急性脑梗死课件

急性脑梗死1急性脑梗死第一节急性脑梗死的概述是由于局部脑血流中断引起,时间超过2小时，DWI上有表现。占脑卒中的85%。85%预后是好的，15%的缺血脑卒中预后差，死亡率高。2急性脑梗死第二节急性脑梗死的病因脑动脉粥样硬化：高血压、高血脂、吸烟小血管玻璃样变：高血压、糖尿病低灌注性脑梗死：动脉狭窄心源性脑栓塞：冠心病、风心病血管炎：SLE、结核、螺旋体动脉炎其它：避孕药。3急性脑梗死第三节急性脑梗死的分类OCSP：按临床症状分：完全前循环、部分前循环、完全后循环、腔隙性脑梗死ASCO：A-动脉硬化，S-小血管，C-心源性，O-其它4急性脑梗死第四节急性脑梗死的诊断血脂、糖代谢、HCY心脏、血管彩超头颅CT及CTA头颅MRI及MRADSA5急性脑梗死6急性脑梗死OCSP完全前循环：意识障碍、眼球凝视、语言障碍加偏瘫（皮层枝加深穿支）部分前循环：皮层枝或深穿支完全后循环：四肢瘫痪、眩晕、意识障碍腔隙性脑梗死：21型，常见有5型。7急性脑梗死

急性脑梗死的治疗陆正齐中山大学附属第三医院神经病学科

8急性脑梗死脑梗死的急性期治疗超早期溶栓治疗抗栓治疗他汀类药物抗高血压药物控制高血糖抗炎神经保护剂脱水问题9急性脑梗死超早期溶栓治疗10急性脑梗死抗栓治疗TheannualizedratesoftotalMajorbleedingeventsSecondarystrokepreventionofantithromboticsAmJCardiol.2009，15;103(8):1107-12.11急性脑梗死Design13studiesfollow-up：>or=1yeartocompare：aspirin(<or=325mg/day),clopidogrel,anticoagulants(warfarinandothervitaminKantagonists),aspirinplusclopidogrel,andaspirinplusextended-releasedipyridamole(ER-DP)

12急性脑梗死Totalbleedingrate4.8%-aspirin(<or=325mg/day)2.9%-clopidogrel3.6%-aspirinplusER-DP10.1%-aspirinplusclopidogrel16.8%-anticoagulation13急性脑梗死Majorbleedingrate1%-aspirin(<or=325mg/day)0.85%-clopidogrel0.93%-aspirinplusER-DP1.7%-aspirinplusclopidogrel2.5%-anticoagulation

14急性脑梗死ConclusionThecombinationofaspirinandclopidogrelisassociatedwithsignificantlygreaterbleedingthaneitheraspirin(<or=325mg/day)orclopidogrelalone.AspirinplusER-DPhasagreaterbleedingratethanclopidogrelbutalowerratethanaspirin(<or=325mg/day)alone

15急性脑梗死Proton-pumpinhibitors(PPIs)andclopidogrel

13,608patients33%(n=4529)ofpatientswereonaPPIatrandomisationNoassociationexistedbetweenPPIuseandriskoftheprimaryendpointThecurrentfindingsdonotsupporttheneedtoavoidconcomitantuseofPPIs

Lancet.2009Sep19;374(9694):989-97.Epub2009Aug3116急性脑梗死17急性脑梗死StatinsforstrokePleiotropiceffectsPreventORtreatment?criticallyillpatients?肾病血透病人及肾移植病人?出血性卒中?大剂量与标准剂量?18急性脑梗死pleiotropiceffectsofstatins

pleiotropiceffectsbeyondtheireffectsoncholesterollevelsvasoprotectivemechanismsimprovedendothelialfunctionincreasedbioavailabilityofnitricoxideimmunomodulationandantiinflammationstabilizationofatheroscleroticplaquesantioxidantstemcell-regulatingcapacities19急性脑梗死Preventstrokeandimproveoutcome

statinsreducetheriskofmyocardialinfarctionandstrokestatinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheeventabruptdiscontinuationafteracutecerebrovasculareventsmayimpairvascularfunctionandincreasemorbidityandmortality20急性脑梗死EffectsincriticallyillpatientsMajorsurgerySepsisHigh-vascularriskIVformulationofHydrophilicstatins21急性脑梗死研究名称出版时间处理因素mg对照因素mg平均随访时间（年）病例数(I/C)平均年龄(岁)男性比例（%）基础LDHMg/dl卒中病例数(I/C)致死卒中(I/C)脑出血A(I/C)ALLHAT-ALL2002pravastatin40空白4.85170/51856650146209/23153/56..PROSPER2002pravastatin40安慰剂3.22891/29137548147135/13122/14..GREACE2002atorvastatin10-80空白3800/80059791809/170/11/1HPS2002simvastatin40安慰剂510269/102676575131444/58596/11951/53ASCOT-ALL2003atorvastatin10安慰剂3.35168/5137638113389/121....ALERT2003fluvastatin40安慰剂5.11050/1052506615974/6317/14..CARDS2004atorvastatin10安慰剂3.91428/1410626811721/391/70/0PROVEIT2004atorvastatin80pravastatin4022099/2063587810621/19....AtoZ2004simvastatin80安慰剂22265/2232617611228/35....ALLIANCE2004simvastatin81空白4.31217/1225618314735/39....TNT2005simvastatin82atorvastatin104.94995/5006618198117/155..16/19DDDD2005simvastatin83安慰剂4619/636665412660/4527/133/5IDEAL2005simvastatin84simvastatin204.84439/44496281121151/174....SPARCL2006simvastatin85安慰剂4.92365/23666360133265/31124/4155/33ASPEN2006simvastatin86安慰剂41211/1199616611334/38....MEGA2006simvastatin87饮食5.33866/3966583115650/62..14/16CORONA2007simvastatin88安慰剂2.72514/24977376137103/11514/1115/9JUPITER2008simvastatin89安慰剂1.98901/8901666210833/643/66/9AURORA2009simvastatin90安慰剂3.21389/1384646210093/8140/3625/21SEARCH2009simvastatin91simvastatin206.76031/6033648397255/27957/67..合计......4.168687/6872164691242226/2604354/385186/16622急性脑梗死他汀与安慰剂或空白对照比较对所有卒中预防的meta分析

23急性脑梗死4个研究大剂量与标准剂量他汀对所有卒中预防的meta分析

24急性脑梗死ControllingBPforstroke>or=2medicationswithdifferentmechanismsofactionwillbenecessaryRAAShaveproventobeexcellenttherapeutictargetsAnumberofantiatheroscleroticeffectshavebeenattributedtoangiotensin-convertingenzymeinhibitorsandangiotensinreceptorblockerscombinationtherapywiththeseagentshasbecomethefocusofrecentclinicaltrialsAmHeartJ.2009Jun;157(6Suppl):S24-3025急性脑梗死Cumulativeproportionsofpatientsprescribednewmedicationnewstatin(adding)clopidogrelnewBPloweringmed.2newBPloweringmed.EXPRESSstudy,Rothwelletal,Lancet2007;370:1432-4226急性脑梗死ACEIsclinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.27急性脑梗死ARBs

andischemicstrokepreventionTheStudyonCognitionandPrognosisintheElderly(SCOPE)assessedtheeffectofcandesartantherapyonCVeventsinelderlypatients.SCOPEtrialassessedtheeffectofcandesartantherapyonCVeventsinelderlypatients.Activetreatmentwasassociatedwithasignificantreductioninnonfatalstroke(28%,P=.04vsplacebo)andtotalstroke(24%,P=.056vsplacebo).28急性脑梗死PRoFESStriallimitationsDiastolicBP(<80mmHg)inthefirstmonthpost-strokemayhavebeentoolowinatleastonethirdofthepopulationBaselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)29急性脑梗死CombinationACEI/ARBtherapyCombinationtherapyresultedina2.4/1.4-mmHggreaterdecreaseinBPcomparedwithramiprilaloneAgrowingnumberofstudiesindicatethatARBsandACEIsprovidestrokeprotectionbeyondtheirabilitytoreduce30急性脑梗死Meta-analysis4randomizedclinicaltrialsincluding426patients.94%hadischemicstrokeFluoroquinolonesin2andtetracyclineoracombinationofbeta-lactamantibioticwithbeta-lactamaseinhibitorin1Within24hoursDurationforbetween3and5daysArchNeurol.2009Sep;66(9):1076-81Preventiveantibioticsinpatientswithacutestroke

31急性脑梗死控制高血糖32急性脑梗死ManagementofhyperglycemiaincriticallyillpatientsAbetterlong-termoutcomewasshowninpatientswhosufferedfromMIandwhounderwentmeticulousbloodglucosecontrol1,548surgicalintensivecarepatientshadbeenrandomlyallocatedtoeithertheconventionalapproach(insulininfusionstartedonlywhenbloodglucoselevelsexceeded12mmol/L)orintensiveinsulintherapy(insulininfusedtomaintainbloodglucoseatalevelof4