Management of a stroke is multidisciplinary. Supportive treatment to stabilize the patient is a priority. Stroke specialists, speech and language therapists, occupational therapists, and physiotherapists have key roles in patient rehabilitation. Long-term use of antiplatelet drugs such as aspirin and modification of cardiovascular disease risk factors are important in the secondary prevention of stroke.
In the clinic
Endarterectomy is a surgical procedure to remove atheromatous plaque from arteries.
Atheromatous plaques occur in the subendothelial layer of vessels and consist of lipid-laden macrophages and cholesterol debris. The developing plaque eventually accumulates fibrous connective tissue and calcifies. Plaque commonly occurs around vessel bifurcations, limiting blood flow, and may embolize to distal organs.
During endarterectomy, plaque is removed and the vessel reopened. In many instances a patch of material is sewn over the hole in the vessel, enabling improved flow and preventing narrowing from the suturing of the vessel.
In the clinic
Cerebral aneurysms arise from the vessels in and around the cerebral arterial circle (of Willis). They typically occur in and around the anterior communicating artery, the posterior communicating artery, the branches of the middle cerebral artery, the distal end of the basilar artery (Fig. 8.41), and the posterior inferior cerebellar artery.
As the aneurysms enlarge, they have a significant risk of rupture. Typically patients have no idea that there is anything wrong. As the aneurysm ruptures, the patient complains of a sudden-onset “thunderclap” headache that produces neck stiffness and may induce vomiting. In a number of patients death ensues, but many patients reach the hospital, where the diagnosis is established. An initial CT scan demonstrates blood within the subarachnoid space, and this may be associated with an intracerebral bleed. Further management usually includes cerebral angiography, which enables the radiologist to determine the site, size, and origin of the aneurysm.
Usually patients undergo complex surgery to ligate the neck of the aneurysm. More recently radiological intervention has superseded the management of some aneurysms in specific sites. This treatment involves cannulation of the femoral artery, and placement of a long catheter through the aorta into the carotid circulation and thence into the cerebral circulation. The tip of the catheter is placed within the aneurysm and is packed with fine microcoils (Fig. 8.42), which seals the rupture.
In the clinic
Summary of relationships and clinical significance of the scalp and meninges (Fig. 8.47).
In the clinic
Head trauma is a common injury and is a significant cause of morbidity and death. Head injury may occur in isolation, but often the patient has other injuries; it should always be suspected in patients with multiple injuries. Among patients with multiple trauma, 50% die from the head injury.
At the time of the initial head injury two processes take place.
First the primary brain injury may involve primary axonal and cellular damage, which results from the shearing deceleration forces within the brain. These injuries are generally not repairable. Further primary brain injuries include intracerebral hemorrhage and penetrating injuries, which may directly destroy gray and white matter.
The secondary injuries are sequelae of the initial trauma. They include scalp laceration, fracture of the cranial vault, disruption of intracerebral arteries and veins, intracerebral edema, and infection. In most cases these can be treated if diagnosed early, and rapid and effective treatment will significantly improve the patient’s recovery and prognosis.
In the clinic
Types of intracranial hemorrhage
The many causes of a primary brain hemorrhage include aneurysm rupture, hypertension (intracerebral hematoma secondary to high blood pressure), and bleeding after cerebral infarction.