神经病学课件：脑血管疾病

1、 Cerebrovascular Diseases脑血管疾病Outline 概要Introduction 简介Transient Ischemic Attacks (TIA) 短暂性脑缺血发作Ischemic stroke 缺血性脑卒中Intracerebral Hemorrhage 颅内出血Subarachnoid Hemorrhage 蛛网膜下腔出血Introduction 简介Definition 定义a group of brain dysfunctions related to disease of the blood vessels supplying the brain 一组与脑

2、血管疾病相关的脑功能障碍Stroke 中风: cerebrovascular accident 脑血管意外sudden loss of blood circulation to an area of the brain, with corresponding loss of neurologic function. 脑部某区域的血循突然丧失，结果造成相应神经功能丧失As if “struck by the hand of God” 仿佛“被上帝之手击打”Epidemiology 流行病学Third leading cause of death 第三大死因Approximately 2 mill

3、ion new strokes each year in china 在中国每年大约有200万新发中风患者Associated with risk factors 与危险因素相关联(see below 见下文)Blood supply of the Brain 脑部血供internal carotid artery 颈内动脉vetebral-basilar artery 椎-基底动脉they are interconnected by an arterial circle 它们通过一个动脉环相联系(of Willis)INTERNAL CAROTID ARTERY 颈内动脉INTERNAL C

4、AROTID ARTERY 颈内动脉Enters cranium via the carotid canal of the temporal bone 通过颞骨内的颈动脉管进入颅内Supplies dura, hypophysis, tympanic cavity and trigeminal ganglia 供应硬脑膜、垂体、鼓室和三叉神经节Provide direct branches to the optic nerve, optic chiasm, hypothalamus and genu of internal capsul 直接分支于视神经、视交叉、下丘脑以及内囊膝部Termin

5、al branches are the anterior and middle cerebral arteries 终末支为大脑前及大脑中动脉Anterior cerebral artery 大脑前动脉(ACA)Anterior cerebral artery 大脑前动脉Cortical branches supply all the medial surface of the cerebral cortex (basal ganglia, corpus callosum) as far back as the parieto-occipital sulcus.Key functional a

6、reas Primary motor cortex for leg and foot Motor planning in medial frontal lobe Middle and anterior corpus callosumAnterior cerebral artery 大脑前动脉皮质支供应大脑皮层全部内侧面 (基底神经节，胼胝体) ，远至顶枕沟.重点功能区下肢主要皮质运动区额叶的运动计划胼胝体前部及中部Middle cerebral artery 大脑中动脉Middle cerebral artery 大脑中动脉(MCA)Largest branch, Runs in the la

7、teral sulcus 外侧沟Divides into superior and inferior branchSuperior MCA lateral and inferior frontal 侧叶和额下回 , anterior part of parietal 颅顶骨前部Inferior MCA lateral temporal 颞叶外侧 , posterior parietal 颅顶骨后部 , lateral occipital 侧枕Central perforating branches 中央穿通支 supply the lentiform 豆状核 and the caudate n

8、uclei 尾状核 and the internal capsule 内囊Deep branches of MCA MCA深部分支Key functional areas of MCA 重点功能区Primary motor cortex for face, arm, leg 面部、臂、腿部的主要运动皮层Primary sensory cortex for face, arm, leg 面部、臂、腿部的主要感觉皮层Brocas language area 布罗卡语言区(superior MCA)Wernickes area 韦尼克区(inferior MCA)Perception of own

9、body, outside world and ability to express emotions 本体、外界感觉以及表达情感的能力Area of supply of cerebral arteries 脑动脉的供应区域VERTEBROBASILAR SYSTEM 椎基底动脉系统Enter the cranial cavity through the foramen magnum. 经枕骨大孔入颅腔Just inferior to the pons, fuse to form the basilar artery. 位于脑桥正下方，融合形成基底动脉Key functional areas

10、重点功能区1/3 of posterior brain 后脑cerebellum 小脑Spinal cord tracts 脊髓神经束 pyramidal 锥体束 and spinothalamic 脊髓丘脑束Cranial nerves 颅神经 3 - 12VERTEBROBASILAR SYSTEM椎基底动脉系统Vertebral artery branches 椎动脉分支The meningeal branches 脑膜分支The posterior spinal artery 后脊髓动脉The anterior spinal artery 前脊髓动脉Posterior inferior

11、 cerebellar artery 小脑下后动脉(PICA)Small medullary arteries 小髓动脉（？）BASILAR ARTERY BRANCHES 基底动脉分支Pontine arteries 脑桥动脉Labyrinthine artery 迷路动脉(Supplies the internal ear 供应内耳)Anterior inferior cerebellar artery 前下小脑动脉(AICA)Superior cerebellar artery 上小脑动脉(SCA)Anterior and posterior spinal artery 前后脊髓动脉Po

12、sterior cerebral artery 大脑后动脉(PCA)Posterior cerebral artery 后脑动脉(PCA)Blood supply for midbrain 中脑, half thalamus 半丘脑, geniculate bodies 膝状体occipital lobe 枕叶, visual cortex 视皮质, inferior temporal lobe 后颞叶, including the hippocampus 包括海马Key functional areas 重点功能区Primary visual cortex初级视皮层3rd nerve in

13、midbrain 位于中脑的第三对脑神经Sensory control 感觉控制 temperature 体温, pain 疼痛, sleep 睡眠CIRCLE OF WILLIS Willis环-Bridges ICA 颈内动脉 and vertibrobasilar artery 椎基底动脉CIRCLE OF WILLIS Wills环Formed by anastomosis between two internal carotid and two vertebral arteries 由两条颈内动脉和两条椎动脉融合而成The contributing arteries are 参与构成

14、的动脉包括The anterior communicating 前交通动脉The anterior cerebral 大脑前动脉The internal carotid 颈内动脉The posterior communicating 后交通动脉The posterior cerebral 大脑后动脉The basilar 基底动脉Cerebral blood flow 脑血供(CBF)The brain accounts for 2%3% of body weight but utilizes 利用 20%25% of glucose 葡萄糖and energy.Regulation of C

15、BFBlood pressure 血压: CBF is automatically regulated 自动调节 when mean arterial pressure 平均动脉压 (MAP) is between 60-160mmHg (Bayliss effect 贝利斯效应). Autonomic regulation will not be effective when MAP is below 60mmHg or above 160mmHg (hypertension 高血压).Chemicals 化学物质: O2, CO2 and pH in blood and CSF 脑脊液.C

16、ommon forms of CVD 脑血管疾病的常见形式TIA 短暂性脑缺血发作Ischemia（缺血性,8590%）Thrombosis（脑血栓形成）Embolism（脑栓塞） Hemorrhage（出血性,1015%）Intracranial hemorrhage（脑出血） Subarachnoid hemorrhage （蛛网膜下腔出血）Risk factors of CVD CVD风险因素Non-modifiable risk factors 不可控风险因素Age 年龄, Sex 性别, Race 种族, Genetics 遗传Modifiable 可控风险因素: TIAs 短暂性脑

17、缺血发作High blood pressure 高血压Atrial fibrillation 房颤Diabetes 糖尿病Cholesterol 胆固醇Others: smoking 吸烟, alcohol 喝酒, drugs 药物 (contraceptive 避孕药, cocaine 可卡因, amphetamines 冰毒/安非他明), lack of physical activities, obesity 肥胖Primary prevention 一级预防Treatment of risk factors in individuals with no previous history

18、 of stroke 处理无中风病史个体的危险因素Hypertension 高血压: blood pressure to 140/90mmHgAtrial fibrillation 房颤: 1/6 of stroke in patients 60 years oldWarfarin 华法林+statins 他汀类(lipid reduction 降脂)Diabetes 糖尿病Secondary prevention 二级预防Risk factor treatment for those who have experienced a strokeBlood pressure lowering:R

19、ecommended even for normal blood pressure without stenosisCholesterol loweringLow dose of statins is suggested even for normal cholesterol levelAntiplatelet agents aspirin + dipyridamole (双嘧达莫) is better than aspirin aloneClopidogrel: aspirin allergy, or with coronary artery diseaseAnticoagulants: A

20、trial fibrillation, or TIACarotid intervention: Stenosis of 50%: Endarterectomy(proven beneficial for symptomatic, applied within 2 weeks), stenting (angioplasty, 支架成形术, recommended in younger patients of 50%: 动脉内膜切除术（被证明对症状有利，2周内使用），支架（血管成形术, 建议用于较为年轻的患者70 years old）动脉瘤: 剪下或卷起Supposed to know in th

21、is sectionRisk factors 危险因素Concepts of primary and secondary prevention of CVD 脑血管疾病的一级和二级预防Outline 概要Introduction 简介Transient Ischemic Attacks 短暂性脑缺血发作(TIA)Ischemic stroke 缺血性脑卒中Intracerebral Hemorrhage 颅内出血Subarachnoid Hemorrhage 蛛网膜下腔出血Transient Ischemic Attacks短暂性脑缺血发作(TIAs)Are episodes of strok

22、e symptoms that only last briefly, with average duration of 12min. Without evidence of infarction50% of TIA recovered within the first hour, 90% recovered within 4 hours. Infarcts do occur in 15 to 40% of TIAs even though neurologic signs and symptoms are absentUrgent risk stratification is required

23、Transient Ischemic Attacks短暂性脑缺血发作(TIAs)为短暂性中风症状发作，平均持续时间小于12min。没有证据显示有梗塞发生50% 的患者在1小时内恢复，90%的患者在4小时内恢复。 尽管不存在神经系统的症状和体征，确实有15%-40%的患者发生了梗塞 必须进行紧急危险分层（？）Causes and pathophysioloy 病因与病理生理Causes are similar to all stroke 病因与各种中风相同Pathophysiology 病理生理Blood flow dynamics 血流动力学: Atherosclerosis or steno

24、sis 动脉粥样硬化或狭窄 + blood pressure fluctuation 血压波动, or with high coagulative state 或伴有高凝状态, Micro-emboli 微栓子: Atherosclerosis 动脉粥样硬化, arterial or ventricular sources 动脉或心室来源Others 其它: Arteritis 动脉炎, arterial steal syndrome动脉窃血综合征(ASS) Clinical presentations 临床表现Age: 5070 years oldWith risk factors: hyp

25、ertension 高血压, heart disease 心脏病, diabetes 糖尿病, abnormal blood lipid 血脂异常Abrupt onset 突然发作Brief neurologic deficits 短暂的神经功能缺损Internal carotid system 颈内动脉系统Vertibro-basal system 椎基底动脉系统Internal carotid 颈内动脉 TIAsCommon features 共性: contralateral hemiplegia 对侧偏瘫, sensory loss or numbness 感觉丧失或麻痹Charact

26、eristic presentations 特性: transient monocular blindness 一过性单眼盲(ophthalmic artery 眼动脉), with contralateral hemiplegia or sensory disturbance 对侧偏瘫或感觉障碍Honers sign (hypothalamus 下丘脑) with contralateral hemiplegia 对侧偏瘫Aphasia 失语症(MCA occlusion 闭塞)Vertibral-basal 椎基底动脉 TIAsCommon features 共性: Vertigo, us

27、ually without tinnitus (耳鸣); nausea, vomiting Characteristic featuresDrop attack: brain stemTransient global amnesia: temporal lobe, the hippocampusPossible symptoms: Diplopia (复视), nystagmus, dysarthria(构音障碍), dysphgia(吞咽困难),ataxia, disturbance of consciousnessCrossed sensory disturbance: Wallenber

28、g syndrome Crossed paralysis: cranial nerves (brain stem syndromes), will be discussed in detail in next sectionVertibral-basal 椎基底动脉 TIAsCommon features 共性: 眩晕，通常不伴有耳鸣，恶心， 呕吐 Characteristic features 特性颠仆发作: 脑干发作性全面性遗忘症: 颞叶，海马Possible symptoms 可能的症状: 复视，眼球震颤，构音障碍，吞咽困难，共济失调，意识障碍交叉性感觉障碍:瓦伦贝格综合征（延髓外侧综合

29、征）交叉性瘫痪: 颅神经（脑干综合征），将在下一节具体讨论Diagnostic tests 诊断性测试Risk factors 危险因素:Blood pressure 血压, serum lipid and sugar 血脂和血糖, coagulation 血凝(ESR, Erythrocyte sedimentation rate 红细胞沉降率; Thrombin time 凝血酶时间),artery diseases 动脉疾病(atherosclerosis 动脉粥样硬化, arthritis 关节炎), heart disease 心脏病(atrial fibrillation 房颤,

30、patent foramen ovale 卵圆孔未闭),TCD (transcranial Dopplar 经颅多谱勒):Large artery blood flow dynamics 大动脉血流动力学Arterial stenosis 动脉狭窄: MRA 磁共振血管造影, CTA 血管成像, sometimes DSA 数字减影血管造影Diagnosis 诊断Heavily relies on history 非常依赖于病史Aged people 老年人Transient signs or symptoms 一过性症状或体征Internal carotid 颈内动脉 or vertibra

31、l-vassal 椎基底动脉 systemlast for min and are recovered in 24 hrsImage study 影像学检查 fails to show any lesions 损伤Differential diagnosis 鉴别诊断 Epilepsy: symptoms last for seconds(5min), stereotyped, loss of consciousness (events can not be recalled), EEG abnormalityMeniere Disease: vertigo/nausea several hr

32、s, with hearing impairment, vestibular dysfunctionMigraine: vertigo sometimes, younger in age (35 years old), responsive to ergotsOthers: multiple sclerosis (MRI lesions), hypoglycemia, hypotension, cerebella hemorrhage, Chronic subdural hematoma, tumorsDifferential diagnosis 鉴别诊断 癫痫: 症状持续数秒(5min)，刻

33、板的，意识丧失(不能回忆)，脑电图异常梅尼埃病: 眩晕/恶心数小时，伴有听觉障碍，前庭功能障碍偏头痛: 时而眩晕，青壮年发病(60 years old; duration 10minSymptoms: unilateral motor weakness 单侧肌肉无力, speech disturbance 言语错乱Hypertension 140/95mmHgDiabetes Treatment 治疗: Hospitalization suggested 建议住院Aspirin 阿司匹林 or aspirin + clopidogrel 氯吡格雷 for 2 weeksBlood pressu

34、re control 控制血压Lowering blood sugar 降血糖Drug treatment 药物治疗 for TIAsAntiplatelets 抗血小板药: Aspirin 50300mg qd 每天一次.Or aspirin 100mg qd + dipyridamole 双嘧达莫 2550mg tid 每天三次Or aspirin 100mg qd + clopidagrel 氯吡格雷 75mg qd (in acute phase 急性期 5070%)Endarterectomy or angioplasty 动脉内膜切除术或血管成形术Heart diseases 心脏

35、病Hypertension 高血压Diabetes 糖尿病Hyperlipidaemia 高血脂Statins 他汀类Important notes 注意事项 in TIAsDiagnosis of TIAsAged people 老年人 brief presentation 短暂性发作 (minutes), recovered within 24hrsNo positive image 影像学 findingsDifferential diagnosis of TIAsTreatment principles 治疗原则Identify 鉴别 high risk TIAsDrug choice

36、 药物选择Underlying pathology control 潜在病理控制Outline 概要Introduction 简介Transient Ischemic Attacks (TIA) 短暂性脑缺血发作Ischemic stroke (cerebral infarction) 缺血性脑卒中Intracerebral Hemorrhage 颅内出血Subarachnoid Hemorrhage 蛛网膜下腔出血Cerebral infarction 脑梗死(cerebral ischemic stroke 缺血性脑卒中)Major forms of ischemic stroke 缺血性

37、脑卒中的主要表现Atherosclerotic thrombotic cerebral infarction 动脉粥样硬化性血栓性脑梗死Cerebral embolism 脑栓塞Lacunar infarction 腔隙性脑梗死(small-vessel stroke 小血管中风)Border zone infarction 交界区脑梗死(cerebral watershed infarction)They share common pathophysiology and therefore the treatment is similar.Etiology 病因Common 常规: Thro

38、mbus 血栓: Atherosclerosis 动脉粥样硬化, dehydration 脱水Embolus 栓子: artery-to-artery, cardioembolic 心源性血栓, valvular lesions 瓣膜病变, patent foremen ovale 卵圆孔未闭Less common 不常规: Hypercoagulable disorders 高凝状态: sickle cell anemia 镰状细胞性贫血, SLE 系统性红斑狼疮, homocysteinemia 同型半胱氨酸, oral contraceptives 口服避孕药Venous sinus t

39、hrombosis 静脉窦血栓形成Vasculitis 血管炎Vasospasm after subarachnoid hemorrhage 蛛网膜下腔出血后血管痉挛Drugs 药物: cocaine 可卡因, amphetamine 冰毒/安非他明,Moyomoya disease 烟雾病CBF in ischemia 局部缺血时脑血流量Normal CBF is approximately 5060 ml/100 g /minPermanent ischemia 永久性局部缺血 17 - 18 ml/100g/min histological changes 组织学改变2 hours is

40、chemia 12 ml/100g/min histological changes 组织学改变Reduction 减小 of CBF of less than 10 ml/100 g/min results in irreversible neuronal injury 不可逆的神经损伤Ischemic cascade 缺血级联反应Lack of oxygen supply to ischemic neuronesATP depletionMembrane ions system stops functioningDepolarisation of neuroneInflux of calc

41、iumRelease of neurotransmitters, including glutamate, activation of N-metyl -D- aspartate and other excitatory receptorsat the membrane of neuronesFurther depolarisation of cellsFurther calcium influxCarrol and Chataway,2006Ischemic cascade 缺血级联反应缺血的神经元缺氧ATP耗尽离子膜系统停止工作神经元去极化钙内流神经递质释放， 包括谷氨酸，活化N-甲基 -

42、D- 天冬氨酸以及其他位于神经元膜上其它的兴奋型受体进一步去极化细胞进一步钙内流Carrol and Chataway,2006Energy failure / depolarisationTransmitter releaseand receptor activation Ca2+Lipolysis (DAG PKC) ProteinphosphorylationProteolysisDisaggregationof microtubuli(FFAs.LPLs)EnzymeconversionBreakdown ofcytoskeletonDamage to membranestructur

43、e and functionDysfunction ofreceptors andion channelsFree radicalformationInhibition of axonaltransportConsequences of brain ischemia 脑缺血的结果能量耗竭/ 去极化递质释放、受体激活 Ca2+脂解(DAG PKC) 蛋白质磷酸化蛋白质水解微管解聚(FFAs.LPLs)酶转化细胞骨架破坏膜结构和功能损伤受体与离子通道功能障碍自由基形成轴突运输抑制Consequences of brain ischemia 脑缺血的结果Ischemic penumbra 缺血半影区

44、Ring-like area around ischemic center 缺血中心Blood flow range between the thresholds of transmitters release 递质释放阈值 and cell membranes failure 细胞膜破坏Functional activity of the neurons is suppressed 抑制 although structural integrity of the cell is still preserved 细胞的结构完整性仍然保留- neurons are injured but stil

45、l viable 神经元受损但依然可存活It provides a rational basis for functional improvements in injured brain tissue occurring long after the onset of stroke 它为中风（脑卒中）发生较长时间后受损脑组织功能得到改善提供了理论基础 MRI of ischemic penumbraDWI/PWI mismatch 错配 is increasingly being used to identify patients who are most likely to benefit

46、from new interventions 新干预措施 in acute ischaemic stroke 急性缺血性脑卒中Cell death and tissue edema 细胞死亡与组织水肿Two types of cell death 细胞死亡的两种形式Necrosis 坏死: core of infarct 梗死Apoptosis 凋亡: may exists in penumbra 半影区Brain edema 脑水肿: leading cause of death especially in the first week 致死的主要原因，尤其在第一周Mixture of cy

47、totoxic and vasogenic edema 细胞毒性和血管性水肿兼有Cytotoxic occurs early due to cell energy failure 由于细胞能量耗竭，细胞毒作用在早期发生Vasogenic edema occurs latter due to disrupted blood-brain barrier 由于血脑屏障破坏，晚期发生血管性水肿The concept of diaschisis 失联络Remote disturbances 远程干扰 of brain cells due to the suppression 抑制 of neurons

48、connected to the injured (ischemic) region 损伤（缺血）地区The remote focus 远程焦点 of brain suffer a kind of shock when deprived from afferent input comming from ischemic focus 缺血中心缺乏营养输入（？）Disturbed neurotransmitter metabolism 干扰神经递质代谢Appears within 30 min after the onset of ischemia 缺血发作30分钟内出现; reverses af

49、ter a few month 数月后逆转（？）Also seen in spinal shock 脊髓休克 after acute myelitis 急性脊髓炎Atherosclerotic thrombotic cerebral infarction动脉粥样硬化性血栓性脑梗死Atherosclerotic thrombotic cerebral infarction动脉粥样硬化性血栓性脑梗死Types 分类:complete stroke 完全性卒中 develops within 6 hrs, progressive stroke 进展性卒中 develops in 6hrs to se

50、veral daysMiddle to old age 中老年人多发Risk factors 危险因素Neurologic defects 神经系统缺陷: hemiplegia 偏瘫, hemianesthesia 偏身感觉障碍, aphasia 失语, ataxia 共济失调. Sometimes vomiting 呕吐 and coma 昏迷 , and , death.Stroke syndromes 中风症状Internal carotid artery 颈内动脉MCA 大脑中动脉, ACA 大脑前动脉Motor, sensory and advanced brain function

51、 运动、感觉和高级大脑功能Vetebrobasilar artery 椎基底动脉Brain stem 脑干, cerebellum 小脑, part of hypothalamus 部分下丘脑, thalamus 丘脑Cranial nerve, cerebellar dysfunction with crossed characteristics 有交叉特征的颅神经、小脑功能障碍ACA occlusion ACA闭塞Usually without neurologic deficit 神经功能缺损Collaterals from MCA,PCA, or anterior communicat

52、ing artery MCA、PCA或前交通动脉脉络丛Paralysis and sensory loss of opposite foot and leg 对侧下肢麻痹及感觉障碍Urinary incontinence 尿失禁(paracentral lobule 中央旁小叶)Contralateral gasp and sucking reflex 对侧喘息和吸吮反射（？）Abbulia (akinetic mutism 无动性缄默症), slowness 行动迟缓MCA occlusion MCA闭塞Complete block 完全阻塞: 3 HEMIs: contralateral

53、hemiplegia 对侧偏瘫, hemianesthesia 偏身感觉障碍, homonymous hemianopia 同侧偏盲Gaze preference to ipsilateral side 注视患侧（？）Advanced brain function 高级大脑功能Aphasia 失语症, anosognosia 病觉缺失, constructional apraxia 结构性失用Vertibral arteries occlusion 椎动脉闭塞Wallenberg Syn.(lateral medullary syn. 侧髓综合征)VIII, IX, X cranial ner

54、ve: Vertigo 眩晕, hoarseness 声嘶, dysarthria 构音障碍, dysphagia 吞咽困难,Crossed surface sensory loss 交叉表面感觉丧失: ipsilateral face and contralateral trunk and limb 同侧面部和对侧躯干与四肢Horners sign (ipsilateral 同侧) Ataxia 共济失调(ipsilateral 同侧)Cerebellar infarction 小脑梗塞Gait unsteadiness 步态不稳 ,nausea 恶心, vomiting 呕吐, with

55、headache 伴头痛, neck stiffness 颈项强直Edema can lead to sudden respiratory arrest 水肿可导致突发性呼吸停止Basilar artery occlusion 基底动脉闭塞Three groups: paramedian 中央旁(7-10 branches), short circumferential 短周(5-7) and bilateral long circumferential 双侧长周(SCA 小脑上动脉 and AICA 前下小脑动脉)Affects corticospinal and corticobulbar

56、 tracts 影响皮质脊髓和皮质延髓束, ascending sensory tracts and cranial nerve nuclei 提升感觉束和脑神经核（？） (sensory + motor+ cranial nerves 颅神经 +cerebellum)Complete block usually causes bilateral signs 双侧症状Common syndromes 常见症状: basilar artery occlusion 基底动脉闭塞Medial inferior pontine syn. 内侧下桥综合征(Millard-Gubler Syn.)Ipsi

57、lateral facial and abduct nerve palsy 同侧面部及外展神经麻痹Contrlateral hemiparalysis 健侧偏瘫Lock-in syn. 禁闭综合征 (bilateral pontine infarction 双侧脑桥梗死)Preserved consciousness 意识存在Quadriplegia and lower cranial nerve signs 四肢瘫痪和低位颅神经体征Top of the basilar syn. 基底动脉尖综合征(TOBS, SCA 小脑上动脉+PCA 大脑后动脉)Rostral brain stem 延髓脑

58、干: dysfunctional eye movement 眼球运动异常 and pupil(anisocoria,瞳孔不等), disturbance of consciousness 意识障碍, hypersomnia 嗜睡PCA: memory loss 记忆丧失, homonymous hemianopia 同侧偏盲Hallucination of cerebral peduncle 大脑脚幻觉（？）: animated 活跃, vivid 生动的 charateristicsTOBS 基底动脉尖综合征PCA occlusion PCA闭塞Cortical branches 皮质支:

59、contralateral homonymous hemianopia 对侧同向偏盲 with macula sparing 抽出黄斑（？） , acute disturbance of memory 急性记忆障碍Penetrating branches 穿通支:3rd nerve palsy 麻痹 with contralateral hemiplegia 对侧偏瘫 (Weber syndrome), or contralateral ataxia 对侧共济失调 or dyskinesia 运动障碍(Benedikt Syndrome, red nucleus 红核)Thalamic syn

60、drome 丘脑综合征: contralateral hemisensory loss 对侧偏身感觉丧失 or burning pain 烧灼痛Imaging studies 影像学检查CT 电脑断层扫描useful for identifying ischemia 缺血 from hemorrhage 出血sensitive to ischemia in brain hemisphere 大脑半球 after 24hrsMRI 核磁共振成像Can find small and posterior fossa 窝 ischemiaSensitive in several min, but ti