2. Impacto del Stroke 700.000 personas tienen un stroke anual (EEUU) 500.000 casos nuevos (Greater Cincinnati/Northern Kentucky Stroke Study) Tercera causa de muerte. Primera causa de incapacidad severa a largo plazo. Cada 25 segs. alguien tiene un stroke (EEUU). El Stroke mató 157.804 personas en EEUU (2003). 3 de cada 5 muertes por stroke son mujeres. Un 8 a 12% de los strokes isquémicos terminan en muerte a 30 días. (Stroke 1999;30:736–43; Stroke 2004;35:1552-6) Costo estimativo del Stroke para el año 2006 en USA: US 57,9 billones US 15000 por cada stroke
8. TIA La mayoría de los AIT tienen una duración de menos de 1 hora. La duración promedio para los de la circulación anterior es de 14 minutos y 8 minutos para los de la circulación posterior.
10. Los síntomas dependen del área cerebral afectada Síntomas de Stroke Hemisferio Derecho Parálisis izquierda Alteraciones de la percepción Dificultad para la lectura Neglect izquierdo Pérdida de la memoria reciente
11. Los síntomas dependen del área cerebral afectada Síntomas de Stroke Hemisferio Izquierdo Parálisis derecha Dificultad para el discurso o el lenguaje Dificultad para cumplir órdenes complejas Pérdida de memoria
12. Los síntomas dependen del área cerebral afectada Síntomas de Stroke Tronco cerebral Alteraciones en la respiración. Pérdida de la conciencia. Alteración en los movimientos de los ojos, en el oído o en el discurso. Efectos variables en la presión arterial Signos de parálisis cruzados
13. Los síntomas dependen del área cerebral afectada Síntomas de Stroke Cerebelo Pérdida de equilibrio. Ataxia. Náuseas, vómitos. Pérdida de algunos reflejos. Mareos y vértigo.
25. 80s … Ev o lución natural Prevención de complicaciones médicas Prevención de recurrencia del stroke : Anticoagula c i ó n Plan: Rehabilitación, e xclusión social año 2000 Stroke = Emergencia médica Concepto de reperfusi ó n Interrupción del Stroke Alta precoz Plan: Reintegración social Cambio de mentalidad ...
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28. Unidad - Team de Stroke Neurologo Vascular Neurocirujano Neurorradiólogo Cardiólogo Neurointensivismo Cirugía Vascular Neurofisiologo Enfermería esp. Hematólogo Hemodinamia Neuropsicologo Kinesiólogos STROKE UNIT
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30. El stroke debe equipararse a la urgencia con que se maneja un IAM, por lo tanto la conducta diagnóstica y las decisiones terapéuticas deben ser inmediatas.
36. Evolución de la isquemia Estudio precoz con TC TC a las 24 horas Borramiento de los surcos, diferencias en los surcos y en la densidad insulares Dr. Ricardo Romero Mayo 2010
Cerebrovascular disease is a heterogeneous disease. A stroke occurs when a blood vessel that supplies oxygen and nutrients to the brain becomes blocked or ruptures. A portion of the brain dependent on blood flow from this vessel becomes deprived of oxygen. Within minutes, nerve cells begin to die, which results in permanent disability. Strokes can be categorized as either hemorrhagic or ischemic.[1] Hemorrhagic strokes occur as a result of bleeding into the brain caused by an injury to the head or a ruptured aneurysm. Although less common than ischemic strokes, hemorrhagic strokes produce more fatalities. Hemorrhagic strokes are further categorized as intracerebral or subarachnoid. An intracerebral hemorrhage occurs when a defective artery in the brain ruptures and the surrounding area of the brain fills with blood. A subarachnoid hemorrhage occurs when a blood vessel on the surface of the brain ruptures and bleeds into the subarachnoid space between the skull (but not within the tissues of the brain). Ischemic strokes can be further divided into subcategories. A cerebral embolism is a result of a clot or embolus that forms in another portion of the body such as the heart (in the case of atrial fibrillation) and is carried through the bloodstream, becomes lodged in an artery that supplies blood to the brain, and blocks the flow of blood. Atherosclerotic cerebrovascular disease results in stroke when there is an impediment to normal blood perfusion as a result of severe arterial stenosis or occlusion due to atherosclerosis and coexisting thrombosis.[2] Lacunar infarcts result from microatheroma, lipohyalinosis, and other occlusive diseases of the small penetrating arteries of the brain; these are sometimes referred to as subcortical infarcts. Cryptogenic infarcts refer to ischemic strokes in which the underlying etiology remains obscure. Of the definite or probable strokes reported in the National Heart, Lung, and Blood Institute’s (NHLBI’s) Atherosclerosis Risk in Communities (ARIC) study [3], 83% were ischemic, 10% were intracerebral, and 7% were subarachnoid hemorrhages. Among the 178 confirmed thrombotic brain infarctions, 38% were classified as lacunar strokes, occurring in small blood vessels of the brain. American Stroke Association. Impact of Stroke . Available at: www.strokeassociation.org. Accessed June 21, 2002. Albers GW, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke. Chest . 1998;114:683S-698S. Rosamond WD, Folsom AR, Chambless LE, et al. Stroke incidence and survival among middle-aged adults: 9-year follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort. Stroke . 1999;30:736-743.
Look at physiological aspect of cell death. In the ischemic brain tissue, there is gradient of energy level from near zero in the infarct core to the full supply in penumbra. In the middle, transient zone supply low level of ATP. In the core, the lack of blood and energy supply, within 3 hours, neurons will die by necrosis, due to compromise mitochondrial membrane integrity followed by protease/endonucleaase, breaks down cellular structure and random DNA fragmentation. After 12 hours of recanalization, in the penumbra area, the energy supply is fully restored and mitochondria (Energy) dependent apoptotic cascades are activated. Then eventurely the cell develop ordered DNA fragmentation and morphological appearance of apoptosis. In the transient zone with low level of ATP allows the initiation cell death program. However, the commitment to die by apoptosis may be shifted to necrosis in the worsening of energy supply. Some researchers call this cell death as “active cell death”. The location on the scale of this continuum toward apoptosis is dependent upon the energy supply and the availability of other associated factors.
