CerebrovascularDisease.ppt

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1、Section 1 IntroductionnDefinition nCVD: The term of CVD designates any abnormality of the brain resulting from various pathological process of the blood vessels. 脑血管病是各种脑血管病变引起脑脑血管病是各种脑血管病变引起脑部疾病的总称。部疾病的总称。nDefinition nStroke: The stroke is a syndrome characterized by the acute onset of a neurologic

2、 deficit that reflects focal/diffused involvement of the CNS and is the result of a disturbance of the cerebral circulation. n n脑卒中是指急性起病脑卒中是指急性起病 、迅速出现局限性、迅速出现局限性或弥漫性脑功能缺失征象的脑血管性事件或弥漫性脑功能缺失征象的脑血管性事件。nEpidemiology:nCVD is the third most common cause of death after heart disease and cancer.nIncidence

3、: 100300/100,000nmorbidity: 100740/100,000nmortality: 50100/100,000nAbout 50%70% of survivors shows disability in different degree. Classification of CVDnAccording to the lasting time of neurologic deficit:nTIA (24h).nAccording to the severity of neurologic deficit:nminor stroke nmajor stroke n sile

4、nt strokenAccording to the pathological features:nischemic strokenhemorrhagic stroke (see table 8-1)脑部的血液供应脑部的血液供应-Blood supply in brainn颈内动脉系统颈内动脉系统 - internal carotid artery (ICA) S. 眼动脉眼动脉-ophthalmic artery 后交通动脉后交通动脉-post communicating artery 脉络膜前动脉脉络膜前动脉-anterior choroidal artery 大脑前动脉大脑前动脉-ant

5、erior cerebral artery (ACA) 大脑中动脉大脑中动脉-middle cerebral artery (MCA)n供应眼部及大脑半球前供应眼部及大脑半球前3/53/5部分即额叶、颞叶、顶叶及基部分即额叶、颞叶、顶叶及基地节的血液地节的血液n见图见图the circle of Willis环环n见图脑基底部动脉见图脑基底部动脉n椎椎- -基底动脉系统基底动脉系统-vertebral-basilar artery S.n椎动脉椎动脉(VA): Which is divided into nanterior spinal artery (脊髓前动脉脊髓前动脉)nposterio

6、r spinal artery (脊髓后动脉脊髓后动脉)nmedullary artery (延髓动脉延髓动脉)n posterior inferior cerebellar artery (小脑小脑后下动脉后下动脉)n基底动脉基底动脉(BA): Which has branches of nanterior inferior cerebellar artery（小脑前下动脉）（小脑前下动脉）nbranches of pons（脑桥支）（脑桥支） ninternal auditory artery（内听动脉）（内听动脉）nsuperior cerebellar artery （小脑上（小脑上动

7、脉）动脉）n大脑后动脉大脑后动脉 (posterior cerebral artery, PCA) , which is the terminal division of BAn椎基底动脉系统供应脑干椎基底动脉系统供应脑干,小脑及大脑小脑及大脑 半球半球后后2/5部分即枕叶及颞叶的基底面，枕叶的部分即枕叶及颞叶的基底面，枕叶的内侧及丘脑等。内侧及丘脑等。Etiology of CVDn Vascular disordern AtherosclerosisnInflammatory disorders (TB,syphilitic arteritis, SLE, etc.)nCongenital

8、 vascular malformation (aneurysm, AVM )nLesions of any cause Etiology of CVDnHeart diseases and blood kinetics changesnHypertention or hypotensionnAtrial fibrillation, Rheumatic heart disease, arrhythmias etc.nChanges in blood constituent and hemodynamicsnIncrease in blood viscositynAbnormality in b

9、lood coagulation mechanismnOthersnSuch as emboli of air , fat, cancer cells. Blood vessel spasm, trauma, etc.Risk factorsnSeveral factors are known to increase the liability to stroke. The most important of these are:nHypertention nHeart diseases nDiabetesnTIA or stroke history Risk factorsnSmoking

10、and alcohol nHyperlipidmianOthers: food, symptomless ICA bruit, overweight, drug abuse, contraceptive，age, sex, family history, race, etc.Section 2 Transient Ischemic Attack, TIA (短暂性脑缺血发作短暂性脑缺血发作)nConceptnEtiology and mechanismnClinical findingsnInvestigative studiesnDiagnosis and differentiationnT

11、reatment and preventionTIA-ConceptnTIA is brief, repeated, reversible episodes of focal ischemic neurologic disturbance. The duration of which should be less than 24h (usually lasting about several min to 1h).nRepeated TIAs of uniform type are more often a warning sign of ischemic stroke.TIA-Etiolog

12、y and mechanismThere is little doubt that they are due totransient focal ischemia.Their mechanism is not fully under-stood. But they might be thought of asfollows: Micro-emboli Vascular spasm Hemotologic disorders and bloodconstituent changes OthersTIA-Clinical findingsnAge of onset, 5070, male fema

13、lenBasic features:nTransient episode (30 seconds-metabolic change, 1 min - cease of neuron activity, 5min - cerebral infarct.nIschemic penumbra (缺血半暗带缺血半暗带）ntime window (6h)PathophysiologynReperfusion damage: possible mechanisms:n自由基自由基 (free radical)形成及其瀑布式形成及其瀑布式反应反应n神经细胞内钙超载神经细胞内钙超载(calcium overl

14、oad)nEAA毒性作用毒性作用(toxic effect of excitatory amino acid)n酸中毒酸中毒(acidosis)Typesn大面积脑梗死（大面积脑梗死（a large area CI）n分水岭脑梗死分水岭脑梗死 (cerebral watershed infarction, CWSI)n出血性脑梗死出血性脑梗死 (hemorrhagic infarct, HI)n多发性脑梗死多发性脑梗死 (multiple infarct, MI)Clinical features nClinical typesnComplete stroke: reaches peak wi

15、thin several hours (24h and recovering within 3wsClinical featuresnGeneral features:nMiddle-aged or elderly people (caused by Atherosclerosis), youth or middle-aged people (caused by arteritis).nStroke onset at quiet state and reaches the peak within several hours to 12 days. Clinical featuresnGener

16、al features:nUsually, the patients are awake and alert except for those with a large area of CI or infarction in brainstem.Clinical syndromes of CInOcclusion syndrome of carotid artery nCarotid artery occlusion may be asymptomatic. Symptomatic occlusion results in syndromes follow: nTransient monocu

17、lar blindness caused by ipsilateral retinal artery ischemia.nHorners sign.Clinical syndromes of CInOcclusion syndrome of carotid artery nCarotid artery or ophthalmic artery bruit and a weakened pulse in carotid artery.n Contralateral hemiplegia, hemisensory deficit, and homonymous hemianopia.nAphasi

18、a, if dominant hemisphere involvement.Clinical syndromes of CInOclusion syndrome of MCAn主干闭塞主干闭塞 (Occlusion in stem): is a severe stroke syndrome which combines the features of superior and inferior division stroke.n三偏症状三偏症状 (contralateral hemiparesis, hemisensory deficit, and homonymous hemianopia)

19、.Clinical syndromes of CInOclusion syndrome of MCAn失语症失语症、体象障碍体象障碍 (globle aphasia, if dominant hemisphere is involved, and body image disturbence )n意识障碍、颅内压增高、脑疝可导意识障碍、颅内压增高、脑疝可导致死亡致死亡(disturbence of consciousness, increased ICP, and herniation)Clinical syndromes of CInOclusion syndrome of MCAn皮层支闭

20、塞皮层支闭塞(occlusion in superior division)n中枢性面舌瘫和偏瘫，偏瘫上肢重中枢性面舌瘫和偏瘫，偏瘫上肢重于下肢于下肢 (contralateral hemiparesis that affects the face, hand, and arm but less severe in the leg).Clinical syndromes of CInOclusion syndrome of MCAn皮层支闭塞皮层支闭塞(occlusion in superior division)n伴感觉障碍，主要是皮质感觉障碍伴感觉障碍，主要是皮质感觉障碍 (contral

21、ateral hemisensory deficit,mainly shows cortical sensory deficit)n失语失语、体象障碍体象障碍 (aphasia and body image disturbence)Clinical syndromes of CInOclusion syndrome of MCAn深穿支闭塞深穿支闭塞(occlusion in inferior division)n对侧偏瘫对侧偏瘫(contralateral hemiparesis, upper and lower limbs evenly affected)n对侧偏身对侧偏身感觉障碍及偏盲感

22、觉障碍及偏盲(contralateral hemisensory deficit and homonymous hemianopia)n可有失语可有失语(dominant hemisphere involved)Clinical syndromes of CInOcclusion syndrome of ACA n主干闭塞主干闭塞(occlusion in stem)n中枢性面舌瘫、偏瘫下肢重于上肢中枢性面舌瘫、偏瘫下肢重于上肢(挑扁担样瘫挑扁担样瘫) (Shoulde-pole-carry-like), 伴轻度感觉障碍伴轻度感觉障碍n尿便障碍或尿急尿便障碍或尿急(旁中央小叶损旁中央小叶损),

23、 (incontinence , paracentral lobule is affected) Clinical syndromes of CInOcclusion syndrome of ACA n主干闭塞主干闭塞 (occlusion in stem)n精神症状精神症状 (psychiatric symptom) (颞颞极与胼胝体受累，极与胼胝体受累，temporal pole andcorpus callosum are affected)，常可见强握、常可见强握、吸吸吮反射吮反射 (额叶病变额叶病变) (grasp reflex, suck reflex are common sig

24、ns, lision in frontal lobe). Clinical syndromes of CInOcclusion syndrome of ACA n皮层支闭塞皮层支闭塞(occlusion in superior division)n对侧偏瘫，下肢重于上肢对侧偏瘫，下肢重于上肢 (sensorimotor deficit of the opposite leg and foot and , to less degree, of the shoulder and arm ) Clinical syndromes of CInOcclusion syndrome of ACA n深穿

25、支闭塞深穿支闭塞 (occlusion in inferior division)n面、舌、肩瘫面、舌、肩瘫 (contralateral paresis includes face, lingua, shoulder)Clinical syndromes of CInOcclusion syndrome of PCAn主干闭塞主干闭塞 (occlusion in stem )：n对侧偏盲、偏瘫及偏身感觉障碍对侧偏盲、偏瘫及偏身感觉障碍(较较轻轻)n 丘脑综合症丘脑综合症 (thalamic syndrome)n主侧半球病变可有失读症主侧半球病变可有失读症(alexia). Clinical

26、syndromes of CInOcclusion syndrome of PCAn皮层支闭塞（皮层支闭塞（ occlusion in superior division ）n对侧同向性偏盲对侧同向性偏盲(contralateral homonymous hemianopia)、象限盲象限盲(quadrant hemianopia)、皮质盲皮质盲(cortical blidness, bilateral involvment) Clinical syndromes of CInOcclusion syndrome of PCAn皮层支闭塞（皮层支闭塞（ occlusion in superio

27、r division ）n主侧颞下动脉闭塞时可见视觉性失认症主侧颞下动脉闭塞时可见视觉性失认症 (visual agnosia)和颜色失认和颜色失认(achromatopsia)n主侧半球顶枕动脉闭塞可有对侧偏盲，主侧半球顶枕动脉闭塞可有对侧偏盲，失语失语。Clinical syndromes of CInPCA occlusion syndromen深穿支闭塞深穿支闭塞 (occlusion in inferior division) n丘脑穿通动脉闭塞：红核综合征丘脑穿通动脉闭塞：红核综合征（Claude syndrome)n丘脑综合征丘脑综合征(thalamic syndrome): s

28、nesory loss, spontaneous pain and dysesthesias, choreoathetosis, intention tremor, spasm of hand, mild hemiparesis.Clinical syndromes of CInPCA occlusion syndromen深穿支闭塞深穿支闭塞 (occlusion in inferior division) n中脑分支闭塞：中脑分支闭塞：Weber syndrome: third nerve palsy ad contralateral hemiplegia.Clinical syndrom

29、es of CInSyndrome of vertebral- basilar artery occlusionn主干闭塞：广泛脑干梗死。主干闭塞：广泛脑干梗死。Shows symptoms of cranial nerves, pyramidal tract, and cerebellum.Clinical syndromes of CInSyndrome of vertebral- basilar artery occlusionn基底动脉尖综合征（基底动脉尖综合征（Top of the basilar Syndrome）:nAbnormality in eye movement and

30、pupilsndisturbance of consciousness (loss of consciousness)nhomonymous hemianopia or cortical blindnessnsevere memory disorderClincal syndromes of CInSyndrome of vertebral- basilar artery occlusionn脑干分支闭塞脑干分支闭塞nWeber syndromenMillard-Gubler syndromenFoville syndromeClincal syndromes of CInSyndrome o

31、f vertebral- basilar artery occlusionn小脑后下动脉闭塞小脑后下动脉闭塞-延髓背外侧综合症延髓背外侧综合症(Wallenberg syndrome) n眼球震颤眼球震颤 (nystagmus)n交叉性感觉障碍交叉性感觉障碍 (crossed sensory deficit) n球麻痹球麻痹 (bulbar paralysis) n病灶侧病灶侧Horner征征 (ipslateral Hornor sign)n病灶侧小脑性共济失调病灶侧小脑性共济失调 (ipslateral cerebellar ataxia) Clincal syndromes of CIn

32、Syndrome of vertebral- basilar artery occlusionn闭锁综合征闭锁综合征(Locked -in syndrome): 基底动基底动脉分支双侧闭塞脉分支双侧闭塞nCerebellar infarction n由小脑上动脉由小脑上动脉(superior cerebellar artery)、小脑后下动脉小脑后下动脉(posterior inferior cerebellar artery)、小脑前下动脉闭塞小脑前下动脉闭塞 (anterior inferior cerebellar artery)所致所致。Laboratory findingsnCT s

33、can：normal at the day of onset of the stroke, shows the low density of the infarct after 2448h. CT is preferred for initial diagnosis since it can make the critical distinction between ischemia and hemorrhage (见图见图 )Laboratory findingsnMRI：may be superior to CT scan for demonstrating early ischemic

34、infarcts, showing ischemic stroke in brainstem or cerebellum and detecting thrombosis occlusion of venous sinuses.Laboratory findingsnCerebral angiography：MRA, DSAnBlood tests and ECG: Serum glucose, cholesterol and lipid ,hemorheology.nTCD and CSFDiagnosis and differentiationnDiagnosisndiagnosis ca

35、n be made depending on the clinical features (Patients presenting with focal central nervous system dysfunction of sudden onset, Lasting more than 24h)nCT and MRI changesDiagnosis and differentiationnDifferential diagnosis: nCerebral hemorrhagencerebral embolismnOther structural brain lesions: tumor

36、,abscess, etc. 脑出血和脑梗塞的鉴别要点脑出血和脑梗塞的鉴别要点 脑出血脑出血 脑梗塞脑梗塞1.1.发病年龄发病年龄 6060岁以下岁以下 多多6060岁以上岁以上2.TIA2.TIA史史 多无多无 常有常有3.3.起病状态起病状态 活动中活动中 安静状态或睡眠中安静状态或睡眠中4.4.起病速度起病速度 急急( (分、时分、时) ) 较缓较缓( (时、日时、日) )5.5.血压血压 明显增高明显增高 正常或增高正常或增高6.6.全脑症状全脑症状 明显明显 多无多无7.7.意识障碍意识障碍 较重较重 较轻或无较轻或无8.8.颈强直颈强直 可有可有 无无9.9.头颅头颅CTCT 高密

37、度病灶高密度病灶 低密度病灶低密度病灶10.10.脑脊液脑脊液 血性血性, ,洗肉水样洗肉水样 无色透明无色透明其中最重要的是其中最重要的是2 2、3.3.两条。两条。Treatmentn急性期治疗（急性期治疗（Treatment in acute stage） 治疗原则：治疗原则： 超早期治疗超早期治疗-力争溶栓；力争溶栓； 综合保护治疗；综合保护治疗； 个体化治疗；个体化治疗； 整体化治疗；整体化治疗； 对危险因素及时予以预防性干预措对危险因素及时予以预防性干预措施。施。Treatmentn超早期溶栓治疗超早期溶栓治疗n目的：溶解血栓；迅速恢复梗死区血目的：溶解血栓；迅速恢复梗死区血流灌注

38、；减轻神经元损伤。（流灌注；减轻神经元损伤。（6h）ncomplications: Hemorrhage, reperfusion damage and brain edema, reocclusion.Treatmentn超早期溶栓治疗超早期溶栓治疗nThrombolytic agents :Urokinase (UK), Straptokinase (SK), recombinant tissue plasminogen activator (rt-PA)Treatmentn超早期溶栓治疗超早期溶栓治疗nIndications: nAge 75 n no disturbance of co

39、nsciousnessnwithin 6h(or 12h for progressive stroke) of onset nBp 200/120mmHgnno hemorrhage shown on CT scanningnexclusion of TIAnno other hemorrhagic diseases TreatmentnAntiplatelet agentsnThe regime is as described in the section of TIA. nAnticoagulation agents: to prevent the progression of throm

40、bosis. The agents used are the same as mentioned in the section of TIA.nFibrinogen degradation therapy: 降纤酶降纤酶 (Defibrase), 巴曲酶巴曲酶 (Batroxobin), 安洛克酶安洛克酶(Ancrod)和引激酶。和引激酶。TreatmentnNeuroprotective agents:n抗自由基：抗自由基：V-E V-C 甘露醇甘露醇 激素等激素等n抑制脑代谢抑制脑代谢急性期时应降低脑代谢，减急性期时应降低脑代谢，减少脑细胞耗氧量使缺血区血流量增加少脑细胞耗氧量使缺血区血流

41、量增加n钙离子拮抗剂：西比灵钙离子拮抗剂：西比灵 尼莫地平等尼莫地平等n亚低温亚低温n胰岛素维持血糖正常低限水平胰岛素维持血糖正常低限水平TreatmentnOther forms of medical treatment: such as therapies aimed at improving blood flow: hemodilution, metabolic improving agents-ATP, Co-A, 脑活素等脑活素等。TreatmentnSurgical treatmentnGeneral treatmentnICU: monitoring ECG, Bp, R, P,

42、 etc.nAntiedema agentsnPreventing infectionnPhysical therapy and rehabilitationnPreventive measures腔隙性脑梗塞腔隙性脑梗塞-Lacunar InfarctionnConcept： nSmall penetrating arteries located deep in the brain may become occluded as a result of changes in the vessel wall induced by chronic hypertension and atherosc

43、lerosis. n是指发生在大脑半球深部白质及脑干的缺血性微是指发生在大脑半球深部白质及脑干的缺血性微梗死因脑组织缺血、坏死、液化并由吞噬细胞移梗死因脑组织缺血、坏死、液化并由吞噬细胞移走而形成走而形成腔隙腔隙，占脑梗死的。，占脑梗死的。多见于基底节区、多见于基底节区、放射冠、丘脑、脑干等部位放射冠、丘脑、脑干等部位。 腔隙性脑梗塞腔隙性脑梗塞-Lacunar InfarctionnCommon types:n纯运动性卒中纯运动性卒中(Pure motor hemiparesis, PMH)n纯感觉性卒纯感觉性卒(Pure sensory stroke, PSS)n共济失调性轻偏瘫共济失调性

44、轻偏瘫(Ataxic-hemiparesis, AH)n构音障碍构音障碍-手笨拙综合征手笨拙综合征 (Dysarthric- clumsy hand syndrome, DCHS)n感觉运动性卒中感觉运动性卒中(Sensorimotor stroke, SMS)n腔隙状态腔隙状态(Lacunar state)脑栓塞脑栓塞-Cerebral embolismnConceptnEtiology and mechanismnClinical findingsnInvestigative studiesnDiagnosis and differentiationnTreatment and progn

45、osis脑栓塞脑栓塞-Cerebral embolismnConcept：nembolism produces stroke when cerebral arteries occluded by the distal passage of thrombus from the heart,aortic arch, or large cerebral arteries. n脑栓塞指各种栓子随血流进入颅内动脑栓塞指各种栓子随血流进入颅内动脉系统使血管腔急性闭塞引起相应供脉系统使血管腔急性闭塞引起相应供血区脑组织缺血坏死及脑功能障碍。血区脑组织缺血坏死及脑功能障碍。脑栓塞脑栓塞-Cerebral em

46、bolismnEtiologyn心源性心源性 (Cardiogenic)n非心源性非心源性 (non-cardiogenic)n 来源不明来源不明 (source unknown)nPathology n多见于颈内动脉系统，尤其是左侧大多见于颈内动脉系统，尤其是左侧大脑中动脉，病理上与脑血栓形成基本脑中动脉，病理上与脑血栓形成基本相同。但栓子常为多发切易破碎。相同。但栓子常为多发切易破碎。Clinical findingsn发病急骤，症状在数秒或数分钟内达高峰，发病急骤，症状在数秒或数分钟内达高峰，是血管病中最快的是血管病中最快的n多属完全性中风，栓塞部位继发血栓时病情多属完全性中风，栓塞部位

47、继发血栓时病情可逐渐进展可逐渐进展n可有头痛、局灶性癫痫和不同程度的意识障可有头痛、局灶性癫痫和不同程度的意识障碍碍n神经系统定位体征神经系统定位体征n原发病的症状和体征原发病的症状和体征n易发生梗塞后出血易发生梗塞后出血Laboratory Findings nCT, MRI: indicate ischemic Infarct or hemorrhagic infarctnMRA shows the stenosis of large cerebral arteries.nCSF examination: Can be normal, or with increased ICP. Red

48、blood cells can be seen grossly or under microscope.Laboratory FindingsnECG: 心律失常心律失常 (arrhythmia)、心肌梗塞、心肌梗塞(myocardical infarction, MI) 等等nUltrasonographynEchocardiographynCerebral angiographyDiagnosis and differentiationn诊断：急骤起病，有定位体征，有栓子诊断：急骤起病，有定位体征，有栓子来源来源n鉴别诊断：鉴别诊断：n与脑出血、脑血栓鉴别与脑出血、脑血栓鉴别n有局限性癫痫

49、者应与其它引起癫痫的有局限性癫痫者应与其它引起癫痫的疾病鉴别疾病鉴别. .Treatment and prognosisnTreatment：nAntiedema and increased ICPnRecurrence prevention treatment: emboli originated disease treatment. nVasodilation agentsTreatment and preventionnTreatment：nothersnprognosis: nmortality - 5%15%. Die from severe cerebral edema, hern

50、iation, respiratory system infection, and heart failure.nMajority of Survivors will have severe disability本课重点本课重点nTIATIA的临床特点，颈内动脉和椎的临床特点，颈内动脉和椎- -基底动基底动脉脉TIATIA的最常见的表现及特有症状的最常见的表现及特有症状n脑血栓形成的常见病因，好发部位，临脑血栓形成的常见病因，好发部位，临床特点及治疗重点床特点及治疗重点n腔隙性脑梗死的常见临床类型几表现腔隙性脑梗死的常见临床类型几表现n脑栓塞的常见病因、临床特点及鉴别诊脑栓塞的常见病因、临床特