3 Course ECNR Antalya

Early Confluent & Confluent True ischemic lesions- A continuum of increasing tissue damage  Perivascular myelin rarefaction  Mild/moderate fiber loss  varying extents of gliosis.

  • Stenosis > 70%

• Patients included <17 days after first stroke •

Female

• Asymptomatic stenosis • Stenosis < 70 % • Unstable patients • Basilar stenosis ? • Old patients • Diabetic

• Symptomatic stenosis > 70 % with failure 2 antiplatelet • Hemodynamic stenosis with no reserve after Diamox! • Embolic stenosis ? • Female • Smokers???

  Call flemming Syndrom Worst headache of live Spontanous Or pregnancy , drug, Cannabis ,  Benigne course Ca channelm Blocker

SympatIc activitiy Endeothelial dysfunction - vasocontrictiv or breakdokwn (PRES) 94% recurrent thunderclap headache in 1 week Reversible Ischaemie possible Bleeding possible Benign liquor Miltufocal narrowing  DD primäre cns vasculitis

Venöser vascultischer befall - im hirnstAmm fliessen Venen nur in eine richtung - stase bei Befall 

  Moyamoya Dissection Vasculitis - String of bead Focal cerebral arthropathie (lenticulostristal infarction, Varizellen, nach krankheit, unilateral, selflimiting Metabolic stroke - melas mitochondrial defekt Fabry disease - Large basilasris, pulvinar Sign(hyperintense T1 thalami). Galatinase x linked Heart disease

Moyamoya - collaterals pial with slower flow

Fabry disease - Large basilasris, pulvinar Sign(hyperintense T1 thalami). Galatinase x linked Strokes

  Vascular malformation  rendu-osler multiple avm Aneurysma patholocial other than adults - mycotic, dissction, venous, Phace, dysplasia Brain Tumors - delayed break Down of blood products

Ependymoma with cap sign  

Venous thrombosis deep venous system DVA bleeding compressing while birth Thromozytopenia Gentic col41 defect The cerebellum has a external granoukomats Layer till 1 year - germinal Matrix empfindlich fuer bleeding  

Cognitiv impairment by vascular pathologisch inkl small vessel disease

DWI > 100 ml

TTP > 10 sek

Weitere Blutungen und ischemia in nächsten 5-7 Jahre 

pial kollaterales with Slow Flow Flair 

Good sign for collaterals in infarct

1-2 Prozent /Year bleeding

cavernomas 0.5 % /y

Only 8%

SUSAC syndrome •Triad (frequently incomplete) •encephalopathy •branch retinal artery occlusions •sensorineural hearing loss (young females)   •Fluctuating clinical course, self-limiting / relapsing •Long-term sequela and permanent functional deficits •Brain MRI, retinal fluorescein angiography, and audiography findings enable diagnosis      

SUSAC syndrome Characteristic MRI features:

snowballs in cc , String of pearls in capsula interna

•Focal T2 white / grey matter lesions supra and infratentorial (infarcts)

•Small and widespread

•Enhancement

•Diffusion restriction •

Constant involvement of the corpus callosum (central) •Cortex, basal ganglia, brainstem amd cerebellum also involved  

Leptomeningeal enhancement (1/3)

  Characteristic MRI features:  

• Multiple focal T2 subcortical and deep white matter lesions (hypoxic- ischaemic), lacunar infarcts
• More common in males and with increasing age
• Involvement of the temporal lobe

• T1 hyperintensity of the pulvinar (25-30% of patients)
• basilaris widending

Reversible Cerebral Vasoconstriction Syndrome (RCVS) Transient disturbance in control of cerebral vascular tone Clinical •“Thunderclap” headache •Often recurrent •Mimics aSAH Characterized by •Reversible, multifocal vasoconstrictions •No or minimal (superficial) SAH •“Atraumatic” convexity SAH < 60y? Think RCVS! Imaging •NECT often negative •MR may show ischemic foci •DSA shows diffuse segmental arterial constrictions

Small vessel disease

 neuromyelitis optica

fabry - Snow ball

cadasil

ms

• Patients with time from symptom onset 4.5 hours

• Proximal cerebral arterial occlusion (ICA, M1, M2, BA, etc.)

• Evidence for salvageable /ssue (MR: DWI/clinical mismatch, MRP: DWI/PWI mismatch, CTP: CBV/MTT mismatch, etc.)

thrombus laenger 8 mm

IA tPA / IA UK up to 6 hours

Mechanical thrombolysis up to 8 hours

Alone or bridged to ivtPA

Siehe Bild 

8

8 mm

Proact II

ECASS III

  •  Any intracranial hemorrhage •  Blood pressure >185/110 mmHg despite intervention •  Surgery or trauma within 14 days •  Active internal bleeding •  Coagulopathy; INR >1.7, aPTT >40, plt <100,000 mm3 •  Non-compressible arterial puncture within 7 days •  Large hemispheric hypodensity

Sekundaer mit warafarin

keine primäre Prophylaxe 

aspirin nicht wertvoll ntt 125 primär und 40 sekundaer

auch Aspirin mit Plavix ist schlechter als Warfarin

Treat symptomatic extracranial ICA stenosis ≥ 50%    with CEA or CAS, provided that perioperative morbidity/mortality <6% (Class I/ IIa, Level A/B) •  If no contraindication, revascularization should be done within 2 weeks of symptoms (Class IIa, Level B) •  For occlusion, EC-IC bypass is not recommended routinely (Class III, Level A)

> 70 Jahre operativ, wegen aorta kalk und ischaemien

< 70 Jahre stenting