Maria Blasich, Maria Rosaria De Simone*, Fausto Passariello, Fernando Schiraldi,
Vincenzo Vitiello*
Div. di Medicina d'urgenza, Osp. S. Paol, *Div. di Neurochirurgia, Osp. N. Pellegrini, Napoli
Italy

The clinical conditions of the patient often do not allow a direct anamnesis, so that companions must be interrogated, pointing the attention on:

1. Age, habits, familiarity for cardiovascular and dismetabolic diseases
2. Concomitant diseases of other systems or peculiar to CNS
3. Onset modalities of the ongoing disease
4. Usual drug assumption
5. Recent laboratory and instrumental examinations
 
 

It is useful to remind that in most cases there are two onset modalities of the neurological deficit.

• an ICV produced by occlusive vascular events, sometimes with a progressive evolution;
• a more speedily worsening ICV, consequence of a cerebral embolism (often connected to left heart valve disease or to chronic atria fibrillation) or of an intra-cerebral or sub-arachnoid haemorrhagic event.

Though the Glasgow Coma Scale is indicated as a reliable evaluation of cranial trauma patients, its application could be useful in not traumatic pathology, i.e. also in subjects with acute cerebrovascular insufficiency, because it could allow the serial evaluation, a reliable one also if not performed by medical personnel (Tab 1); it is also interesting to note that more than 8 scores have in 85% of cases a favourable "quoad vitam" prognosis, while less than 5 scores are joined to 97% of death or persistent vegetative state. An "essential" neurological evaluation should always be performed in E.R. also by not neurologists; the posture (decerebrated/decorticated, obliged head deviation ...), myoclones, meningeal as well as palpebral, ocular, pyramidal signs, breath characteristics, vomiting, bradycardia, arterial hypertension, halitosis characteristics can guide the diagnostic orientation and the first therapeutic approach, while waiting for instrumental examinations.
 
 

At the onset of an episode of acute cerebrovascular insufficiency, independently of "oriented" therapeutic choices ( of specialist kind), a common path can be devised, which can be practised in most cases, with the aim of guaranteeing a first "stabilisation" of the patient. A minimal and correct approach should always guarantee a sufficient supply of O₂, blood flow and glucose.
1. Airways patency must be controlled and guaranteed, taking in account the possibility, in an unconscious patient, of the lack of defence reflexes of airways or of the posterior fall of the tongue with retro-pharyngeal obstruction (safety position, Guedel oro-pharyngeal tube, eventual frequent oro-tracheal aspiration, nose-gastric tube).
2. Respiratory activity must be monitored, as the Acid Base Balance (ABB), because it is frequent to observe a tendency to respiratory alkalosis, not very dangerous by itself; but hypoxemia and/or hypercapnia are also possible, for concomitant pathologies, which are of course harmful to the cerebral function.
3. The haemodynamic equilibrium is a target of great importance, because in presence of an episode of acute cerebrovascular insufficiency the encephalon looses its auto-regulation capability: cerebral blood flow becomes directly dependent on the perfusion pressure (CPP), which is dependent on the mean arterial pressure (MAP) and on the mean intracranial pressure (MICP) as follows:

In absence of sophisticated and invasive monitoring procedures, a reasonable target could be that of sustaining arterial pressure values between 120 and 160 mmHg of systolic value and below 90 mmHg of diastolic value, starting with short mean life time drugs, to allow frequent adjustments of dose, comparing to clinical evolution. The most strictly cardiac aspect is as well significant, owing to the importance of the cardiac output to guarantee the supply of O₂ (DO₂) to vital organs, in conformity with the equation:

where C.O. means cardiac output and CaO₂ is the O₂ arterial content, depending on PaO₂ and hemoglobinemia
4. Hydro-electrolytic balance is another primary point of interest, whether for the influence of plasmatic concentrations of K+, Ca++ and Mg++ on neuro-muscular eccitability (pay attention to forced diuresis!) or above all for the potential of natriemia and plasmatic osmolarity on the neuronal cito-architettonics; it is well known that neurones - in conditions of reduced energy availability - behave as osmometers. So during the acute cerebrovascular insufficiency it should be useful to avoid whether hypo-natriemia (which could increase cellular swelling) or the hyper-tonic dehydration , which draining water out of neurones could cause biochemical and morphological damages to neurones.
5. Other relatively recent therapeutic approaches (possible use of Ca-blockers) or the most recent ones (forced anti-aggregation, thrombolysis) are at the moment under discussion and clinical experimentation, in specialist environments.
 
 

Between the factors which can significantly influence the evaluation and the prognosis in an ICV patient, nursing quality plays a prevalent role. In extreme synthesis, the key points of a good nursing should take in account the necessity:
1. of improving the communication level between the personnel, the patient and the relatives: in ICV the problem becomes more complex owing to the insufficient perceptive capabilities of the patient, in part a solvable problem paying a greater attention to not verbal communication.
2. of inspiring into relatives and, whether it is possible, into the patient a feeling of assurance and reliability, which can significantly reduce anxiety and uncertainty, which would surely have a negative influx. As to this, it is a good point of reflection to consider how often we speak about the patient and how little to the patient.
3. Informations about fluid balance, abdomen, consciousness and on main vital parameters, reported on the nursing schedule and referred to the physician, contribute surely to an optimal management of our patients.
 
 

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