脑血管病-1

脑 血 管 疾 病 cerebrovascular diseases,中南大学湘雅医院神经内科 谷文萍Wenping Gu,MD.PhD. Neurology Department, Xiangya Hospital, central south University,脑血管疾病Cerebrovascular Diseases， CVD,在脑血管病变基础上发生的局限性或弥漫性脑功能障碍 the cerebral diseases that are resulted from various cerebrovascular diseases,急性脑血管疾病分类classification of acute cerebrovascular diseases,短暂性脑缺血发作（transient ischemic attack，TIA）颈动脉系统internal carotid artery system TIA椎基底动脉系统basilar-vertebral artery system TIA脑卒中（stroke, apoplexy, cerebrovascular accident）蛛网膜下腔出血（subarachnoid hemorrhage）脑出血（intracerebral hemorrhage, ICH）脑梗死 (cerebral infarction) 动脉粥样硬化性血栓性脑梗死 (arterothrombotic cerebral infarction)脑栓塞(cerebral embolism)腔隙性脑梗死(lacunar infarction), 等,其他分类脑血管疾病 other classification of cerebrovascular diseases,椎基底动脉供血不足（Vertebrobasilar arterial insufficiency）脑血管性痴呆（cerebral vascular dementia）高血压脑病（hypertensive encephalopathy）颅内动脉瘤（intracranial aneurysm）颅内血管畸形（intracranial vascular malformation）脑动脉炎（cerebral arteritis）颅内静脉、静脉窦血栓形成（thrombosis of venous sinus）颅外段动、静脉疾病其他动脉疾病(other arterial diseases),脑的血液循环blood circulation of cerebullar,颈内动脉系统(internal carotid artery system),椎基底动系统(basilar-vertebral artery,脑组织(brain tissue),静脉系统(vein system),静脉窦(vein sinuses),颈内静脉(internal carotid vein),颈内动脉系统internal carotid artery system,眼动脉(ophthalmic artery后交通动脉(posterior communicating artery)脉络前动脉(anterior choroidal artery)大脑前动脉(anterior cerebral artery)大脑中动脉(middle cerebral artery),椎-基底动脉系统vertebrobasilar circulation,椎动脉vertebral artery基底动脉basilar artery大脑后动脉posterior cerebral artery,脑的供血区域,颈内动脉系统(internal carotid artery)又称前循环,供应额、颞、顶叶和基底核等大脑半球前3/5血流provide the blood of frontal lobe,temporal lobe and parietal lobe ,et al椎-基底动脉系统（basilar-vetebral artery)又称后循环，供应小脑、脑干、丘脑和枕、颞叶等大脑半球后2/5血液 provide the blood of cerebellum ,brain stem,cerebral ganglion,occipital lobe,脑动脉细小分支,穿通支（perforating branch）间脑(diencephalon)、纹状体(corpus striatum)、内囊(internal capsule)、脑干基底部中线旁结构皮质支（cortical branch） 大脑半球皮质及皮质下白质与脑干的背外侧,脑底动脉环大脑中动脉近端基底动脉,脑动脉侧支循环compensatory circulation,Willis环双侧颈内动脉 internal carotic artey双侧大脑前动脉 anterior cerebral artey双侧大脑后动脉 posterior cerebral artery前交通动脉 anterior communicating artery双侧后交通动脉 posterior communicating artery,其他侧支循环(other compensatory circulation),大脑前、中、后动脉皮质支在大脑表面彼此交通颈内、外动脉围绕眼耳、鼻、的深浅分支互相吻合大脑动脉皮质支与来自颈外动脉的脑膜动脉分支也存在丰富的侧支吻合分水岭脑梗死cerebral watershed infarction,脑的静脉(cerebral veins),大脑上静脉大脑中静脉大脑下静脉superior,middle,inferior cerebral veins,上矢状窦Superior sagittal sinus海绵窦sinus横窦Transverse sinus,大脑大静脉Great cerebral vein,直窦Straight sinus,颈内静脉Internal carotidvein,已状窦Sigmoid sinus,下矢状窦Inferior sagittal sinus,大脑镰静脉Falx cerebral vein,脑血流及其调节blood circulation regulation,脑血供丰富。在正常情况下，脑血流量（CBF）具有自动调节作用：CBF=（MAP-ICP）r4/（8L）。在缺血或缺氧的病理状态下，脑血管的自动调节机制紊乱，血管扩张或反应异常，脑水肿和颅内压升高，就会出现缺血区的充血和过度灌注或脑内盗血现象In the normal conditions , cerebral blood flow can autoregulate . CBF can increase while cerebral perfusion pressure rises and cerebrovascular resistance is decreased. In the ischemic and hypoxic pathologic behavior, the autoregulation mechanisms disorder,blood vessels ectasia or response abnormality ,cerebral edema and intracranial pressure will rise ,so it appears hyperemia and superperfusion or cerebral steal phenomenon in the ischemic region,脑卒中(Stroke),流行病学epidemiology,我国城市脑血管病的年发病率、死亡率和时点患病率分别为219/10 万、116/10 万和719/10 万农村地区分别为185/10 万、142/10 万和394/10 万,在对脑卒中进行有效治疗的同时积极开展针对脑血管疾病危险因素的预防更加重要the preservation of the risk factors is more important than the treatment of stroke,分类classification,一级预防：防发生first-level prevention: prevent occurrence二级预防：防复发second-level prevention: prevent recidivation三级预防：发病后治疗third-level prevention: the therapy after morbility,一级预防(primary prevention),指发病前的预防，即通过早期改变不健康的生活方式，积极主动地控制各种危险因素，从而达到脑卒中不发生或推迟发病年龄的目的,脑卒中危险因素risk factors,可干预性may intervene ：高血压(hypertension)、心脏病(heart dieases) 、糖尿病(diabetes) 、血脂异常(hyperlipemia) 、高同型半胱氨酸血症、短暂性脑缺血发作(historic stroke) 、吸烟(smoking) 、酗酒(heavy alcohol consumption) 、肥胖、无症状性劲动脉狭窄、口服避孕药物、肺炎衣原体感染、情绪应激、抗凝治疗等不可干预性non-intervention ：年龄、性别、种族、遗传因素等,二级预防(secondary prevention ),是针对发生过一次或多次脑卒中的患者，通过寻找卒中事件发生的原因，纠正所有可干预的危险因素，达到降低卒中复发危险性的目的二级预防主要是防止中风复发,脑卒中主要症状和体征sings and symptoms,起病突然(onste suddenly)全脑症状(whole brain symptom )局灶性症状和体征(focal sings and symptoms)颈内动脉系统表现 (internal carotid artery)椎-基底动脉系统表现 (basilar-vetebral artery)脑膜刺激征 (meningeal irritation sign),短暂性脑缺血发作,transient ischemic attack,短暂性脑缺血发作transient ischemic attack , TIA,脑动脉一过性供血不足 transient insufficiency of blood in cerebral arteries短暂发作 transient attack局灶性脑功能障碍 focal brain disorder24小时内完全恢复 complete recovery in 24 hours可反复发作 recurrent attacks,病因和发病机制etiopathogenisis and pathogenesy,微栓塞 microembolism脑血管痉挛、狭窄或受压 cerebrovascular spasm血流动力学改变hemodynamics disorders血压、血液成分改变blood compotents disorders其他 others,临床表现clinical situation,50岁 patients older than 50, 常伴有动脉硬化、高血压、糖尿病、冠心病等 accomply with angiosclerosis, hypertension, diabetes, coronary artery disease发病突然，迅速出现局限性神经功能障碍 acute onset of a neurologic deficit持续时间短 ，24小时 neurologic deficit persists for less 24 hours不留后遗症 no residual可反复发作 recurrent attacks,颈内动脉系统TIA TIA of internal carotid artery,短暂性偏侧或单肢无力 transient hemiparesis面部、单肢或偏身麻木 hemisensory disturbances同向偏盲或单眼一过性失明 homonymous hemianopia or transient ocellanae acroisa失语 aphasia,椎基底动脉系统TIATIA of vertebrobasilar circulation,眩晕（vertigo）、复视（diplopia）、吞咽困难（acataposis）、共济失调（ataxia）交叉性瘫痪（crossed paralysis）跌倒发作（drop attack）、短暂全面性遗忘症（transient global amnesia TGA）、双眼视力障碍发作（the onset of binocular vision disorders）,诊断approach to diagnosis,中老年患者 senior突然出现局限性神经功能障碍 acute onset of a neurologic deficit24小时完全恢复 complete recovery in 24 hoursCT、MRI（）TCD监测,鉴别诊断differential diagnosis,部分性癫痫（part epilepsy）梅尼埃病（Meniere disease）颅内占位性病变（intracranial spaceoccupying lesion）,治疗treatment,药物治疗(drug treatment)抗血小板聚集 (antiplatelet therapy)Asprin 50150mg，po， Qd噻氯匹定（ticlopidine)氯吡格雷(clopidogrel)双嘧达莫 (dipyridamole,DPA)奥扎格雷(ozagrel) 80mg，ivgtt，bid抗凝 (anticoagulation)肝素(heparin)100mg+5%葡萄糖500ml，ivgtt，1020滴/min低分子肝素(low molecular weight heparin)4000IU，腹壁皮下注射，bidWarfarin 钙拮抗剂：尼莫地平、盐酸氟桂嗪（nimodipine、flunarizine）其他（others）中药治疗（tranditional medicine treatment）扩血管治疗：罂粟碱、倍他司丁、烟酸（papaverine、betahistine、nicotinic acid）,治疗treatment,病因治疗(etilogical treatment)手术治疗(surgery)管腔狭窄70%，伴反复TIA，可考虑介入治疗或颈动脉内膜剥除术,预后prognosis,脑梗死 cerebral infarction反复发作 recurrent attacks自行缓解 release without treatment,缺血性脑卒中,cerebral ischemic stroke,缺血性脑卒中cerebral ischemic stroke , CIS,由于脑部血液供应障碍，缺血、缺氧引起的局限性脑组织的缺血性坏死或脑软化又称脑梗死（cerebral infarction,CI),临床常见类型有动脉粥样硬化性血栓性脑梗死、脑栓塞和腔隙性梗死等。脑梗死约占全部脑卒中的80Cerebral ischemic stroke is again called cerebral infarction, which is caused by insufficient inflow of blood , then ischemia and hypoxia cause local cerebral tissues ischemic necrosis or encephalomalacia,动脉粥样硬化性血栓性脑梗死arterothrombotic cerebral infarction,通常是指脑动脉的主干或其皮层支因动脉粥样硬化等血管病变，导致的官腔狭窄或闭塞并进而发生学栓形成，造成脑局部供血区血流中断，发生脑组织缺血、缺氧、软化坏死，出现相应的神经系统症状和体征the vessel diseases are caused by cerebral arterial stems or its cortex branches atherosclerosis and various arteritis, which cause vessel constriction or emphraxis and then form thrombosis and local blood flow breaks. So cerebral tissue ischemia, hypoxia ,softening and necrosis,which cause corresponding nervous system symptoms and signs.,病因etiopathogenisis,脑动脉粥样硬化cerebral atherosclerosis高血压 hypertension糖尿病 diabetes 血脂异常hyperlipemia脑动脉炎cerebral arteritis 结缔组织疾病connective tissue diseases先天性血管畸形congenital vascular malformation真性红细胞增多症polycythemia rubra vera血高凝状态hypercoagulabale state 血小板增多症thrombocythemia,发病机制nosogenesis,脑梗死(cerebral infarction)灶形成机制脑血流障碍(cerebral blood flow disorder)神经细胞缺血性损害(nerve cell ischemia damage )能量代谢障碍(energy metabolism disorder )和酸中毒(acidosis )兴奋性氨基酸（excitatory amino acid)毒性和钙超载(calcium overload)磷脂降解(phospholipid degradation )和脂类介导的毒性作用自由基(free radical)损伤缺血性脑水肿(ischemic brain edema )一氧化碳(nitric oxide)毒性即早基因(immediate early genes)、神经营养因子(neurotrophic factors)和热休克蛋白(heat shock protein)等基因表达改变细胞因子,再灌注时间窗reperfusion time window,超早期治疗的关键是抢救缺血半暗带，采取脑保护措施减轻再灌注损伤，目前普遍把脑缺血的超早期治疗时间窗定为6小时之内The key to therapy is to salvage ischemic penumbra in the ultra-earlier period and take actions to reduce reperfusion damadge .At present , cerebral ischemic therapy time window in the ultra-earlier period is settled within 6 hours,临床表现clinical manifestation,老年人(senior)有动脉粥样硬化、高血压、糖尿病或冠心病史(with angiosclerosis, hypertension, diabetes, coronary artery disease)常在安静或睡眠中起病(onset at quiet or sleep)一般无头痛、呕吐、昏迷等全脑症状(no headache、vomit、coma）,颈内动脉系统脑梗死临床表现(clinical manifestation),颈内动脉血栓形成（internal carotid artery thrombosis）大脑中动脉血栓形成(middle cerebral artery thrombosis)大脑前动脉血栓形成(anterior cerebral artery thrombosis),椎-基底动脉系统脑梗死(basilar-vetebral artery system infarction),大脑后动脉血栓形成(posterior cerebral artery thrombosis)椎动脉血栓形成(vetebral artery thrombosis)延髓背外侧综合征(Wallenberg syndrome)基底动脉血栓形成(basilar artery thrombosis)脑桥腹外侧综合征(Millard-Gubler syndrome)闭锁综合征(locked-in symdrome)基底动脉尖综合征(top of the basilar artery syndrome),辅助检查auxiliary examination,血常规BR和生化检查CTMRI血管造影(cerebral arteriography) DSA、CTA、MRAB超、TCDSPECT、PETCSF,急性期一般治疗general treatment in acute stage,维持呼吸功能(retain respiratory function)调整血压(adjusted blood pressure)控制血糖(control blood sugar)控制体温(control body temperature)预防并发症(precaution complication)营养支持(nutritional support),急性期溶栓治疗thrombolysis treatment,溶栓时间窗（time window)起病3小时内，36小时可慎重选择病例，6小时后疗效不佳，并有较大出血危险适应征(indcation)年龄小于75岁瘫痪肢体肌力3级以下无明显意识障碍用药时血压低于180/110mmHg禁忌征(taboo)有出血倾向、大面积脑梗死、严重心、肝、肾疾病者常用药物(general drug )组织型纤维蛋白溶解酶原激活剂(tPA)尿激酶(UK)链激酶(SK)溶栓治疗有颅内或身体其他部位出血的危险，有的可导致死亡,其他治疗(other treatment),抗凝治疗(anticoagulation)降纤治疗（defibrase）抗血小板聚集(antiplatelet aggregation )治疗脑保护治疗(brain conservation )神经保护剂压低温治疗脱水降颅压(dehydration )血液稀释疗法(hemodilution )中医中药治疗(Chinese crude drug )外科介入治疗(surgery)卒中单元（stroke unit,SU）,康复期治疗treatment in convalescence stage,康复治疗 convalescent care二级预防 second-level prevention,脑栓塞,cerebral embolism,脑栓塞cerebral embolism,是指各种栓子随血流进人颅内动脉系统使血管腔急性闭塞引起相应供血区脑组织缺血坏死及脑功能障碍Cerebral embolismcerebral tissue ischemia , necrosis and cerebral function disorders that are caused by various emboli entering cranium artery system following blood flow and making blood vessel acutely emphraxis,病因etiopathogenisis,心源性脑栓塞(Cardiogenic cerebral embolism)心房颤动AF心脏瓣膜病和心内膜病感染性心内膜炎心肌梗死、心肌病心脏手术先天性心脏病心脏肿瘤非心源性脑栓塞(nonCardiogenic cerebral embolism)原因不明(unknown aetiology),临床表现clinical manifestation,任何年龄均可发病，青壮年多见。活动中突然起病，数秒或数分达高峰，是发病最急的脑卒中，且多为完全性卒中Cerebral embolism can be found at any age, but most of them is at young prime of ones life.The onset suddenly starts at activities, achieves peaks after a few second or minutes. It is the acutest stroke among all strokes,and most of them are completed strokes局限性神经缺失症状与栓塞动脉供血区的功能相对应Limited nerve deletion symptoms are corresponded with embolism artery sufficient blood regions大多数病人有栓子来源的原发病Most of patients trouble proepisode that emboli come from,诊断及鉴别诊断diagnosis and differential diagnosi