Cerebral vascular accident

A cerebral vascular accident (AVC), sometimes called “brain attack”, is a neurological deficit suddenly of vascular origin (problem of the circulation the blood).

The apoplexy or tackles apoplexy is a term in the past employed, more general. It is in fact the visible effect of the AVC: loss of consciousness, with stop partial or complete of the cerebral functions, or an attack causing the loss of conscience or the sudden death of the patient (striking down apoplexy).

One uses sometimes the adjective “apoplectic” to describe an unverifiable fury.

The AVC are sometimes related to a bad hygiene of life (Tabagisme, Obésité), but they can also occur because of heredity and certain specific diseases (arterial Hypertension, Hypercholestérolémie, auricular fibrillation, disorders of blood coagulation).

The Middle Age of occurred is seventy years, but a AVC can occur at any age. The AVC represent the recent majority of the causes of Hémiplégie and strike approximately 100.000 subjects per annum, in France. Mortality in six months is from 30 to 40%. It is the third cause of mortality in France after cancers and the cardiopathies, and the first cause of the acquired physical handicaps.

Signs of a AVC

Six characteristic signs can occur (not necessarily all):

loss of the force of an arm, of a leg, half of the face or totality on a side of the body (hémiplégie); a deviation of the mouth is frequently observed;
loss of the sensitivity of an arm, of a leg, face or on all the side of a body;
sudden difficulty to find the words or to express them: the sentences or the words are incomprehensible (Aphasie); sudden difficulty to speak, move the language, impossibility of swallowing saliva.
sudden disorder of balance and the walk, which can lead to the fall;
sudden loss of the vision of an eye; Diplopia or turbid vision (due to disorders of accommodation). This disturbed vision can appear 12 hours before the AVC, during a few minutes, then to disappear. Dazzling, (impossibility of opening the eyes with the light), pupils unequal and/or nonreactive
headaches violent ones and intense.

They can be also translated, much more rarely, by a convulsive crisis or a state of mental confusion, apparently isolés.
These signs can have another cause, for example a Tumeur with the brain, an intoxication, a cerebral edema or a cranial Traumatism. One of the characteristics of the AVC is that these signs appear in a sudden way ; however, they are often neglected, minimized when they are short; in certain cases, one can have the impression that the person is drunk. In the most serious cases, the victim loses conscience (Coma).

Whatever the cause of these signs (AVC or other), it acts of a vital urgency which must be treated as soon as possible. It is thus important to have an immediate medical diagnosis when one of these signs occurs, by calling the medical emergency. Any delay in the treatment can even lead to important after-effects (Paralysie) with the death.

The cerebral vascular accident can be transitory ( HAS ) with rapid return at the normal state, without after-effects (i.e. in less than one hour). The deficit can be on the contrary permanent. One then speaks about cerebral vascular accident made up ( AIC ).

Clinical mechanisms and forms

the AVC are classified in accidents ischemic S and accidents hemorrhagic S.

- the ischemic accidents must with the occlusion of a cerebral artery or cerebral destination (Carotide S or vertebral arteries). It involves a cerebral Infarctus (also called softening of the brain ). The mechanism of this occlusion is generally either a obstructive Athérome, or a clot (of local formation or by Embolie, in this case, generally of cardiac origin), but of other causes can exist: tear of the wall of the artery ( dissection ), compression by a tumor. The deficit relates to a well defined territory of the brain: it known as is systematized.

the softening of the brain of ischemic origin can secondarily become complicated bleeding on the level of the lesion: one speaks then about hemorrhagic softening.

- the hemorrhagic accidents are in connection with the rupture of a pathological vessel. There exist various etiologies, most frequent being a degenerative attack of the small perforating arteries. The rupture of an aneurism arterial within spaces under-arachnoïdiens causes a méningée Hémorragie, possibly associated with a ventricular flood or a intraparenchymateux hématome.

the hématome is formed quickly, giving focal neurological signs of brutal appearance in connection with the structures destroyed or compressed by the lesion. In addition it constitutes an edema around the hématome, which worsens the compression of the brain in the brain-pan, involving or worsening an intracranial hypertension (HTIC). The hématome can break in a ventricle cerebral.

the various types of AVC are:

- the ischemic Accident made up , or cerebral Infarction, is a final loss of part of cerebral fabric, with presence of more or less important neurological after-effects.

- the transitory ischemic Accident is a neurological deficit regressing completely in less than 20 minutes after its appearance.

- the méningée Hémorragie is a consecutive cerebral vascular accident with the massive irruption of blood in the meninges.

- the intracerebral Hémorragie is a secondary AVC with the rupture of a cerebral artery within the parenchyma, at the origin of a hématome dilascérant cerebral fabric.

- the cerebral Thrombophlébite

- the cerebral Gap

Diagnosis

Interrogation

It is necessary to question the patient and his entourage on the current event (mode of installation and evolution since the last hours), to seek antecedents of signs or transitory symptoms neurological and cardiac (palpitations) by directed questions, to specify the ground and the risk factors personal and family. Better is worth to describe the type of embarrassment than tests the patient with words of the language running than to use too precise terms hastily obstructing the later reflection (dysarthrie, aphasia, ataxia, cérébelleux syndrome, amaurose…).

neurological Examination

To initially privilege the total operations, the analytical examination (muscular force and coordination, sensitivity, reflexes, sensoriality) coming to specify the localization. The study of the visual system often informative affirming an attack is known-tentorielle (reached field of vision and in particular Hémianopsie) or of posterior pit (nystagmus, paralysis of a nerve oculomotor). Swallowing must be tested while making drink to 2 or 3 recoveries a small water spoon then a mouthful with glass in order to avoid pneumopathies of swallowing by a too fast food with the acute phase.

cardiovascular Examination

The catch of the blood-pressure to the two arms, the search for a cardiopathy emboligene (valvulopathy, disorder of the rate/rhythm) by the sounding and the ECG are systematic. The sounding of the vessels of the neck and the known-claviculaire hollows can find a breath but it is not specific of an arterial lesion (breaths of flow, venous breaths, transmitted breaths) and disappears in the event of sténose hyperserrée.

the cerebral tomodensitometry

The scanner in general finds a normal aspect in the first hours of the infarction of the brain. Later, of the modifications will appear at the stage of after-effects. The advantage of the scanner is to eliminate the other diagnoses and in particular the brain hemorrhage which MIME the same symptoms, treatment being radically different. It is necessary in front of the suspicion of a AVC to practice a scanner systematically to determine if it is about an infarction (treatment: to flux the blood) or of a hemorrhage (not to flux blood). IRM is more precise when this examination is possible. In practice, the access to the scanner is faster and the time of examination is shorter.

the IRM

The IRM revolutionized the diagnosis of the cerebral vascular accident. Indeed, the realization of a special sequence, the diffusion, makes it possible to make the diagnosis of the ischemic AVC in the minutes which follow the stop of the oxygenation of a zone of the brain. In addition, without injecting a product of contrast, it is possible by a angiographic sequence to visualize the vessel (more specifically the large vessels: Carotid S, vertebral S and Polygon of Willis) occluded at the origin of the disease, the smaller vessels will require the injection of Gadolinium. Finally an old hemorrhagic cerebral vascular accident is highlighted by sequences in echo of gradient: the deposits of Hémosidérine are at the origin of an artefact of susceptibility magnetic causing a small vacuum of signal in hemorrhagic in the past zones.

Principles of the treatment

After a hospital assessment, the treatment merges with that of the cause:

anticoagulants in the event of cardiopathy emboligene,
antiagrégants plate in the event of ischaemia,
endarteriectomy carotidienne if there exists a sténose carotidienne,
antihypertensor (S) in the event of arterial hypertension

the study PROGRESS (2001) seems to show the benefit of the association of périndopril and indapamide on the reduction of the risk of repetition of a AVC.

neurosurgical treatment in the particular cases, rare, of brain hemorrhage, cérebelleux infarction and malignant hemispherical infarction.
the Altéplase is the first treatment thrombolytic suggested in ischemic indication AVC of origin, when it is dealt with less than 3 hours after the primary symptoms. Although it does not bring a benefit as for total mortality, it allows a recovery supplements more frequent. However, being given its potential undesirable effects (in particular intracranial hemorrhages), the room for maneuver, between the benefit of this treatment and its risks, is very narrow. It should be used only in specialized centres and for patients selected according to very precise criteria.
rehabilitation after a AVC forms integral part of the treatment: according to the cases, kinesitherapy, orthoepy, food mode.

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