous vessel </li></ul><ul><li>- bleeding disorders - brain tumou </li></ul><ul><li>- acute bact meningitis - arteritis SLE </li></ul><ul><li>- spinal AVM - co arcitation of Ao </li></ul><ul><li>- APKD - Marfan’s </li></ul>
  • 34. <ul><li>Berry aneurysm: </li></ul><ul><li>- post & ant communicating arteries </li></ul><ul><li>- middle cerebral art </li></ul><ul><li>- basilar, PICA, retinal & intra cavernous </li></ul><ul><li>carotid art </li></ul><ul><li>- bleeds </li></ul><ul><li>- pressure on surrounding structures e.g. </li></ul><ul><li>3 rd CN </li></ul><ul><li>AVM: </li></ul><ul><li>- developmental anomaly within za brain </li></ul><ul><li>- SAH </li></ul><ul><li>- focal neurological deficits & epilepsy. </li></ul>
  • 35. <ul><li>Clinical features : </li></ul><ul><li>- occurs during exertion high Bp </li></ul><ul><li>- sudden severe occipital headache </li></ul><ul><li>- neck stiffness & +ve Kerning sign </li></ul><ul><li>- fever & vomiting </li></ul><ul><li>- photophobia & irritability </li></ul><ul><li>- consciousness may be lost & seizures </li></ul><ul><li>may develop </li></ul><ul><li>- sub hyaloid hage & papilloededema </li></ul><ul><li>- focal neurological signs (ischemia from </li></ul><ul><li>arterial spasm & bleeding into brain </li></ul><ul><li>- CT diagnostic </li></ul><ul><li>- LP if CT is –ve (hagic) </li></ul><ul><li>- look for bruits over head & eyes </li></ul><ul><li>- DD= meningitis, migraine, meningism, C malar </li></ul>
  • 36. <ul><li>Complications : </li></ul><ul><li>- hydrocephalus due to obstruction of </li></ul><ul><li>subarachnoid space by clots. </li></ul><ul><li>- intra cranial arterial spasm & neurological deficits </li></ul><ul><li>Management: </li></ul><ul><li>- Immediate : bed rest, control of HT, </li></ul><ul><li>dexamethazone if brain oedema </li></ul><ul><li>- Specific: refer to neurosurgical unit as </li></ul><ul><li>soon as diag is proven.? Angiography, </li></ul><ul><li>clipping of za neck of aneurysm </li></ul><ul><li>micro embolization, focal R/T & surgery for AVM </li></ul>
  • 37. <ul><li>Prognosis: </li></ul><ul><li>-50% early mortality </li></ul><ul><li>- 10-20% die from rebleeding within 2Ws </li></ul><ul><li>- comatosed pts & those wz severe </li></ul><ul><li>neurological deficit carry bad prognosis. </li></ul>
  • 38. <ul><li>Cerebral venous thrombosis </li></ul><ul><li>- Uncommon </li></ul><ul><li>- Causes patchy hagic ischemia & ICP </li></ul><ul><li>- predisposing factors </li></ul><ul><li>- dehydration - hypotension </li></ul><ul><li>- polythycemia - pregnancy </li></ul><ul><li>- Anti phospholipid syndrome - OCP </li></ul><ul><li>- Severe intercurrent infection </li></ul><ul><li>- Para nasal sinusitis - Facial skin infection </li></ul><ul><li>- Otitis media - mastoiditis </li></ul><ul><li>- meningitis -Subdural embyema </li></ul><ul><li>- Fracture skull - penetrating head inury </li></ul>
  • 39. <ul><li>1- Cortical venous thrombosis </li></ul><ul><li>- fever </li></ul><ul><li>- focal cerebral dysfunction: </li></ul><ul><li>- epilepsy - hemiparesis </li></ul><ul><li>- dysarthria </li></ul><ul><li>2- Cerebral venous sinus thrombosis </li></ul><ul><li>Depends on za sinus involved </li></ul><ul><li>a- cavernous sinus: Often bilateral </li></ul><ul><li>- pt very ill, headache, ptosis, </li></ul><ul><li>proptosis, ophthalmoplegia, fever </li></ul><ul><li>papilloedema, sensation ophth V </li></ul>
  • 40. <ul><li>b- Superior sagittal sinus: </li></ul><ul><li>headache, seizures, papilloedema, </li></ul><ul><li>+/- advancing motor & sensory def </li></ul><ul><li>c- Transverse sinus: </li></ul><ul><li>hemiparesis, seizures, & papilloedem </li></ul><ul><li>spreading to jugular foramen </li></ul><ul><li>X1, X, X11 palsies. </li></ul><ul><li>Investigations </li></ul><ul><li>- CT, MRA to detect occluded v or sinus </li></ul><ul><li>- CSF under pressure </li></ul>
  • 41. <ul><li>Treatment </li></ul><ul><li>- broad spectrum antibiotics </li></ul><ul><li>- drain infected site ( sinus, middle ear) </li></ul><ul><li>- dexamethazone for brain oedema </li></ul><ul><li>- anticoagulants early on may limit the </li></ul><ul><li>spread of thrombosis. </li></ul>
  • 42. <ul><li>Chronic subdural haematoma (SDH) </li></ul><ul><li>- affects elderly & alcoholics even with </li></ul><ul><li>minor head trauma </li></ul><ul><li>- fluctuating headache, drowsiness and </li></ul><ul><li>confusion </li></ul><ul><li>- focal signs: hemiparesis, hemisensory </li></ul><ul><li>loss </li></ul><ul><li>- seizures, papilloedma, stupor & coma </li></ul><ul><li>- fatal if untreated </li></ul><ul><li>- conservative TR hoping that spontaneous </li></ul><ul><li>stopping of bleeding, otherwise burr hole. </li></ul>
  • 43. <ul><li>Extradural hage </li></ul><ul><li>- due to tearing of middle meningeal art </li></ul><ul><li>following linear skull vault fracture. </li></ul><ul><li>- brief loss of consciousness (concussion) </li></ul><ul><li>followed by lucid interval of recovery </li></ul><ul><li>- with progressive hemiparesis, stupor and </li></ul><ul><li>rapid transtentorial coning with ipsilat </li></ul><ul><li>dilated pupil followed by dilatation of </li></ul><ul><li>of za other, quadriparesis & death if </li></ul><ul><li>untreated. </li></ul><ul><li>- prompt CT & MRI if suspected & urgent </li></ul><ul><li>neurosurgery. </li></ul>

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