（参考课件）颈动脉夹层.ppt

颈动脉夹层,1,动脉夹层的定义,动脉剥离(arterdissection)是血液进入动脉壁形成血肿或动脉壁内自发性血肿,使血管壁间剥离,导致动脉管腔狭窄或血管破裂如果形成瘤样突起，称为夹层动脉瘤(dissectinganeurysm),2,动脉夹层模式图,TheNeurologist2008;14:6673,3,颈动脉夹层的模式图,NEnglJMed.200122;344(12):898-906,4,病例分享,5,病例分享,6,病例分享,Neurosurgery.43(2):357-359,7,病例分享,8,病例分享,9,DSA常见征象,10,卒中或者TIA的发病机制,栓子？血流动力学？,11,TCD栓子监测,Stroke.1996;27:1226-1230,12,影像学特点与发病机制,Stroke.1998;29:2646-2648.,13,抗栓开始和结束的时间,14,局部症状和缺血的时间间隔,Stroke.1995;26:235-239,15,抗栓治疗的时限,动脉夹层最初36个月有再发卒中的风险6个月后很少再发,16,颈动脉夹层抗凝vs抗血小板,17,很多学者倾向于抗凝,Stroke.2007;38:2605-2611,18,19,2008meta-analysis,MedlineandPubMedweresearchedfrom1966to8April2007cervicalarterydissection34non-randomisedstudies762patients,JNNP,2008;79;1122-1127,20,Outcome:Stroke,JNNP,2008;79;1122-1127,21,Outcome:TIA+Stroke,JNNP,2008;79;1122-1127,22,Outcome:Stroke+Death,JNNP,2008;79;1122-1127,23,2008meta-analysisConclusions,对于颈动脉夹层的患者，没有证据支持抗凝治疗优于抗血小板治疗需要前瞻性的随机对照试验对比抗凝治疗和抗血小板治疗的有效性,JNNP,2008;79;1122-1127,24,Aspirinvsanticoagulationincarotidarterydissection,Neurology2009;72:18101815,Prospectivelycollecteddatafrom298consecutivepatientswithsICAD，nonrandomized,Anticoagulation,(n96),Aspirin,ProspectivelycollecteddataofconsecutivepatientswithsICAD,(n202),newcerebralischemicevents,Outcome,Outcome,symptomaticintracranialhemorrhagemajorextracranialbleeding,25,Outcome,Neurology2009;72:18101815,26,Conclusions,局限性：非随机的研究自发颈动脉夹层的患者其新发生的脑和视网膜缺血事件的发生频率较低新发事件与抗栓治疗的方法可能无关（抗凝vs抗血小板）,27,最大型的研究CADISS仍在进行中,CADISSCervicalArteryDissectioninStrokeStudyprospectivemulticentrerandomisedcontrolledtrialinacute(within7daysofonset)carotidandvertebralarterydissectionIntracerebralarterydissectionisexcluded,IntJStroke.2007Nov;2(4):292-6,28,CADISS-Design,Antiplatelettherapyaspirin,dipyridamoleorclopidogrelaloneorindualcombinationAnticoagulationtherapyheparinfollowedbywarfarinaimingforanInternationalNormalisedRatio(INR)intherange23foratleast3monthsSamplesize-3000,IntJStroke.2007Nov;2(4):292-6,29,2011AHA二级预防指南（总结）,合并缺血性卒中或者TIA的颅外颈动脉或者椎动脉夹层的患者，抗栓治疗至少3-6个月(ClassIIa;LevelofEvidenceB).合并缺血性卒中或者TIA的颅外颈动脉或者椎动脉