心源性脑栓塞

心源性脑栓塞1.病历特点中年男性，反复发作渐进性病程；既往高血压史，夹层动脉瘤及主动脉瓣关闭不全换瓣术后3年，口服抗凝药不规范。近2年多次脑梗塞史。发病表现为反复发作的神经功能缺损，渐进性的神经功能缺损。查体主要表现为言语表达障碍，构音含混，右面部麻木及右肢轻偏瘫，及右侧同向偏盲。辅助检查：凝血象（INR）偏低；

CT：脑内多发梗塞2.定位诊断双侧颈内动脉系统，左侧著椎基底动脉系统？

3.定性诊断心源性栓塞主动脉机械瓣膜组织栓子脱落

4.AorticDissectionAnatomy,PhysiologyandPrinciplesofTherapy5.History1555–Vesaliusdiagnosedapulsatingtumornearthevertebraeinapatient’sbackandcalledit“adilatationoftheaorta”18261826–Laennecintroducedthetermdissectinganeurysm1800’s–surgerywasperformedontheentitybyJohnHunter,AstleyCooperandothersevenbeforetheeraofgeneralanesthesiaEarlyoperationsweredesignedtoproducedistalinternalfenestrationtocausedownstreamdecompressionoftheaorta.6.History1951LamandAramintroducedhomograftsforrepairofdescendingthoracicaneurysms1953CooleyandDeBakeyusedartificialgraftsforrepair1953Bahnsonintroducedaneurysmorrhaphy1957cardiopulmonarybypassbecameavailable7.DefinitionTrueaneurysm–localizedenlargementoftheaortacontainedbyallthelayersoftheaorticwallFalseaneurysm–enlargementcontainedbytheaorticadventitiaandperiaorticfibroustissue.8.9.10.DefinitionAorticdissection–SuddencatastrophiceventinwhichatearintheintimaallowsbloodtoescapefromthetruelumenoftheaortarapidlyseparatingtheinnerfromtheouterlayerofthemediaColumnofbloodisdrivenbytheforceoftheleftventricularsystolicpressurewhichstripstheintimafromtheadventitia11.DefinitionAcute–lessthan14daysoldChickenortheegg?–Hemorrhageinthemediacausesruptureoftheintimaordissectinghematomainanintimaltear.12.CausesofAneurysmMedialdegenerationandlocaldilatationAtherosclerosisSyphilis(ascendingonly)Bacterialinfections(mycotic)CongenitalabnormalitiesTraumaAnnuloaorticectasia13.CausesofDissectionInherentweaknessoftheaorticwallHypertension–70-90%PregnancyIatrogenicBicuspidaorticvalveandcoarctationClosedchesttrauma14.PathophysiologyLawofLaplace:Asasphereincreasesinsize,thewalltensionofthesphereincreasesWeakenedwallDilatationExpansionwithpressure-relatedsymptomsRupture15.NaturalHistoryNotwelldocumentedSigns,symptomsandprognosisrelatedtothesizeoftheaneurysmThoracicaneurysmslargerthan6cmaremorepronetorupturethanthesmallerones5yearsurvivalforsymptomaticaneurysmsis27%whereas58%withasymptomaticonessurvivedthesameperiodoftime.Ruptureisthemostcommoncauseofdeath16.NaturalHistoryManypatientswithdissectiondieacutelyduetocardiactamponadeordissectionoftheLAD8%ofascendingrupturessurvivewithouttreatment75%survivedescendingdissection17.ClassificationTypeI-BeginsattheaorticvalveandmayproceedtoandincludetheabdominalaortaTypeII–Beginsdistaltotheleftsubclavianarteryandcanencompasstheentireaortatotheiliacarteries18.19.20.21.AnatomicalConsiderations22.PathoanatomyDissectionoftheascendingaortaariseswithinseveralcentimetersoftheaorticvalve–66%DissectionofthedescendingaortaoccurjustbeyondtheleftsubclavianarteryattheligamentumarteriosumSmallpercentageoccuratthetransversearchordescendingaorta23.PathophysiologyAfterdissectionintothemedia,bloodrushesintothedissectedareaNecrosisoftheaorticwallthendevelopsseveraldaysaftertheevent–observedin62%ofcasesComplicationsincludeaorticrupture,obstructionandocclusionofaorticbranches24.25.ClinicalSignsandSymptoms26.DemographicsMales>females3:1SixthorseventhdecadeoflifePatientswithascendingdissectionareabouttenyearsyoungeratpresentationthanthosewithdescendingdissection27.SymptomsSudden,severechestpain–tearingsensationintheanteriorchestradiatingtothearmsortobetweenthescapulaeMayhavesyncope,neurologicsigns,weakness,hypotension.28.PhysicalFindingsParalysisMuffledhearttonesNewonsetaorticinsufficiencymurmurUnequalbloodpressureandpulsesintheextremitiesJugularvenousdistention–tamponadeAbdominalpain–acuteAcutehypertensionandanuria29.DiagnosisPlainchestradiograph–widenedmediastinum,pleuraleffusionElectrocardiogram–mayresembleacutemyocardialinfarctionparticularlyiftheLADisaffectedCTscan–identifiestheproblembutdoesnotprovidearoadmapAngiography–goldstandardTransesophagealechocardiography30.31.32.33.34.Therapy35.AscendingDissectionSurgicalemergencyCanonlybetreatedbyoperationMayormaynotrequireaorticvalvereplacementand/orcoronarybypasssurgerydependingontheprogressionofthedissectionMortality–about20%dependingonothermedicalproblemsandthepresenceofneurologicalsymptoms36.DescendingDissectionTherapycontroversialIfrupturepresent–operationistheonlyalternativeIntheabsenceofrupture,medicallytreatedpatientsdobetterthanthoseundergoingoperationduetocomorbidities37.GoalofOperativeTherapyObliterationofthesiteoftheintimaltearandthefalselumenReapproximationofthedissectedaortaRepairofaorticvalveorreplacementwithvalveconduitPerformbypassgraftingasneeded38.ConductoftheOperationAppropriatepreoperativeassessmentGeneralanesthesiaCardiopulmonarybypassAscendingdissection–profoundhypothermiawithcirculatory