ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with...
Transcript of ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with...
![Page 1: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/1.jpg)
ACVVASCULOPATIASOCLUSIVAS
![Page 2: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/2.jpg)
FISIOPATOLOGIADELACV• Laisquemiacerebralfocal(regional)ogeneralizada
(global)delFSC• Reversibleoirreversible• Cuandoelvolumensanguíneocerebralestapordebajodeun
determinadoumbral,laisquemiaseconvierteeninfartoirreversible
• Laisquemiapuedeafectarterritoriosarterialesterminalesozonasdeirrigaciónlimítrofemicrocirculaciónterminal
• Losterritorioscerebralesterminalesdelasarteriasmayoressonafectadosporémbolosyaterosclerosis
• LaszonaslimítrofessuelensufrirencefalopaMahipoxica• Laszonasdesustanciagrissonlasprimerasensufrirla
disminucióndelFSC
![Page 3: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/3.jpg)
EVOLUCIONDELOSPACIENTESINFARTOCEREBRAL
MUERTE10-15%
INVALIDEZPROLONGADA
30-50%
INTERNACIONENESTABLECIMIENTOSANITARIO20-25%
![Page 4: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/4.jpg)
EVOLUCIONDELOSINFARTOS
Ø Hiperagudo:<de6horas
Ø Agudo:6horas-3días
Ø Subagudo:3días-3meses
Ø Crónico:>de3meses
![Page 5: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/5.jpg)
OBJETIVOSDELOSESTUDIOSPORIMAGEN
• Idenaficaraquienesaeneuninfartocerebral• Determinarlaextensióndelinfarto• Reconocerelcentroinfartadoyzonadepenumbra
• Idenaficarlosinfartoshemorrágicos• Determinarsilossíntomassedebenaotrascausasquenoseanisquemia
• 10%detodoslosACVsedebenalesionesquenosonsecundariasaoclusiónvascular
![Page 6: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/6.jpg)
DIAGNOSTICOPORIMÁGENESv TOMOGRAFIACOMPUTADA• Convencional• AngioTC• TCperfusiónv RESONANCIAMAGNETICA• Convencional• AngioRM• RMdifusión• RMperfusión• EspectroRMv ECOGRAFIADOPPLERv ANGIOGRAFIAPORCATETERISMOv PROCEDIMIENTOSINTERVENCIONISTAS
![Page 7: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/7.jpg)
MANIFESTACIONESENTCv Levehipodensidaddelputamenyglobopálido“signolenacularevanescente”
v Hipodensidaddelacortezainsularylasustanciablancasubyacente“signodelahipodensidadoribeteinsular”
v HiperdensidaddelaarteriaCMEDIAv Obliteracióndelossurcoscoracalesv “Borramientodelauniónsustanciagrisyblanca”
![Page 8: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/8.jpg)
TCENELSTROKE
• DISPONIBLE• 60%DELOSINFARTOSSEVENENTRELAS3-6HS• VIRTUALMENTETODOSLOSINFARTOSINSTAURADOSSEVENALAS24HS
• EDEMACITOTOXICO-FALLAENLABOMBADESODIO-POTASIO
• DISMINUCIONDELATP• SENSIBILIDAD64%• ESPECIFICIDAD85%
![Page 9: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/9.jpg)
UalidaddelaTCsincontrasteenlavaloracióndelictusisquémicoagudo
Ø Altamentesensibleparaladeteccióndelesioneshemorrágicas(contraindicaciónalaterapiatrombolíaca)
Ø Puedeayudaradetectarotraslesionesquepuedencondicionardéficitsneurológicossemejantesalictus(p.ej.neoplasias,MV)
Ø Úalparaladeteccióndesignosprecocesdeinfartoestablecido,cuyoshallazgosprincipalesson:
![Page 10: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/10.jpg)
§ HIPODENSIDADDELOSNÚCLEOSLENTIFORMESdebidoaledemacitotóxico.LasramaslenMculo-estriadasdelaACMsonvasosterminales,porloquelosnúcleoslenaformesestánpredispuestosasufrirdañoisquémicoprecozeirreversibleenloscuadrosdeoclusiónproximaldeACM.
§ HIPODENSIDADCONOBLITERACIÓNDELOSSURCOSDELCÓRTEXINSULAR(SIGNODELRIBETEINSULAR),queesunáreaalejadadelacirculacióncolateraldelasACAyACM,porloqueestápredispuestoasufrirdañoisquémicoprecozeirreversible.
§ (SIGNODELAARTERIACEREBRALMEDIAHIPERDENSA),yqueaenealtaespecificidadparaeldiagnósacodeoclusiónarterial.LapresenciadepuntoshiperdensosenramasdistalesdelaACM(signodelpuntohiperdenso)puedencorresponderaoclusionesdistales.
![Page 11: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/11.jpg)
TEJIDOMUERTO
PENUMBRA
![Page 12: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/12.jpg)
![Page 13: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/13.jpg)
![Page 14: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/14.jpg)
![Page 15: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/15.jpg)
![Page 16: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/16.jpg)
![Page 17: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/17.jpg)
![Page 18: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/18.jpg)
![Page 19: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/19.jpg)
![Page 20: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/20.jpg)
ANGIOTCNORMALDEPOLIGONODEWILLIS
![Page 21: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/21.jpg)
![Page 22: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/22.jpg)
![Page 23: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/23.jpg)
![Page 24: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/24.jpg)
![Page 25: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/25.jpg)
RMCONVENCIONAL• T2,DPyFLAIR• DETECTAN80%DELOSINFARTOSANTESDELAS24HS
• PUEDESERNEGATIVAENTRELAS2-4HORASPOSTICTUS
• HIPERINTENSO=EDEMA• COMPARABLEALAHIPODENSIDADENTC
![Page 26: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/26.jpg)
T2 FLAIR
![Page 27: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/27.jpg)
A, Arrows show normal brownian motion in extracellular space with normal-size cells.
B, Failure of sodium-potassium-ATP pump leads to intracellular edema, swelling of cells (cytotoxic edema), decreased extracellular fluid, and hence decrease in brownian motion.
C, Large influx of Ca2+ inside cells leads to mitochondrial damage and cellular wall disruption, which in turn leads to cell rupture and increase in extracellular fluid (vasogenic edema).
MovimientonormalMoléculasdeagua
FALLA
AlteraciónbombaNa-K-ATPEDEMACITOTOXICO
EntradadeCaRupturacelularEDEMAVASOGENICO
![Page 28: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/28.jpg)
Difusioneninfartosdearteriascerebralesposterior,anteriorymedia
§ ElmetodomassensibleparaelStroke§ EssensibleporlarestricciondelmovimientoBrownianodelmovimiento
delaguaextracelulardebidoaldisbalancecausadoporeledemacitotoxico
§ Normalmentelosprotonesdeaguaaenenlacapacidaddedifundirextracelularlmenteyporlotantopierdenseñal
§ Lahiperintensidadindicarestricciondelacapacidaddelosprotonesdeaguadedifundirextracelularmente.
![Page 29: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/29.jpg)
DIFUSIONRM
![Page 30: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/30.jpg)
DIFUSIONRM
![Page 31: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/31.jpg)
AGUDO
![Page 32: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/32.jpg)
INFARTO
T2
DIFUSION
MAPAADCCOEF.DEDIFUSIONAPARENTE
<6HS 3DIAS 7DIAS
30DIAS
ISOINTENSO
BRILLA
NEGRO
BRILLA
BRILLA
BRILLA
MUYBRILLANTE BRILLA
ISO
NEGRO
BRILLA
MUYNEGRO
![Page 33: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/33.jpg)
EVOLUCIONDELAINTENSIDADDESEÑALDELOSINFARTOSCEREBRALESENIMÁGENESDEDIFUSIONPORRM
HIPERAGUDO
AGUDO
SUBAGUDO
SUBAGUDOTARDIO-CRONICO
Casisiemprehiperintenso
Normal,ausenciadevacíodeseñal,Refuerzointravascular
HiperintensoSigdehiperagudo+HiperintcorIcal.BorramientodeLossurcos
<HiperintensoSeudonormalizacion2-3semanas
Signosdelestadoagudo+Realcemeningeoyparenquimatoso
NegaavaRealceparenquimatoso+
atrofia
PERIODO IMÁGENESENRMDIFUSION
![Page 34: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/34.jpg)
ZONALIMITROFECORTICALENTREACAYACM
ZONALIMITROFECORTICALENTREACPYACM
ZONALIMITROFEINTERNAENTREALEYACM
![Page 35: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/35.jpg)
PequeñosinfartoszonaslimitrofesProfundasycoracalesEntrelaACMYACPenellobuloizquierdo
![Page 36: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/36.jpg)
INFARTOSHEMORRAGICOS• Siconaenesangredentrodelas24hsdelictus• Seconsideraisquémicoysetransformóenhemorrágicosilasangreapareceentreel2-14díasdespuésdelictus
• Lamayoríasonelproductodeinfartosisquémicossubyacentes
• Reperfusiónrepenana“hemorragiaporirrupción”• Puedensercomplicaciónfrecuentedeemboliasépaca
• Necrosislaminar• Infartosvenos• EnTCsoloel5%sonhemorrágicosdesdeunprincipio• Enel15a50%deACVmasivos• TerritoriodelaACM
![Page 37: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/37.jpg)
![Page 38: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/38.jpg)
INFARTOSLACUNARES• PEQUEÑOSINFARTOSENLASZONASPROFUNDASDELENCEFALO
• GANGLIOSBASALES• TRONCOENCEFALICO• SUST.BLANCAPROFUNDA• 25%DELOSSTROKES• OCLUSIONDEUNARAMADELASARTERIASPENETRANTESPROFUNDAS
• BUSCARCAUSASCARDIACAS
![Page 39: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/39.jpg)
![Page 40: ACV - smiba.org.ar · B, A, Arrows show normal brownian motion in extracellular space with normal-size cells. motion. Failure of sodium-potassium-ATP pump leads to intracellular edema,](https://reader031.fdocuments.us/reader031/viewer/2022013016/5bb830af09d3f2687f8c63ba/html5/thumbnails/40.jpg)