stroke
・Apoplexy or stroke collectively refers to sudden disturbance of consciousness and other neurological abnormalities due to damage to the cerebrovascular system.
・Stroke includes subarachnoid hemorrhage, cerebral infarction (cerebral thrombosis, cerebral embolism), and intracerebral hemorrhage. This page provides an overview of subarachnoid hemorrhage, cerebral infarction, and cerebral hemorrhage.
・Risk factors for stroke include hypertension, diabetes, hyperlipidemia, smoking, heavy drinking, and stress.
・ Even in the chronic stage, there are many sequelae such as consciousness disturbance, aphasia, hemiplegia, and gait disturbance, and rehabilitation, whole body management, and long-term care are required.

subarachnoid hemorrhage
・In Japan, it occurs in 10 to 20 people per 100,000 people per year. The male-to-female ratio is 1:1.5, which is more common in females, and 95% of them are caused by ruptured cerebral aneurysms.
・In descending order, anterior communicating artery (30%) ≒ bifurcation of posterior communicating artery of internal carotid artery (30%) > bifurcation of middle cerebral artery (13%) > vertebrobasilar artery (6%).
・In subarachnoid hemorrhage due to cerebral aneurysm rupture, 10-15% die immediately upon onset, and 20-30% die even after receiving treatment at a hospital, making this a very life-threatening disease. .
・ Once a cerebral aneurysm has been torn, it is unlikely that life will be saved if it is torn again.
・ To prevent rerupture, rest, administration of sedatives and analgesics, administration of hemostatic agents, blood pressure control, etc. are important, and craniotomy clipping and endovascular surgery (cerebral aneurysm coil embolization) are performed as surgical treatments. .
・From the 3rd to 14th day after subarachnoid hemorrhage occurs, the cerebral arteries become thinner and thinner due to spasm substances in the blood and cerebrospinal fluid circulatory disturbance. During this period, increase fluid transfusions and administer prophylactic drugs (antiplatelet agents, statins, fasudil hydrochloride) to prevent cerebral infarction. If the cerebral arteries are still narrowed beyond their limit, the arteries must be widened by endovascular treatment.
・The brain floats in the cerebrospinal fluid, but when subarachnoid hemorrhage occurs, this cerebrospinal fluid becomes cloudy and difficult to absorb. The condition in which cerebrospinal fluid accumulates in the brain is called hydrocephalus. Hydrocephalus can be treated with ventricular drainage in the acute phase and with ventriculoperitoneal shunt surgery in the chronic phase.
・Aneurysms ruptured at the top of the basilar artery often have branches to the midbrain protruding from the aneurysm. ), endovascular surgery (cerebral aneurysm coil embolization) is performed. In this way, depending on the location of the aneurysm, cerebral endovascular surgery may be easier to perform, but on the other hand, craniotomy clipping may be better in some cases, such as middle cerebral aneurysm.
・If the aneurysm diameter exceeds 10 mm, it is called a large aneurysm, and if it exceeds 25 mm, it is called a giant aneurysm. Large aneurysms are difficult to treat with both clipping and endovascular surgery.

cerebral infarction
・Occlusive cerebrovascular disease is divided into (1) transient ischemic attack (symptoms disappear within one day, called TIA: transient cerebral ischemic attack), and (2) Progressive apoplexy (symptoms progress and worsen, and about 10% of all ischemic strokes fall into this category. Even if you are hospitalized and receive IV treatment, your symptoms may worsen, which may lead to distrust of medical care.), (3) It is classified as a completed stroke (one in which symptoms are completed in one attack).
・Cerebral infarction is caused by atherothrombosis, which is caused by narrowing of blood vessels due to arteriosclerosis (atherosclerosis), and cardiogenic brain, which is caused by blood clots formed in the heart due to arrhythmia, etc. Embolism, lacunar infarction caused by clogged arteries at the tip of the branching branches of the brain (less than 15 mm in brain MRI, lacunar means "small hole"), and relatively large cerebral infarction caused by blockage of thick perforating arteries. BAD: branch atheromatoous disease, and hemodynamic cerebral infarction that occurs when thick arteries narrow due to arteriosclerosis and blood flow disturbance occurs beyond them.
・If the symptoms of cerebral infarction appear within 4.5 hours, a thrombolytic agent (tPA: tissue-type plasminogen activator, can be used for both embolism and thrombosis) is administered. 30-40% of people who receive this treatment are able to walk home, but complications such as cerebral hemorrhage occur in 6%. In the acute phase of occlusion of large blood vessels in the brain, if the DWI of the brain MRI shows a high signal but the FLAIR shows an equal signal (diffusion-FLAIR mismatch), thrombectomy may be considered for cerebral endovascular treatment.
For cerebral thrombosis, in addition to administration of anticoagulants (heparin or argatroban) and antiplatelet agents (ozagrel sodium), infusions, plasma substitutes (low-molecular-weight dextran), and cerebral protective agents (edaravone) are administered. .
・Surgical treatment to prevent recurrence of cerebral infarction includes bypass surgery from the external carotid artery system to the internal carotid artery system (superficial temporal artery-middle cerebral artery anastomosis = STA-MCA anastomosis) and endarterectomy of the internal carotid artery.
・In the chronic phase, in the case of embolism, anticoagulants (warfarin, Pradaxa, Xarelto, etc.), in the case of thrombosis, oral antiplatelet agents (clopidogrel, cilostazol, aspirin). Eliminate it (treat hypertension, diabetes, hyperlipidemia, improve lifestyle habits).

intracerebral hemorrhage
Classification
1)Hypertensive intracerebral hemorrhage,
2)Intracerebral hemorrhage due to organic disease (e.g. aneurysm rupture, cerebral arteriovenous malformation (AVM) bleeding, bleeding from hemangioma, bleeding from other tumors, etc.),
3)Bleeding due to abnormal coagulation (liver failure, renal failure, patients on dialysis, hemophilia, DIC, etc.)
・Hypertensive intracerebral hemorrhage can be prevented from recurring by imroving lifestyle habits and treating hypertension, diabetes, and hyperlipidemia. I have.
・Hypertensive intracerebral hemorrhage is commonly seen in the following order: putaminal hemorrhage > thalamic hemorrhage > (subcortical blood) > cerebellar hemorrhage > pontine hemorrhage.
・For putaminal hemorrhage, cerebellar hemorrhage, and subcortical hemorrhage, craniotomy may be performed for large cases. In particular, cerebellar hemorrhage may result in cerebral herniation even with a diameter of about 3 cm, and is subject to emergency surgery.
・Thalamic hemorrhage tends to perforate the 3rd ventricle from the site, and even a small hemorrhage may cause hydrocephalus. If hydrocephalus is complicated, ventricular drainage is performed (ventriculoperitoneal shunt is performed in the chronic stage).