中西结合医院脑血管狭窄的诊断

脑血管狭窄的诊断,1,脑血管狭窄的介入治疗：团队工作方式（Team Work）的重要性,脑动脉狭窄的识别,术前评估（分型、病因、血流储备）,支架植入术,再狭窄的预防,2,神经内科医生的责任,筛选有无脑动脉狭窄判定狭窄与临床症状的关系脑动脉狭窄原因的判定脑动脉狭窄的分型（临床分型、LMA分型）斑块的性质（vulnerable plaque）血管重构(remodeling)的判定脑血流储备的评价选择合理的治疗策略（strategy）和路径（pathway）危险因素的评估和控制药物治疗（PAS),3,脑血管狭窄的原因,动脉粥样硬化夹层动脉瘤纤维肌发育不良其它,4,颈动脉粥样硬化的分期,IMT增厚斑块形成血管重构血管狭窄完全闭塞,5,6,7,阳性重构,Culprit Lesion,EEM Contour,ProximalReference,ProximalReference,动脉血管重构的类型,Schoenhagen et al. Circulation 2000; 101:598-603,阴性重构,Culprit Lesion,EEM Contour,Remodeling Ratio (RR) = EEM area lesion / EEM area proximal reference,Negative RemodelingRR 1.05,8,阳性重构,Proximal Reference,Lesion,EEM = 14.9 mm2,EEM = 18.9 mm2,9,阴性重构,Proximal Reference,Lesion,EEM = 16.0 mm2,EEM = 11.5 mm2,10,随年龄出现的血管重构,随年龄出现的血管重构,11,动脉狭窄期,12,perfusion-computed tomography raw data,regional cerebral blood flow,regional cerebral blood volume,prognostic map,mean transit time,13,脑血管狭窄的诊断,14,脑血管狭窄的诊断,临床表现,临床血管检查,TCD,颈部Dupplex,MRA/CTA,DSA,15,16,临床表现,所有缺血性脑血管病病人都应怀疑有脑血管狭窄尤其是血流动力学TIA和脑梗死,17,TIA,血流动力学型密集短暂刻板,微栓塞稀疏较长非刻板,18,血流动力学脑梗死,临床旁证特殊影像模板,19,临床旁证,病史中有导致全身血压下降的佐证由坐位或卧位变为直立位使起病病史中反复一过性黑朦颈动脉检查发现有高度狭窄影像学上特征性发现,20,Derdeyn CP, et al. Radiology 2001;220:195-201,21,Derdeyn CP, et al. Radiology 2001;220:195-201,22,23,24,特殊影像模板,透明模板电子模板,25,模板,26,27,28,29,脑血管狭窄的诊断,临床表现,临床血管检查,TCD,颈部Dupplex,MRA/CTA,DSA,30,31,32,33,34,35,36,脑血管狭窄的诊断,临床表现,临床血管检查,TCD,颈部Dupplex,MRA/CTA,DSA,37,38,近侧壁,远侧壁,39,40,Meijer弓,41,研究观察指标,0526,颈内动脉(IC),颈外动脉 (EC),皮肤,近侧壁,远侧壁,1.0 cm,0.5-1.0 cm,1.0 cm,CBMmax :双侧颈总动脉、动脉分叉8 条近侧和远侧壁最大IMT的平均值Mmax:双侧颈总动脉、动脉分叉和颈内动脉共12条近侧和远侧壁最大IMT的平均值Tmax:双侧12近侧和远侧壁最大IMTCCmax:双侧4个颈总动脉远端近侧和远侧壁平均最大IMTCBmax:双侧颈动脉分叉处4个近侧和远侧壁平均最大IMTICmax:双侧颈内动脉近端4个近侧和远侧壁平均最大IMTFWmax:双侧颈内动脉近端、分叉处、颈总动脉远端6个远侧壁平均最大IMTNWmax:双侧颈内动脉近端、分叉处、颈总动脉远端6个近侧壁平均最大IMT,动脉分叉 (Bif),颈总动脉(CC),42,颈动脉斑块的声学定量斑块的鉴定,0718,mCs-平均色阶,象素数,纤维型mCs=178.921.4,脂肪型mCs=203.514.4,纤维钙化型mCs=12849.2,动脉粥样硬化斑块放大图,43,RMCA,44,45,CTA,46,颈动脉粥样硬化的诊断流程,临床表现,临床血管检查,TCD,颈部Dupplex,MRA/CTA,DSA,47,DSA,48,第2名 (2464) 孤山 the rock Photographers Comments One of the smaller landmasses in the Galapagos ch