脑血管疾病CerebralVascularDisease

脑血管疾病CerebrovascularDisease CVD DepartmentofNeurology2ndhospitalofKunmingMedicalUniversity Section1Introduction DefinitionCVD ThetermofCVDdesignatesanyabnormalityofthebrainresultingfromvariouspathologicalprocessofthebloodvessels 脑血管病是各种脑血管病变引起脑部疾病的总称 DefinitionStroke Thestrokeisasyndromecharacterizedbytheacuteonsetofaneurologicdeficitthatreflectsfocal diffusedinvolvementoftheCNSandistheresultofadisturbanceofthecerebralcirculation 脑卒中是指急性起病 迅速出现局限性或弥漫性脑功能缺失征象的脑血管性事件 Epidemiology CVDisthethirdmostcommoncauseofdeathafterheartdiseaseandcancer Incidence 100 300 100 000morbidity 100 740 100 000mortality 50 100 100 000About50 70 ofsurvivorsshowsdisabilityindifferentdegree ClassificationofCVD Accordingtothelastingtimeofneurologicdeficit TIA 24h Accordingtotheseverityofneurologicdeficit minorstrokemajorstrokesilentstrokeAccordingtothepathologicalfeatures ischemicstrokehemorrhagicstroke seetable8 1 脑部的血液供应 Bloodsupplyinbrain 颈内动脉系统 internalcarotidartery ICA S 眼动脉 ophthalmicartery后交通动脉 postcommunicatingartery脉络膜前动脉 anteriorchoroidalartery大脑前动脉 anteriorcerebralartery ACA 大脑中动脉 middlecerebralartery MCA 供应眼部及大脑半球前3 5部分即额叶 颞叶 顶叶及基地节的血液见图thecircleofWillis环见图脑基底部动脉 椎 基底动脉系统 vertebral basilararteryS 椎动脉 VA Whichisdividedintoanteriorspinalartery 脊髓前动脉 posteriorspinalartery 脊髓后动脉 medullaryartery 延髓动脉 posteriorinferiorcerebellarartery 小脑后下动脉 基底动脉 BA Whichhasbranchesofanteriorinferiorcerebellarartery 小脑前下动脉 branchesofpons 脑桥支 internalauditoryartery 内听动脉 superiorcerebellarartery 小脑上动脉 大脑后动脉 posteriorcerebralartery PCA whichistheterminaldivisionofBA椎基底动脉系统供应脑干 小脑及大脑半球后2 5部分即枕叶及颞叶的基底面 枕叶的内侧及丘脑等 EtiologyofCVD VasculardisorderAtherosclerosisInflammatorydisorders TB syphiliticarteritis SLE etc Congenitalvascularmalformation aneurysm AVM Lesionsofanycause EtiologyofCVD HeartdiseasesandbloodkineticschangesHypertentionorhypotensionAtrialfibrillation Rheumaticheartdisease arrhythmiasetc ChangesinbloodconstituentandhemodynamicsIncreaseinbloodviscosityAbnormalityinbloodcoagulationmechanismOthersSuchasemboliofair fat cancercells Bloodvesselspasm trauma etc Riskfactors Severalfactorsareknowntoincreasetheliabilitytostroke Themostimportantoftheseare HypertentionHeartdiseasesDiabetesTIAorstrokehistory Riskfactors SmokingandalcoholHyperlipidmiaOthers food symptomlessICAbruit overweight drugabuse contraceptive age sex familyhistory race etc Section2TransientIschemicAttack TIA 短暂性脑缺血发作 ConceptEtiologyandmechanismClinicalfindingsInvestigativestudiesDiagnosisanddifferentiationTreatmentandprevention TIA Concept TIAisbrief repeated reversibleepisodesoffocalischemicneurologicdisturbance Thedurationofwhichshouldbelessthan24h usuallylastingaboutseveralminto1h RepeatedTIAsofuniformtypearemoreoftenawarningsignofischemicstroke TIA Clinicalfindings Ageofonset 50 70 male femaleBasicfeatures Transientepisode 24h Reversibleresolvecompletelyrepeatedanduniformtype ClinicalfeaturesofcarotidarteryTIA Commonsymptom sign weaknessofoppositelimbs 对侧单肢无力或轻偏瘫 Characteristicsymptom sign ophthalmicarterycrossingparalysis 眼动脉交叉瘫 Horner scrossingparalysis Horner氏交叉瘫 Aphasia dominanthemisphereisinvolved ClinicalfeaturesofcarotidarteryTIA Possiblesymptoms contralateralsinglelimb orhemi sensorydeficitcontralateralhomonymoushemianopia TIAofVertebra basilarartery Commonsymptom sign vertigo dysequilibrium usuallynotinnitus 眩晕 平衡失调 多不伴有耳鸣 Characteristicsymptom sign dropattack 跌倒发作 transientglobalamnesia TGA 短暂性全面性遗忘 bioccularvisiondisorder 双眼视力障碍 TIAofVertebral basilarartery Possiblesymptom sign swallowingdisorder dysarthria dysphagia 吞咽障碍 构音不清 incoordination 共济失调 disturbenceofconsciousnesswith withoutsmallpupils 意识障碍伴或不伴瞳孔缩小 TIAofVertebral basilarartery Possiblesymptom sign unilateral bilateralfacial perioralnumbnessorcrossingsensorydeficit 一侧或双侧面部 口周麻木或交叉性感觉障碍 extraocularpalsyordiplopia 眼外肌麻痹或复视 crossedparalysis 交叉性瘫痪 TIASymptomsRelatedtoCerebralCirculation TIA Diagnosisanddifferentiation Diagnosis mainlydependuponhistory ButthecausesofTIAareveryimportant differentiation partialseizure 局限性癫痫 M niereDisease 美尼耳氏病 Heartdiseases Adams stokessyndrome severearrhythmia etc ManagementDiagnosisofCarotidStenosis Investigativestudy BloodTest Bloodcount ESR bloodglucose etc EEG CTorMIRECG CardiacUltralsoundCarotidDuplexUltrasoundOthers TIA treatmentandprevention TreatmentintermsofetiologyDrugsforpreventionAntiplateletagents Aspirin ASA Ticlopidine Dipyridamole ClopidogreAnticoagulationtherapy 肝素 heparin 低分子肝素 lowermoleculeheparin 华法林 warfarin TIA treatmentandprevention DrugsforpreventionOthers Chinesetraditionalmedicines vasodilatationagents bloodvolumeenlargementdosesandsurgicaltreatment carotidendoarterectomy intralumenalstents Cerebralprotectiveagents Prognosis1 3willdevelopintocerebralInfarctionafterward1 3recurrence1 3resolved Summary themostimportantpartsneedtobeemphasizedare clinicalfindings diagnosismenagement CaseExample A55yearoldmalepresentstotheemergencydepartmentwithacuteonsetofLeftarmweakness UnabletoliftleftarmoffoflapSymptomsimprovedonthewaytothehospital CaseExample PMHx HypertensionTakesenalaprilSocialHx Smokes1ppd CaseExample PhysicalExamOverweight160 90 80 14 37 5CRightcarotidbruitHeartwithregularrateandrhythm Nomurmur CaseExample Neuroexam30minaftertheonsetofsymptomsMotor4 5strengthinleftupperextremity SensorysubjectivedecreaseinpinprickinleftupperextremitycomparedtotherightReflexeswere2 exceptfortheleftbiceps whichwas3 Gaitsteady CaseExample NeuroexamAfteranimmediateCTscan Thepatient ssymptomshadcompletelyresolvedandhehadanormalneurologicexam Questions Whatisthepossiblediagnosisofthepatient Whicharteryterritoryisinvolved Whatistheprobablecause Howshouldyoumenagetheproblem Section3脑梗塞 cerebralinfarction Concept Cerebralinfarction CI isnecrosisandmalaciaofbraintissuesduetoischemiaandanoxiaofthebrain whichisinturncausedbydeprivedorinsufficientbloodsupplyinbrain 是指脑部血液供应障碍 缺血 缺氧引起脑组织坏死软化 cerebralinfarction Commontypes 脑血栓形成 cerebralthrombosis CT 脑栓塞 cerebralembolism 脑分水岭梗塞 cerebralwatershedinfarction CWSI 腔隙性梗塞 lacunarinfarct 脑血栓形成 cerebralthrombosis CT EtiologyPathologyClinicalFeaturesDiagnosisanddifferentiationtreatmentPrognosisandprevention Etiology StenosisofarterythrombosisAtherosclerosis themostcommoncauseofCTArteritisOthers vascularmalformation blooddyscrasia 高凝状态 hypercoagulablestate 真性红细胞增多症 polycythemiavera 血小板增多 thrombocytosis DIC等 Etiology vascularspasm SAH migraine eclampsia 子痫 trauma etc Indeterminate Pathology 好发部位 大脑中动脉颈动脉虹吸部及起始部椎动脉及基底动脉中下段4 5locatedinregionofICAterritory 1 5locatedinregionofV BA Pathology 超早期 1 6h 脑组织改变不明显 急性期 6 24h 脑组织苍白 轻度肿胀 NC 胶质细胞及血管内皮细胞缺血坏死期 24 48h 组织结构不清神经细胞消失及胶质细胞坏变 炎细胞浸润 脑组织明显肿胀 Pathology 软化期 3d 4w 脑组织开始液化变软恢复期 3 4w 胶质细胞 胶质纤维及毛细血管增生 形成胶质瘢痕和中风囊 Pathophysiology Bloodflowblockage 30seconds metabolicchange 1min ceaseofneuronactivity 5min cerebralinfarct Ischemicpenumbra 缺血半暗带 timewindow 6h Pathophysiology Reperfusiondamage possiblemechanisms 自由基 freeradical 形成及其瀑布式反应神经细胞内钙超载 calciumoverload EAA毒性作用 toxiceffectofexcitatoryaminoacid 酸中毒 acidosis Types 大面积脑梗死 alargeareaCI 分水岭脑梗死 cerebralwatershedinfarction CWSI 出血性脑梗死 hemorrhagicinfarct HI 多发性脑梗死 multipleinfarct MI Clinicalfeatures ClinicaltypesCompletestroke reachespeakwithinseveralhours 24handrecoveringwithin3ws Clinicalfeatures Generalfeatures Middle agedorelderlypeople causedbyAtherosclerosis youthormiddle agedpeople causedbyarteritis Strokeonsetatquietstateandreachesthepeakwithinseveralhoursto1 2days Clinicalfeatures Generalfeatures Usually thepatientsareawakeandalertexceptforthosewithalargeareaofCIorinfarctioninbrainstem ClinicalsyndromesofCI OcclusionsyndromeofcarotidarteryCarotidarteryocclusionmaybeasymptomatic Symptomaticocclusionresultsinsyndromesfollow Transientmonocularblindnesscausedbyipsilateralretinalarteryischemia Horner ssign ClinicalsyndromesofCI OcclusionsyndromeofcarotidarteryCarotidarteryorophthalmicarterybruitandaweakenedpulseincarotidartery Contralateralhemiplegia hemisensorydeficit andhomonymoushemianopia Aphasia ifdominanthemisphereinvolvement ClinicalsyndromesofCI OclusionsyndromeofMCA主干闭塞 Occlusioninstem isaseverestrokesyndromewhichcombinesthefeaturesofsuperiorandinferiordivisionstroke 三偏症状 contralateralhemiparesis hemisensorydeficit andhomonymoushemianopia ClinicalsyndromesofCI OclusionsyndromeofMCA失语症 体象障碍 globleaphasia ifdominanthemisphereisinvolved andbodyimagedisturbence 意识障碍 颅内压增高 脑疝可导致死亡 disturbenceofconsciousness increasedICP andherniation ClinicalsyndromesofCI OclusionsyndromeofMCA皮层支闭塞 occlusioninsuperiordivision 中枢性面舌瘫和偏瘫 偏瘫上肢重于下肢 contralateralhemiparesisthataffectstheface hand andarmbutlesssevereintheleg ClinicalsyndromesofCI OclusionsyndromeofMCA皮层支闭塞 occlusioninsuperiordivision 伴感觉障碍 主要是皮质感觉障碍 contralateralhemisensorydeficit mainlyshowscorticalsensorydeficit 失语 体象障碍 aphasiaandbodyimagedisturbence ClinicalsyndromesofCI OclusionsyndromeofMCA深穿支闭塞 occlusionininferiordivision 对侧偏瘫 contralateralhemiparesis upperandlowerlimbsevenlyaffected 对侧偏身感觉障碍及偏盲 contralateralhemisensorydeficitandhomonymoushemianopia 可有失语 dominanthemisphereinvolved ClinicalsyndromesofCI OcclusionsyndromeofACA主干闭塞 occlusioninstem 中枢性面舌瘫 偏瘫下肢重于上肢 挑扁担样瘫 Shoulde pole carry like 伴轻度感觉障碍尿便障碍或尿急 旁中央小叶损 incontinence paracentrallobuleisaffected ClinicalsyndromesofCI OcclusionsyndromeofACA主干闭塞 occlusioninstem 精神症状 psychiatricsymptom 颞极与胼胝体受累 temporalpoleandcorpuscallosumareaffected 常可见强握 吸吮反射 额叶病变 graspreflex suckreflexarecommonsigns lisioninfrontallobe ClinicalsyndromesofCI OcclusionsyndromeofACA皮层支闭塞 occlusioninsuperiordivision 对侧偏瘫 下肢重于上肢 sensorimotordeficitoftheoppositelegandfootand tolessdegree oftheshoulderandarm ClinicalsyndromesofCI OcclusionsyndromeofACA深穿支闭塞 occlusionininferiordivision 面 舌 肩瘫 contralateralparesisincludesface lingua shoulder ClinicalsyndromesofCI OcclusionsyndromeofPCA主干闭塞 occlusioninstem 对侧偏盲 偏瘫及偏身感觉障碍 较轻 丘脑综合症 thalamicsyndrome 主侧半球病变可有失读症 alexia ClinicalsyndromesofCI OcclusionsyndromeofPCA皮层支闭塞 occlusioninsuperiordivision 对侧同向性偏盲 contralateralhomonymoushemianopia 象限盲 quadranthemianopia 皮质盲 corticalblidness bilateralinvolvment ClinicalsyndromesofCI OcclusionsyndromeofPCA皮层支闭塞 occlusioninsuperiordivision 主侧颞下动脉闭塞时可见视觉性失认症 visualagnosia 和颜色失认 achromatopsia 主侧半球顶枕动脉闭塞可有对侧偏盲 失语 ClinicalsyndromesofCI PCAocclusionsyndrome深穿支闭塞 occlusionininferiordivision 丘脑穿通动脉闭塞 红核综合征 Claudesyndrome 丘脑综合征 thalamicsyndrome snesoryloss spontaneouspainanddysesthesias choreoathetosis intentiontremor spasmofhand mildhemiparesis ClinicalsyndromesofCI PCAocclusionsyndrome深穿支闭塞 occlusionininferiordivision 中脑分支闭塞 Webersyndrome thirdnervepalsyadcontralateralhemiplegia ClinicalsyndromesofCI Syndromeofvertebral basilararteryocclusion主干闭塞 广泛脑干梗死 Showssymptomsofcranialnerves pyramidaltract andcerebellum ClinicalsyndromesofCI Syndromeofvertebral basilararteryocclusion基底动脉尖综合征 TopofthebasilarSyndrome Abnormalityineyemovementandpupilsdisturbanceofconsciousness lossofconsciousness homonymoushemianopiaorcorticalblindnessseverememorydisorder ClincalsyndromesofCI Syndromeofvertebral basilararteryocclusion脑干分支闭塞WebersyndromeMillard GublersyndromeFovillesyndrome ClincalsyndromesofCI Syndromeofvertebral basilararteryocclusion小脑后下动脉闭塞 延髓背外侧综合症 Wallenbergsyndrome 眼球震颤 nystagmus 交叉性感觉障碍 crossedsensorydeficit 球麻痹 bulbarparalysis 病灶侧Horner征 ipslateralHornorsign 病灶侧小脑性共济失调 ipslateralcerebellarataxia ClincalsyndromesofCI Syndromeofvertebral basilararteryocclusion闭锁综合征 Locked insyndrome 基底动脉分支双侧闭塞Cerebellarinfarction由小脑上动脉 superiorcerebellarartery 小脑后下动脉 posteriorinferiorcerebellarartery 小脑前下动脉闭塞 anteriorinferiorcerebellarartery 所致 Laboratoryfindings CTscan normalatthedayofonsetofthestroke showsthelowdensityoftheinfarctafter24 48h CTispreferredforinitialdiagnosissinceitcanmakethecriticaldistinctionbetweenischemiaandhemorrhage 见图 Laboratoryfindings MRI maybesuperiortoCTscanfordemonstratingearlyischemicinfarcts showingischemicstrokeinbrainstemorcerebellumanddetectingthrombosisocclusionofvenoussinuses Laboratoryfindings Cerebralangiography MRA DSABloodtestsandECG Serumglucose cholesterolandlipid hemorheology TCDandCSF Diagnosisanddifferentiation Diagnosisdiagnosiscanbemadedependingontheclinicalfeatures Patientspresentingwithfocalcentralnervoussystemdysfunctionofsuddenonset Lastingmorethan24h CTandMRIchanges Diagnosisanddifferentiation Differentialdiagnosis CerebralhemorrhagecerebralembolismOtherstructuralbrainlesions tumor abscess etc 脑出血和脑梗塞的鉴别要点脑出血脑梗塞1 发病年龄60岁以下多60岁以上2 TIA史多无常有3 起病状态活动中安静状态或睡眠中4 起病速度急 分 时 较缓 时 日 5 血压明显增高正常或增高6 全脑症状明显多无7 意识障碍较重较轻或无8 颈强直可有无9 头颅CT高密度病灶低密度病灶10 脑脊液血性 洗肉水样无色透明其中最重要的是2 3 两条 Treatment 急性期治疗 Treatmentinacutestage 治疗原则 超早期治疗 力争溶栓 综合保护治疗 个体化治疗 整体化治疗 对危险因素及时予以预防性干预措施 Treatment 超早期溶栓治疗目的 溶解血栓 迅速恢复梗死区血流灌注 减轻神经元损伤 6h complications Hemorrhage reperfusiondamageandbrainedema reocclusion Treatment 超早期溶栓治疗Thrombolyticagents Urokinase UK Straptokinase SK recombinanttissueplasminogenactivator rt PA Treatment 超早期溶栓治疗Indications Age 75nodisturbanceofconsciousnesswithin6h or12hforprogressivestroke ofonsetBp 200 120mmHgnohemorrhageshownonCTscanningexclusionofTIAnootherhemorrhagicdiseases Treatment AntiplateletagentsTheregimeisasdescribedinthesectionofTIA Anticoagulationagents topreventtheprogressionofthrombosis TheagentsusedarethesameasmentionedinthesectionofTIA Fibrinogendegradationtherapy 降纤酶 Defibrase 巴曲酶 Batroxobin 安洛克酶 Ancrod 和引激酶 Treatment Neuroprotectiveagents 抗自由基 V EV C甘露醇激素等抑制脑代谢 急性期时应降低脑代谢 减少脑细胞耗氧量使缺血区血流量增加钙离子拮抗剂 西比灵尼莫地平等亚低温胰岛素维持血糖正常低限水平 Treatment Otherformsofmedicaltreatment suchastherapiesaimedatimprovingbloodflow hemodilution metabolicimprovingagents ATP Co A 脑活素等 Treatment SurgicaltreatmentGeneraltreatmentICU monitoringECG Bp R P etc AntiedemaagentsPreventinginfectionPhysicaltherapyandrehabilitationPreventivemeasures 腔隙性脑梗塞 LacunarInfarction Concept Smallpenetratingarterieslocateddeepinthebrainmaybecomeoccludedasaresultofchangesinthevesselwallinducedbychronichypertensionandatherosclerosis 是指发生在大脑半球深部白质及脑干的缺血性微梗死因脑组织缺血 坏死 液化并由吞噬细胞移走而形成腔隙 占脑梗死的 多见于基底节区 放射冠 丘脑 脑干等部位 腔隙性脑梗塞 LacunarInfarction Commontypes 纯运动性卒中 Puremotorhemiparesis PMH 纯感觉性卒 Puresensorystroke PSS 共济失调性轻偏