Definition   It is a slow evolution pathology, characterized by the gradual deposition of fat (cholesterol) and platelets in the carotid artery, which is the main irrigation vessel on each side of the brain, thus forming an atherosclerotic plaque on the vessel wall, promoting, with its evolution : A) decreased blood flow to the brain; B) total occlusion of the affected vessel; C) release of small fragments of this plaque, leading to the closure of vessels of smaller caliber that irrigate the brain (thromboembolism).   Risk factors A) Sedentary lifestyle B) Smoking C) High blood pressure D) Diabetes E) Dyslipidemia (High Cholesterol) F) Obesity G) Family history   People with a history of coronary heart disease have an increased risk of developing carotid disease.   Symptoms Most people affected by this pathology will only present symptoms when they are at an advanced stage of the disease, thus promoting a significant change in blood flow which will lead to a transient ischemic attack (TIA) or stroke (ischemic stroke).   The main signs and symptoms are: A) Drowsiness B) Decreased force on the face and limbs C) Sudden change in speech and comprehension D) Sudden vision problems (in one or both eyes) E) Dizziness or loss of balance   Diagnostic Tests A) Doppler B) AngioTC C) MRI and AngioRN D) Diagnostic cerebral arteriography   Treatment The major goal is to minimize the possibility of a stroke, varying its options according to the aggressiveness and stage of the disease. Treatment requires a combination of factors that involves lifestyle changes, medications and in some cases surgical procedures.   The treatment variations are: A) Medication - Antiplatelet agents: AAS, Clopidogrel and Ticlopidine are used to decrease thrombus formation, also favoring blood flow. - Statins: promote cholesterol control by decreasing plaque formation. - Antihypertensives: control blood pressure as an important risk factor for the occurrence of strokes. B) Surgical - Endarterectomy: A conventional surgical procedure consisting of mechanical removal of the plaque that promotes the reduction of vessel size. - Angioplasty: an endovascular procedure that searches through the implantation of stent and use of balloons to restore the normal caliber of the vessel affected by the atheromatous plaque.

Definition   It is characterized by being an abnormal tangle of vessels that promotes a direct connection between the arterial vessels and the veins, without the capillary interface, being thus a system of greater fragility that is under greater pressure.   Veins are not structures designed to receive blood under pressure, so as a form of adaptation, they become more calibrous and tortuous. The fragility points of these points that are not prepared for the blood under pressure may eventually rupture and cause bleeding (intracranial hemorrhages); Or may develop small aneurysms. The normal tissue surrounding the malformation may undergo changes in its normal functioning due to the so-called "steal" of flow, causing the arterial blood to go to the AVM and thus does not adequately irrigate the brain tissue.   Symptoms Symptoms may vary depending on the type of malformation, its location, and its size. Most commonly, the most extensive AVMs present with seizures and headache, while the smallest are mostly asymptomatic, usually being diagnosed on routine exams or after hemorrhagic phenomena.   The risk of bleeding from an AVM is around 2-3% per year, with a morbi / mortality rate of 10-30%. It is important to note that once a hemorrhagic phenomenon occurs, the patient has increased to about 13% the chance of a further hemorrhage during the first year.   Diagnosis Diagnostic exams are important to determine the location, size and type of the malformation, as well as assist in the assessment of the nearby brain structures that correlate with AVM.   The exams are:

• Computed tomography
• Nuclear magnetic resonance
• Cerebral arteriography

  Treatment Treatment options can range from the conservative option to aggressive surgical procedure, depending on the type, symptoms and location of the malformation.   Intracranial microsurgery, endovascular procedures and radiosurgery are therapeutic options that can be used as a single treatment or combined for the resolution of a cerebral AVM.

Definition   Subarachnoid hemorrhage (SAH) is a type of stroke characterized by the presence of blood in a space around the brain. SAH can be caused by rupture of an aneurysm, AVM, or head injury; And its treatment consists in the control of bleeding and prevention of vasospasm.   What happens? The subarachnoid space is an area between the brain and the skull, which is filled with Cerebrospinal fluid (CSF).   When blood is present in this space it promotes an irritation reaction, increasing intracranial pressure and injuring nerve cells. About 80% of SAH's are caused by ruptured aneurysms.   These inflammatory reactions and the increase of the intracranial pressure lead, in last stay, to a difficulty in supplying oxygen to the brain, resulting in the death of nervous tissue, when not properly treated.   Symptoms If you or someone close to you experiences any of these symptoms, please contact the medical help immediately:

• Severe onset headache (usually described as having the worst headache of my life).
• Nausea and vomiting
• Photophobia (visual sensitivity to light).
• Double or blurred vision.
• Loss of consciousness
• Convulsions.

  Causes About 11 out of 100,000 people will present SAH every year, being more common in females in the 4 and 5 decades of life. The main causes of spontaneous SAH are: cerebral aneurysms and arteriovenous malformations.   Diagnosis A correct and complete neurological examination is the ideal principle for correct diagnosis of an SAH. The most indicated imaging tests that will aid in the investigation of hemorrhage are:   A) Computed tomography: This is a non-invasive test that has excellent sensitivity in the first 48 hours in the diagnosis of SAH. It can be complemented with AngioTC that guides in the etiologic diagnosis of hemorrhage when diagnosed. B) Lumbar puncture: Invasive procedure consisting of the collection of liquor and its evaluation both ectoscopic and laboratory. It is a gold standard examination in the diagnosis of SAH, and should always be performed when the patient has any of the suggestive symptoms but the CT scan does not show blood image. C) Angiography: Invasive examination in which selective catheterization of cerebral vessels is performed and its evaluation through contrast injection.   Treatment With the diagnosis of SAH intensive and targeted treatment is imperative since the mortality rate is very high (50%).   The patient should be directed to the neurointensive unit receiving neurological monitoring and cardiocirculatory parameters.   Rescue measures consist of alleviating the symptoms present, preventing premature new bleeding, and monitoring possible complications such as vasospasm and hydrocephalus.   If the SAH occurred due to the rupture of an aneurysm the surgical treatment becomes essential, having as main goal the occlusion of the aneurysm and the extinction of the possibility of further bleeding.

Definition   Aneurysms are characterized by being saccular structures that form on the vessel walls, especially the arterial ones, in which the elastic layer is not found, making them extremely fragile and susceptible to ruptures. The risk of rupture is related to the size, shape and location of the aneurysm, being treatment options: observation, microsurgical clipping and embolization.   Incidental cerebral aneurysms Aneurysms can occur at any location in the carotids and vertebrae, being more common in areas of bifurcation of these vessels. These are common sites of aneurysm occurrence: - Internal carotid segments - Middle cerebral artery - Anterior cerebral artery - Basilar artery - Vertebrobasilar junction   Thus we have that 80% of the aneurysms occur in what we call posterior circulation, while 20% occur in the vessels of the posterior circulation. Anatomically we can classify aneurysms according to their origin in the vessel: - Sacrum: It is the most common type, originating from one side of the artery, usually having a well-defined colon as its base. - Fusiform: The aneurysm originates in several places of the arterial parade, not being evident a lap of origin. - Dissecting: When we show a lesion in the arterial wall promoting the origin of a second light in the vessel.     Symptoms Common symptoms are:

• Double vision
• The pupil dilated (in only one eye)
• The headache
• O Changing the field of view.

  Causes In addition to smoking, family history has an important correlation with the possibility of occurrence of cerebral aneurysms.   In this risk group, noninvasive tests with AngioTC and AngioRN are indicated for screening.   Other conditions related to the occurrence of cerebral aneurysms are: Marfan syndrome, neurofibromatosis and polycystic kidney.   Incidence About 5% of the population is at risk of developing the pathology and having it diagnosed in imaging tests, with 20% of these individuals having more than 1 aneurysm. Within different ethnicities we will have different incidence rates of the pathology, correlating to this also the lifestyle of these populations. It is a more common disease of the third to sixth decade of life and more present in females.   Diagnosis Most people who discover that they have an incidental brain aneurysm (which has not ruptured) make this diagnosis during the research related to complaints related to other problems. They are then referred to a neurosurgeon.   The tests that most commonly aid in the diagnosis of these aneurysms and provide important information about the size, location, shape and relationship with the brain structures are: A) BRAIN ANGIOTOMOGRAPHY B) ANGIO BRAIN RESONANCE C) BRAIN DIGITAL ARTERIOGRAPHY   Treatment The decision as to the treatment or not of an incidental cerebral aneurysm basically involves the evaluation of the risk of rupture against the risk of the surgical procedure involved. The risk of rupture, in general, is around 1%, with a 50% mortality rate. There are factors related to the rupture of aneurysms: smoking, hypertension, alcohol use and genetic factors.   The treatment options we currently have available are: A) OBSERVATION Very small aneurysms in asymptomatic and healthy patients may present a greater surgical risk than the risk of rupture, and follow-up is indicated by imaging tests in these cases. B) MICROCIRURGICAL CLIPPING The oldest type of treatment, in which the patient under general anesthesia performs the opening of the skull, dissection of the brain and exposure of the aneurysm; Following the placement of a clip that will close the base of the aneurysm. C) ENDOVASCULAR TREATMENT. Performed in a hemodynamic room, embolization represents the most modern and least aggressive treatment of cerebral aneurysms. It is based on catheterization of the cerebral vessels until the aneurysmal sac is reached, and platinum coils (coils) are then deposited which will promote occlusion of the aneurysm and preservation of blood flow in the other vessels.