DIAGNOSIS AND TREATMENT OF CEREBROVASCULAR DISEASE

The neurological examination is fundamental for the diagnosis; further observations were undertaken to confirm the diagnosis. Recently, computerized tomography (CT) has been employed making it possible to differentiate cerebral hemorrhage and cerebral infarction by non-invasive techniques. However, diagnosis of hemorrhage due to ruptured aneurysm and localization of the occluded point of the artery in cerebral infarction still must depend on cerebral angiography. As the utilization of CT is limited, the neurological examination must be considered the fundamental procedure for the diagnosis.We have observed nearly 1250 cases of cerebrovascular disease in Mihara Memorial Hospital during last 5 years. Cerebral infarction accounted for approximately 50% of the cases, followed in frequency by cerebral hemorrhage (30%) and subarachnoid hemorrhage (10%).In our study of 300 cases of cerebral hemorrhage, putaminal hemorrhage accounted for 60% of the cases, thalamic bleeding for 26% and other site for 14% respectively. Among the other sites, pontine hemorrhage and cerebellar hemorrhage were found in a almost the same number and subcortical hemorrhage was less frequent than the above mentioned two. I would like to make special comment about the clinical diagnosis of putaminal and thalamic hemorrhage. We made up our criteria for these diagnosis according to the disturbance of consciousness and grade of paralysis. When the disturbance of consciousness is absent or in slight degree, the diagnosis is made on the basis of the presence at the thalamic syndrome which is confirmed in cases of incomplete paralysis. However, thalamic bleeding is diagnosed when Parinaud's sign is present, and putaminal bleeding is suspected when the thalamic syndrome is absent and aphasia is observed due to lesion in the dominant hemisphere. When there is moderate or severe disturbance of consciousness, putaminal bleeding is indicated by the presence of contralateral deviation of the eyes. Signs such as biocular deviation of the eyes inward and downward, loss of light reflex, or deviation to the “wrong side” in severe cases were considered to indicate thalamic bleeding.In a randomized study by cerebral angiography in 300 cases of cerebral infarction, the number of cases with occlusion, with stenosis, and without occlusion or stenosis each accounted for approximately one third of the total. Among the cases with occlusion, occlusion of the middle cerebral artery was most frequently observed followed by occlusion of the internal carotid artery.Treatment : Surgical procedures include evacuation of hematoma, in cases of putaminal hemorrhage, cerebellar hemorrhage and subcortical hemorrhage. Thalamic hemorrhage is not the object of evacuation. In cases of cerebral thrombosis, superficial temporal artery-middle cerebral artery anastomosis is considered to be effective in some instances, although final evaluation is still not completed and will require more clinical experience. Endoarterectomy of the internal carotid artery is performed in some cases of transient ischemic attacks. A comparative study of medical (79 cases) and surgical (175 cases) treatment of putaminal hemorrhage was evaluated. In cases of moderate to large hematoma showing ventricular hemorrhage and with a disturbance of consciousness between stupor and semicoma, surgical treatment was significantly better than conservative treatment in improving both activities of daily living and mortality rate.