LESSON № 7 (PRACTICAL – 6 HOURS)
Theme:
Cerebral vascular diseases of the Brain and Spinal cord. Initial signs of cerebral vascular insufficiency. Dynamic disorders of cerebral circulation (Transient Ischemic Attack (TIA), hypertensive crisis, acute hypertonic encephalopathy (AHE)), Ischemic stroke, Chronic cerebral ischemia – dyscirculative encephalopathy (DE).
Aim: To study etiology and pathogenesis of transient disturbances of cerebral circulation, clinical characteristics and the maieurological signs of TIAs, AHE, etiology and pathogenesis of strokes, clinical characteristics and the maieurological signs of strokes, which are necessary to put a correct diagnosis and to administer emergency treatment of acute disturbance of the cerebral circulation. To be able himself to make correct topical, clinical diagnosis and prescribe adequate treatment.
Professional orientation of students: diseases of the blood vessels are the most important neurological problem of adults in the world and especially in Ukraine. Stroke ranks first as the cause of death in the adult population in
Methodology of Practical Class (09.00-12.00)
Algorithm of students’ communication with patients with pathology in subject (communication skills):
Complaints and anamnesis taking in patients
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing
4. Find a contact with a patient, try to gain his/her confidence
5. Correct inquest, listening to the patient’s explanation.
6. Conversation accomplishment.
Physical methods of examination
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing
4. Find a contact with a patient, try to gain his/her confidence
5. Explain to the patient the nessessity of the examination and its aim, get his/her informed consent
6. Explain to the patient examination details, its safety and possible sensations
7. Prepare for the examination (clean, warm hands, ets.)
8. Explain to the patient results of his/her tests correctly and accesibly
9. Conversation accomplishment.
Informing about the results of examination
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing
4. Interpretation of test results
5. Calm a patient in the case of precense of pathological changes, inform about the following actions
6. Assure in positive changes and favourable prognosis at implementation of all of the medical recommendations
7.Conversation accomplishment
Work 1.
Cerebral vascular diseases of the Brain and Spinal cord. Initial signs of cerebral vascular insufficiency. Dynamic disorders of cerebral circulation (Transient Ischemic Attack (TIA), hypertensive crisis, acute hypertonic encephalopathy (AHE)), Ischemic stroke, Chronic cerebral ischemia – dyscirculative encephalopathy (DE)
Step I. Aim: To make the clinical diagnosis. For this purpose it is necessary:
To determine types of acute disorders of the cerebral circulation.
To determine Carotid or Vertebrobasilar vessels distribution.
To find the reasons to cause disorders of cerebral circulation.
To formulate the diagnosis, for example:
TIA in Left Carotid Distribution from cerebral atherosclerosis and hypertensive disease, stenosis of the left vertebral vessel
DE III st (intracerebral subarachnoid hemorrhage – aneurysm of cerebral vessel’s, 1995 y)
To determine types of stroke.
To determine Carotid or Vertebrobasilar vessels distribution.
To find the reasons to cause disorders of cerebral circulation.
To find the periods of stroke.
To formulate the diagnosis, for example:
Ischemic atherothrombotic stroke in Left Carotid Distribution from cerebral atherosclerosis and Hypertensive disease, acute period.
Step II. Aim: Administer emergency treatment. For this purpose it is necessary to choose:
1. emergency therapy of TIAs.
2. differentiated emergency therapy of hypertensive crisis.
3. rehabilitation and prophylactic programs for cerebrovascular patients.
4.Undifferentiated emergency therapy of strokes.
5. Differentiated emergency therapy.
Step III. Aim: To conduct expert-preventive measures. Outgoing from the clinical diagnosis and taking into account effectiveness of treatment to form prognosis, providing of preventive measures, to provide expertise of workability, military-medical expertise.
Individual Students Program
You should be prepared for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:
Theme 1. Cerebro-vascular diseases
Epidemiology of transient disturbances of cerebral circulation.
1. The components of the stroke-phone profile.
2. Etiology and pathogenesis of TIAs.
3. Clinical classification of cerebrovascular diseases.
4. Clinical characteristic and main vascular signs of:
a) Transient disturbances of cerebral circulation
b) acute hypertonic encephalopathy (AHE)
c) dyscirculative encephalopathy (DE)
5. Examination program.
a) to determine pathological focus in acute phasis.
b) special methods of neurological paraclinical examinations (EEG, CT-Scan, arteriography, lumbar puncture ets.)
c) to make a correct clinical diagnosis
6. Emergency therapy of TIAs.
7. Differentiated emergency therapy of hypertensive crisis.
9. Differentiated emergency therapy of acute hypertonic encephalopathy.
10. Follow-ups of acute disturbance of the cerebral circulation.
11. Epidemiology of strokes.
12. The components of the stroke-phone profile.
13. Etiology and pathogenesis of strokes. The risk factors of ischemic stroke.
14. Clinical characteristic and main vascular signs of ischemic stroke.
a) cardioembolic, b) atherothrombotic, c) hemodynamic, d) hemorheologic, e) lacuna
15. Examination program.
– to determine pathological focus in acute phase
– special methods of neurological paraclinical examinations (EEG, CT-Scan, arteriography, lumbar puncture ets.)
16. Undifferentiated emergency therapy of strokes.
17. Differentiated emergency therapy of infarction of the brain.
18. Follow-ups of acute disturbance of the cerebral circulation.
Seminar discussion of theoretical issues (12:30-14.00).
Test evaluation and situational tasks
Tests
1. Clinical differentiated signs between transient ischemic attack and ischemic stroke.
2. Clinical differentiated signs between cerebral hypertensive crisis and subarachnoid hemorrhage.
3. When can we localize the pathological focus of apoplectic stroke (or in which stage of process)?
4. Clinical differentiated signs of acute disturbances of the cerebral circulation from stenosis and occlusion includes of magistral cerebral artery.
5. What is the optic-pyramidal syndrome?
6. What is the main reason of Valenberg-Zaharchenko’s sign?
7. Name three main reasons of acute disturbances of the cerebral circulation.
8. The deficit signs of anterior cerebral artery distribution.
9. The deficit signs of median cerebral artery distribution.
10. The deficit signs of posterior cerebral artery distribution.
11. The deficit signs of vertebrobasilar distribution.
12. The components of the stroke-phone profile.
13. Name agents which reduce cerebral edema.
14. Name anticoagulation agents of therapy.
15. Name vasodilators.
16. Name agents which decrease blood pressure.
17. Name platelet inhibition therapy.
18. Name the metabolic agents.
19. Name the calcium antagonists.
20. The deficit signs in spinal vessels distribution.
21. Variants of spinal cord circulation.
22. Types of ischemic stroke.
23. Periods of stroke.
24. Stages of acute period of stroke.
25. Clinical differentiated signs of ischemic stroke.
26. Clinical differentiated signs of ischemic cardioembolic stroke.
27. Differentiated emergency therapy of atherothrombotic stroke.
28. Undifferentiated emergency therapy of strokes in acute stage.
29. Therapy of strokes in chronic stage.
Multiple Choice.
1. What are the main causes of acute disturbances of the cerebral circulation?
a) Atherosclerosis
b) Hypertensive disease
c) Atherosclerosis and hypertensive disease
d) Age, sex and race
e) Chronic stress
2. What are the differentiated signs between transient ischemic attack and ischemic stroke?
a) local neurological signs are absent
b) local neurological signs may be present for minutes or hours before stroke
c) local neurological signs may be present for minutes or hours but not more than 24 hours
d) TIA and ischemic stroke haven’t differentiated signs
e) If the local neurological signs are present – it is ischemic stroke
3. What groups of medicine are used for treatment of acute disturbances of the cerebral circulation?
a) Anticoagulation medicines.
b) Surgery benefits the patients with occlusion of one carotid.
c) Agents which reduce cerebral edema.
d) Cerebral vasodilators and calcium antagonist, which may help to reduce cerebral arterial spasm.
e) All answers are true.
4. What are the main causes of strokes?
a) atherosclerosis
b) hypertensive disease
c) atherosclerosis and hypertensive disease
d) age, sex and race
e) chronic stress
5. What are the differentiated signs between cerebral hypertensive crisis and subarachnoid hemorrhage?
a) local neurological signs are absent
b) local neurological signs may be present for minutes or hours before stroke
c) local neurological signs may be present for minutes or hours but not more than 24 hours
d) cerebral hypertensive crisis and subarachnoid hemorrhage haven’t differentiated signs
e) grossly bloody in cerebrospinal fluid (CSF)
6. What groups of medicine are used for treatment of both types of stroke?
a) anticoagulation medicines.
b) surgery benefits the patients with occlusion of one carotid.
c) agents which reduce cerebral edema.
d) cerebral vasodilators and calcium antagonist, which may help to reduce cerebral arterial spasm.
e) all answers are true.
Real-life situations to be solved:
1. Verbal production of the patient is decelerated, blocked and impaired. Where is the focus of the stroke?
a) in the region of anterior cerebral artery
b) in the region of median cerebral artery
c) in the region of posterior cerebral artery
d) in the region of posterior cerebellar artery
e) in the region of thalamus vessels
2. The patient has headache which spread all over the head, a loss of sensation and strength of movements in the left extremities. Examination has relived central hemiparesis in the left side. There is increased muscular tone and tendon reflexes and Babinski sign on the paralyzed limb. Where is the focus of the acute disturbances of the cerebral circulation?
a) the region of anterior cerebral artery
b) in the region of median cerebral artery
c) in the region of posterior cerebral artery
e) in the region of posterior cerebellar artery
d) in the region of thalamus vessels
3. The patient has acute headache on the back of the head, which were accompanied by dizziness and vomiting and meningeal syndrome. But other local neurological signs are absent. What type of stroke has been occurred in patient?
a) ischemic embolic stroke
b) ischemic thrombotic stroke
c) subarachnoid hemorrhage
d) intracerebral hemorrhage
e) ventricular hemorrhage.
Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.
Student should know:
1. Etiology and pathogenesis of strokes.
2. Clinical classification of cerebrovascular diseases.
3. Clinical characteristic and main vascular symptoms of the acute disturbances of the cerebral circulation.
4. Clinical characteristic and main vascular symptoms of the chronic disturbances of the cerebral circulation.
5. Examination program for these patients.
6. Clinical characteristic and main vascular symptoms of the ischemic stroke.
7. General examination scheme of a neurological status.
8. Anatomy of nervous system and special symptoms of lesion different parts.
9. Clinical features of neurological diseases.
10. Basic diagnostic procedures and treatment of neurological diseases.
Student should be able to:
1. Examine the patients with acute and chronic disturbances of the cerebral circulation.
2. Examine the patients with stroke
3. Make a correct topical diagnosis
4. Make a correct clinical diagnosis
5. Administer emergency treatment
6. Diagnose the neurologic diseases.
Correct answers of test evaluations and situational tasks:
Multiple Choice:
1. c.; 2. c.; 3. e., 4. c; 5. e; 6. d.
Real-life situations:
1. b.; 2. b.; 3. c.
Independent work of students (14:15-15:00).
References:
А – Basic:
1. WEB-site of tdmu.
Material for practical classes
2. Merritt’s Textbook of neurology.- 7th edition.- Edited by Lewis P. Rowland.
3. Neurology for house officer.- 3th edition.
В – Additional:
4. Handbook of Symptom Oriented Neurology/ William H. Olson, Roger A. Brumback, Generoso Gascon, Vasudeva Iyer, Year book medical publishers, inc.
5. Cerebrovascular disease: research and clinical management.- H. Lechner, J.S.Meyer and e. ott editors, Volume 1, 1986
6. Neurology in lectures. Textbook. Edited by the head of Neurology Department – prof. S.І. Shkrobot. – 2007.
Methodical instruction has been worked out by: dotsent N.R. Sokhor
Methodical instruction was discussed and adopted at the Department sitting
29.05.2013 . Minute № 9
Methodical instruction was adopted and reviewed at the Department sitting
__________201 . Minute № ___