神经病学神经病学cvd-2014

1、茫茫医海上下求索2018/9/301精卫一学生教师节送给我的藏头诗胡者自衡阳治学甚严谨平易近学生之其爱病人节际忆师恩日前书推荐快乐愿随君乐事常伴汝2018/9/302才高八斗，望岳长惊叹映醉赏雪月花伴伴伴高宜美人人人One should enjoy flowersin the company of beauties, get drunk under the moonin the company of charming friends, and enjoy the light of snowin the company of highminded scholars.2018/9/303中南大学湘

2、雅二院神经内科胡治平2018/9/304脑 血 管 疾 病Cerebral Vascular Diseases对新事物充满好奇， 将使你时刻处于最佳佳学习状态！2018/9/305 脑血管疾病与心脏病、恶性肿瘤构成多数国家三大 致死性疾病。Preface序我国： 年新发病例:130-150万 患病人数:500-600:100万 致残率：75%2018/9/306PrefaceIn the United States序 The third leading cause of death Killed 157,991 people in 1995 accounted for 1 of every 1

3、5 deaths On the average:one stroke every minuteone death from stroke every 3.4 minN Eng J Med. 1995;333:1392-40002018/9/307疾Definition脑血管疾病（ cerebral vascular disease ）是指各种病因使脑血管发生病变引起脑部病的总称Classification颅内蛛网膜下腔脑硬膜外硬膜下短暂性缺血发作高血压脑病颅内血管畸形脑动脉盗血综合征颅内静脉系统血栓脑梗死脑血栓脑栓塞腔隙性梗死血管性痴呆脑供血不足颅内动脉瘤动脉炎颅内异常血管网脑动脉硬化症中风S

4、troke2018/9/3010Stroke is a syndrome characterized bythe acute onset of a neurologic deficitthat persists for at least 24 hours, reflectsinvolvement of the central system, and isthe result of a disturbance of the cerebralcirculation.2018/9/3011Approachtodiagnosis Acute onset急性发作 Duration of deficit神

5、经功能缺损的持续时间2018/9/30126Approach to diagnosis.Reversible ischemic neurological deficit(RIND)Time course of cerebral ischemic events2018/9/3013Approach to diagnosis Focal involvement局灶症状1 In ischemic stroke, occlusion of a blood vessel producesa more or less stereotyped pattern of focal involvem

6、ent.2 Hemorrhage produces a less predictable pattern of focalinvolvement because such as increased intracranial presure, cerebral edema, compression of brain tissue and blood vessels, or dispersion of blood can impaire brain function at sitesfrom the hemorrhage.3 In most cases of stroke, the history

7、 and neurologic exmainationprovide enough information to localize the lesion to one side20o18f/9/b30rain and the anterior or posterior cerebral circulation.142018/9/3015Symptoms and signs of anterior and posterior Circulation ischmiaIncidence(%)2Symptom or Sign Headacheanterior 25posterior3Altered c

8、onscoiusness Aphasia*Visual field defect Diplopia * Vertigo * DysarthriaDrop attack *Hemi- or monoparesis Hemissensory defect52014003038331602274811161292018/9/30 *Most useful distinguishing feaures.162018/9/3017Approach to diagnosis Vascular origin血管源性1.Ischemia 缺血a.Thrombosis血栓形成b.Embolism Hemorrh

9、age栓塞2. a.Intracerebral hemorrhage 颅内b.Subarachnoid hemorrhage 蛛网膜下腔c.Subdural or epidural hemorrhage 硬膜下或硬膜外2018/9/3018Golgi apparatus2018/9/3019中心坏死区缺血半暗带正常供血区缺血半暗带(penumbra)示意图2018/9/30202018/9/3021缺 血 酸 中 毒脑组织损害碳酸氢盐下降加速离子催化的自由基反应酶的功能和结构蛋白变性水肿缺氧 糖酵解增加 乳酸增加，pH降低Focal cerebral ischemia局灶性脑缺血中南大学湘雅二

10、院神经内科胡治平2018/9/30222018/9/302Focal cerebral ischemiaEtiologyConditions associated with focal cerebral ischemia(1)(2)(3)32018/9/3024Sites of predilection (blue areas) for atherosclerosis in the intracranial arterial circulation.2018/9/3025主动脉切片在光下白色箭头指示的是最明显的脂质条纹2018/9/30262018/9/3027Focal cerebral i

11、schemia局灶性脑缺血PathologOn gross inspection at autopsy, a recent infarct is a swollen, softened area of brain that usually affects both gray and white matter (1).Old infarcts show cystic degeneration with shrinkageof the affected hemisphere and dilatation of the ipsilateral lateral ventricle(2), involv

12、ing spinal cord(3).213Focal cerebral ischemia局灶性脑缺血Pathology Microscopy shows acute ischemic changes in neurons (shrinkage, microvacuolization, necrosis), destruction of glial cells, necrosis of small blood vessels, disruptionof nerve axons and myelin, and accumulation of interstitial fluid from vas

13、ogenic edema. In some cases, perivascular hemorrhages are observed in the infarcted area.Lacunar infarctions-often multipleare found in about 10% of brains in autopsy. The pathologic appearance is of small cavities ranging in size from 0.5 to 15 mm in diameter.2018/9/3028Focal cerebral ischemia局灶性脑缺

14、血Clinicoanatomic correlationArterial supply of the primary motor and sensory cortex(lateral view).2018/9/3029Focal cerebral ischemia局灶性脑缺血Clinicoanatomic correlationArterial supply of the primary motor and sensory cortex(coronal view).2018/9/3030Focal cerebral ischemia局灶性脑缺血Clinicoanatomic correlati

15、on Arterior cerebral artery2018/9/30312018/9/3032FunctionaFunctionall anatomanatomyy ooff cercerebralebral arteriesarteriesKKeyey conceconcepptstsFocal cerebral ischemia局灶性脑缺血Clinicoanatomic correlation Middle cerebral artery occlusion 对侧偏瘫和偏身感觉缺失主要在上肢和面部，伴失语大脑中动脉及其分支供应大脑半球外侧面大部分的血液2018/9/3033Functi

16、onaFunctionall anatomanatomyy ooff cercerebralebral arteriesarteriesKKeyey conceconcepptstsFocal cerebral ischemia局灶性脑缺血Clinicoanatomic correlation Posterior cerebral artery occlusion 对侧同向偏盲，而中心视力保持大脑后动脉及其分支供应枕 、颞内侧面和顶叶尾部血液2018/9/30Focal cerebral ischemia局灶性脑缺血Clinicoanatomic correlation Lacunar inf

17、arctionFour classic and distinctive lacunar syndromes: Pure motor hemiparesis纯运动性轻偏瘫 Pure sensory stroke纯感觉性卒中 Ataxi hemiparesis共济失调性轻偏瘫 Dysarthria-clumsy hand syndrome构音障碍-笨拙手综合症34Investigation:EchocardiographyAbnormalities that are detectable include mitral valve prolapse and atrial myxoma .Invest

18、igation:CTscanningA low density lesion appears, with prominent oedema in about a fifth of the cases. Contrast enhancement is found in about 70 per cent of cases and reaches a maximum intensity after about two weeks.Investigation:CTscanningSometimes the enhancement shows a ring pattern mimicking that

19、 seen in cases of tumour or abscess. Haemorrhagic infarction appears as a lesion of mixed density with the higher density usually lying centrally.CInvestigation:MRIscanningThe oedema is hyperintense on T2-weighted images(b). Any mass effectappearing within the first few days will be detected. Subseq

20、uently,a reduced signal area is found on T1-weighted images(a).In longstanding infarcts, cystic changes show density characteristics ofCSF surrounded by a zone of increased signal on T2-weighted imagescorresponding to areas of gliosis (c).2018/9/3038Investigation:MRIscanningMRI is of particular valu

21、e in the detection of brain stem infarcts. Scanning soon after the onset demonstrates high intensity signal on T2-weighted images (Fig 4.39). Lacunar infarcts, easily missedif only CT scanning is performed, are more readily detected by MRI.Carotid occlusionInvestigation:Duplex scannerHaving identifi

22、ed the common carotid artery, the region of the bifurcation is scanned for any evidence of stenosis or occlusion. Calcified plaques can be identified (Fig 4.41), as can more severe disease or complete occlusions (Fig 4.42). The technique can be used to evaluate asymptomatic carotid stenosis, and to

23、assess any restenosis occurring after carotid endarterectomy.Calcified plaquesCarotid angiogramshowing plaque and stenosisFocal cerebral ischemia局灶性脑缺血Diagnosis（1）常于安静状态下发病（2）大多数无明显头痛和呕吐发病可较缓慢，多逐渐进展，呈阶段性进行，多与脑A硬化有关（3）一般发病后1-2天内意识清楚或轻度障碍（4）有颈内A系统和椎、基底A系统症状和体征（5）腰穿一般不含血（6）鉴别诊断困难时可作CT确诊。Focal cerebral

24、ischemia局灶性脑缺血Treatmentn 急性期治疗1.一般处理 2.调整血压3.不用血管扩张剂 4.溶栓治疗（适应症） 5.抗凝治疗6.防7.血液稀释疗法 8.抗血小板聚集剂 9.治脑水肿钙拮抗剂 10.脑代谢活化剂 11.病因治疗(抗炎等)12.中医药治疗 13.中风病房 14.手术治疗 15 . 关201恢8/9/3复0期治疗功能锻炼、言语训练、针灸等。43美国方案（）：SBP230mmHgDBP140mmHg硝普那静滴SBP 180-230mmHgDBP 105-140mmHg依那普利口服SBP180mmHgDBP105mmHg延缓降压2018/9/3044Intracereb

25、ral hemorrhage颅内中南大学湘雅二院神经内科胡治平2018/9/3045Intracerebral hemorrhage颅内 DefinitionSpontaneous(自发性）intracerebral hemorrhage(bleeding into the intracerebral parenchyma) isusually the result ofetiological factors(nontraumatic).2018/9/3046Intracerebral hemorrhage颅内 Etiology Hypertension Vascular malformati

26、ons Hemorrhage into infarction Cerebral amyloid angiopathy Arteritis Hemorrhage into tumors Coagulopathy Anticoagulation高血压血管畸形梗死后脑淀粉样血管病动脉炎瘤卒中凝血病抗凝2018/9/3047Intracerebral hemorrhage颅内 Pathophysiology Cerebral autoregulation脑血流自动调节Figure. Cerebrovascular autoregulation. A: Cerebral blood flow is ma

27、intained in the normal range over a wide range of blood pressures. At very low pressures, cerebral hypoperfusion occurs, producing syncope. Pressures that rise beyond the autoregulatory range can cause hypertensive encephalopathy.B: Structural changes in cerebral arteries shift the autoregulatory ra

28、nge to higher blood pressures. Hypoperfusion and syncope can occur at normal pressures, and pressures associated withhypertensive encephalopathy are incre4a8sed2018/9/30Intracerebral hemorrhage颅内 Pathophysiology Chronic hypertension慢性高血压Chronic hypertension appears to promote structure changesin the

29、 walls of penetrating arteries（穿支动脉壁结构改变），predisposing them tointracerebral hemorrhage.Acute hypertention急性高血压a sudden increase in blood pressure may itself be sufficient to cause intracerebral hemorrhage.2018/9/3049Intracerebral hemorrhage颅内 Pathology caudate and putaminal (42%)尾状核和壳（42%） basilar a

30、rtery supplying the pons (16%)供应脑桥的基底动脉分支（16%） thalamic (15%)丘脑（15） superior cerebellar(12%)小脑上动脉（12%） some white matter branches (10%)每些白质动脉分支（10%）Fig.The distribution of spontaneous intracerebral haemorrhage2018/9/3050Intracerebral hemorrhage颅内 Clinical findings Certain clinical features, particul

31、arly headache(头痛）,loss ofconsciousness（意识障碍）,seizures（癫痫发作） and vomiting（呕吐）, were once considered so characteristic ofintracerebralhaemorrhage that their absence was thought to cast doubt on the diagnosis. Clinical features vary with the site of hemorrhage(临床特征因部位不同而不同）.2018/9/3051Intracerebral hem

32、orrhage颅内 Clinical findingsCDABA.Haematomas within the putamen and internal capsule. B.Thalamic haematoma.C. Pontine haematoma.D. Cerebellar Haematoma.2018/9/30522018/9/30Anatomic relationshipsin deep cerebral hemorrhage.Top: Plane of section.Bottom:Putaminal (1)and thalamic (2) hemorrhages can comp

33、ress or transect the adjacent posterior limb of the internal capsule. Thalamic hemorrhages can also extend into the ventriclesor compress the hypothalamusor midbrain upgaze center (3)53Clinical features of hypertensive intracerebral hemorrhage2018/9/3054Intracerebral hemorrhage颅内 Differential diagno

34、sisCerebral infarction clinicalCT or MRI CSF2018/9/3055Intracerebral hemorrhage颅内 Treatment Medical mearures1. Preventing elevation of intracranial pressure: 20%Manitol, Katlex防止颅压增高：20%甘露醇、速尿2. Adjusting the blood pressure (to approximately 200/120mmHg)调整血压（大约为200/120mmHg)3. Iso-osmotic fluid to mi

35、nimize free water exacerbating edema给予等渗液减少游离水以免加重脑水肿4. Turned q23h to prevent decubitus ulcers每2-3 小时翻身以防止褥疮溃疡的发生5. Passive exercises 3 to 4 times a day to prevent the development of contractures每天3-4次被动运动以防止肢体挛缩2018/9/3056脑脑水肿超早期（）：血肿血浆蛋白渗出间质性水肿早期（，持续周）：血块释放凝血酶细胞毒性水肿迟发性（达高峰，与水肿高峰一致）：补体系统激活红细胞溶解血脑屏

36、障通透性增加治疗：甘露醇，活动性慎用甘露醇使血肿以外的脑组织脱水后血肿与脑组织压力梯度血肿扩张和活动性加重症状2018/9/3057Intracerebral hemorrhage颅内 Treatment Surgical measures1. Cerebellar decompression小脑减压2. Cerebral decompression （a superficial hemorrhage）大脑减压（表浅）3. Contraindications to surgerySurgery is not indicated for pontine or deep cerebral hype

37、rtensive hemorrhages,外科禁忌症脑干和深部脑2018/9/30584Subarachnoid hemorrhage中南 大学湘 雅 二院 神经内 科胡 治 平2018/9/3059Subarachnoid hemorrhage蛛网膜下腔DefinitionSpontaneous(自发性） subarachnoid hemorrhage(bleeding into the subarachnoid space) is usuallythe result ofetiological factors (nontraumatic).2018/9/3060Subarachnoid h

38、emorrhage蛛网膜下腔 EtiologyCongenital aneurysm先天性动脉瘤AVM动静脉畸形Arteriosclerotic aneurysm动脉硬化性动脉瘤Others : surgical factor etc.2018/9/30其他：手术等61Subarachnoid hemorrhage蛛网膜下腔 PatholgyA.Saccular aneurysmanddevelopmental weakness of the vessl wall2018/9/3062Subarachnoid hemorrhage蛛网膜下腔 PatholgyB.Frequency and di

39、stribution of intracranialaneurysms2018/9/306364Subarachnoid hemorrhage蛛网膜下腔 Pathophysiologydistorts pain-sensitive structures elevates intracranial pressureheadache.retinal hemorrhages（视网膜）reach systemic perfusion pressure acutely decrease cerebral blood flowthe loss of consciousness2018/9/30Subara

40、chnoid hemorrhage蛛网膜下腔 Clinical FindingsAge :30 years to 60 years3060岁Clinical manifestation:headache vomittingmenigeal irritation sign bloody CSF头痛呕吐脑膜刺激征血性脑脊液2018/9/3065Brudziskis Sign2018/9/3066Subarachnoid hemorrhage蛛网膜下腔 Laboratory Findings-Imaging123542018/9/3067Subarachnoid hemorrhage蛛网膜下腔 La

41、boratory Findings-CSF ExaminationElevated pressure Bloody Xanthochromia压力增高血性黄变2018/9/3068Subarachnoid hemorrhage蛛网膜下腔 Differential DiagnosisA.Subrachnoid Hemorrhageheadache nuchal rigiditynonfocal neurologic sign bloody CSF头痛颈项强直无神经局灶征血性脑脊液B.Hypertensive Intracerebral Hemorrhagebloody CSFprominent focal findings血性脑脊液明显局灶症状C.MeningitisCSF examination脑脊液检查D.Traumatic2018s/9p/3i0nal puncturebloody CSFwith colorless离心血性脑脊液supernatantof centrifugation上清液无6色9Subarachnoid hemorrhage蛛网膜下腔 Complications & SequelaeA.B.C