| Affiliation |
(AGL) Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, Texas; Professor of Ophthalmology, Weill Cornell Medicine, New York City, New York; (BL) Class of 2021, Baylor College of Medicine, Houston, Texas |
| Transcript |
So, as you know when you take someone's pulse, you're really measuring the blood flow in the brachial arteries, and those come off the great vessels in your chest (it's different slightly on the right than the left side). If someone is pulseless (but they're still alive, they're not dead), if they're pulseless but they're still alive it usually means there's some more proximal occlusion in the brachial arteries. So, in the great vessels of the chest, coming off of the aorta, the right side and the left side look slightly different. On the right side we have a single trunk, the brachiocephalic, the brachial part is the part that's providing the brachial artery and the cephalic part of course is the carotid artery and the vertebral artery. Those are going to the intracranial circulation. On the left side, the common carotid artery comes directly off of the aortic arch and the subclavian on the left supplies the arm and is under your clavicle and becomes the brachial. The vertebral artery is coming off the subclavian on that side as well. So, when we have pulseless disease, we are missing the pulse and should be a sign to you that we have proximal disease in the great vessels of the chest. So, the thing that comes to neuro-op is when you have inflammation in those arteries and that is arteritis and because these are very big arteries it's going to be a large vessel arteritis. So, the large vessel arteritis that we see in neuro-op in elderly patients is of course Giant Cell Arteritis and in young patients, Takayasu Arteritis. So, both Giant Cell Arteritis and Takayasu arteritis are large vessel vasculitis that can produce pulseless disease. The most common disease that we see when someone is pulseless, if they're alive, is pulseless disease and the most common cause of pulseless disease in a young person is Takayasu Arteritis and an old person is Giant Cell Arteritis. Both have diagnostic criteria-for Giant Cell Arteritis of course we're going to do a temporal artery biopsy, they're both going to have elevated acute phase reactants because they're both arteritis, so they both have elevated sed rate and CRP. But, Takayasu arteritis usually is going to stay in the aorta and its branches, including the lower branches of the aorta, whereas Giant Cell Arteritis has a predilection for the scalp, the external carotid artery branches, and the ophthalmic, and not so much for the intracranial lesions, even though temporal arteritis can appear in any part of your body. So, if you've got someone who's got the history of pulseless, think about pulseless disease: if they're young, less than 40, think Takayasu, if they're old, greater than 50, then Giant Cell Arteritis. If GCA, a temporal artery biopsy and you should know a little bit about the anatomy of the great vessels in the chest. |
