脑血管疾病CerebrovascularDiseaseCVD学习.pptx

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1、Section 1 IntroductionDefinition CVD: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。第1页/共102页Definition Stroke:The stroke is a syndrome characterized by the acute onset of a neurolog

2、ic deficit that reflects focal/diffused involvement of the CNS and is the result of a disturbance of the cerebral circulation.脑卒中是指急性起病脑卒中是指急性起病 、迅速出现局限性或弥漫性脑功能缺失征象的脑、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血管性事件。第2页/共102页Epidemiology:CVD is the third most common cause of death after heart disease and cancer.Incid

3、ence:100300/100,000morbidity:100740/100,000mortality:50100/100,000About 50%70%of survivors shows disability in different degree.第3页/共102页Classification of CVDAccording to the lasting time of neurologic deficit:TIA(24h).According to the severity of neurologic deficit:minor stroke major stroke silent

4、strokeAccording to the pathological features:ischemic strokehemorrhagic stroke(see table 8-1)第4页/共102页脑部的血液供应-Blood supply in brain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-anterior cere

5、bral artery(ACA)image/ci-mca-2.jpg-middle cerebral artery(MCA)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、顶叶及部分即额叶、颞叶、顶叶及基地节的血液基地节的血液见图见图the circle of Willis环环见图脑基底部动脉见图脑基底部动脉第5页/共102页椎椎-基底动脉系统基底动脉系统-vertebral-basilar artery S.椎动脉椎动脉(VA):Which is divided into anterior spinal artery(脊髓前动脉脊髓前动脉)posterior spina

6、l artery(脊髓后动脊髓后动脉脉)medullary artery(延髓动脉延髓动脉)posterior inferior cerebellar artery(小脑后下动脉小脑后下动脉)第6页/共102页基底动脉基底动脉(BA):Which has branches of anterior inferior cerebellar artery（小脑前下动脉）（小脑前下动脉）branches of pons（脑桥支）（脑桥支）internal auditory artery（内（内听动脉）听动脉）superior cerebellar artery（小脑上动脉）（小脑上动脉）第7页/共10

7、2页大脑后动脉大脑后动脉(posterior cerebral artery,PCA),which is the terminal division of BA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 半半球后球后2/5部分即枕叶及颞叶的基底面，枕部分即枕叶及颞叶的基底面，枕叶的内侧及丘脑等。叶的内侧及丘脑等。第8页/共102页Etiology of CVD Vascular disorder AtherosclerosisInflammatory disorders(TB,syphilitic arteritis,SLE,etc.)Congenital vascul

8、ar malformation(aneurysm,AVM)Lesions of any cause 第9页/共102页Etiology of CVDHeart diseases and blood kinetics changesHypertention or hypotensionAtrial fibrillation,Rheumatic heart disease,arrhythmias etc.第10页/共102页Changes in blood constituent and hemodynamicsIncrease in blood viscosityAbnormality in b

9、lood coagulation mechanismOthersSuch as emboli of air,fat,cancer cells.Blood vessel spasm,trauma,etc.第11页/共102页Risk factorsSeveral factors are known to increase the liability to stroke.The most important of these are:Hypertention Heart diseases DiabetesTIA or stroke history 第12页/共102页Risk factorsSmo

10、king and alcohol HyperlipidmiaOthers:food,symptomless ICA bruit,overweight,drug abuse,contraceptive，age,sex,family history,race,etc.第13页/共102页Section 2 Transient Ischemic Attack,TIA (短暂性脑缺血短暂性脑缺血发作发作)ConceptEtiology and mechanismClinical findingsInvestigative studiesDiagnosis and differentiationTrea

11、tment and prevention第14页/共102页TIA-ConceptTIA 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).Repeated TIAs of uniform type are more often a warning sign of ischemic stroke.第15页/共102页

12、第16页/共102页TIA-Clinical findingsAge of onset,5070,male femaleBasic features:Transient episode(30 seconds-metabolic change,1 min-cease of neuron activity,5min-cerebral infarct.Ischemic penumbra(缺血半暗带缺血半暗带）time window(6h)第48页/共102页PathophysiologyReperfusion damage:possible mechanisms:自由基自由基(free radica

13、l)形成及其瀑布式反应形成及其瀑布式反应神经细胞内钙超载神经细胞内钙超载(calcium overload)EAA毒性作用毒性作用(toxic effect of excitatory amino acid)酸中毒酸中毒(acidosis)第49页/共102页Types大面积脑梗死（大面积脑梗死（a large area CI）分水岭脑梗死分水岭脑梗死(cerebral watershed infarction,CWSI)出血性脑梗死出血性脑梗死(hemorrhagic infarct,HI)多发性脑梗死多发性脑梗死(multiple infarct,MI)第50页/共102页Clinical

14、 features Clinical typesComplete stroke:reaches peak within several hours(24h and recovering within 3ws第51页/共102页Clinical featuresGeneral features:Middle-aged or elderly people(caused by Atherosclerosis),youth or middle-aged people(caused by arteritis).Stroke onset at quiet state and reaches the pea

15、k within several hours to 12 days.第52页/共102页Clinical featuresGeneral features:Usually,the patients are awake and alert except for those with a large area of CI or infarction in brainstem.第53页/共102页Clinical syndromes of CIOcclusion syndrome of carotid artery Carotid artery occlusion may be asymptomat

16、ic.Symptomatic occlusion results in syndromes follow:Transient monocular blindness caused by ipsilateral retinal artery ischemia.Horners sign.第54页/共102页Clinical syndromes of CIOcclusion syndrome of carotid artery Carotid artery or ophthalmic artery bruit and a weakened pulse in carotid artery.Contra

17、lateral hemiplegia,hemisensory deficit,and homonymous hemianopia.Aphasia,if dominant hemisphere involvement.第55页/共102页Clinical syndromes of CIOclusion syndrome of MCA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.三偏症状三偏症状(

18、contralateral hemiparesis,hemisensory deficit,and homonymous hemianopia).第56页/共102页Clinical syndromes of CIOclusion syndrome of MCA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)意识障碍、意识障碍、颅内压增高、脑疝可导颅内压增高、脑疝可导致死亡致死亡(disturbence of consciousness,increased

19、ICP,and herniation)第57页/共102页Clinical syndromes of CIOclusion syndrome of MCA皮层支闭塞皮层支闭塞(occlusion in superior division)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).第58页/共102页Clinical syndromes of CIOclusion syndrome of

20、MCA皮层支闭塞皮层支闭塞(occlusion in superior division)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(contralateral hemisensory deficit,mainly shows cortical sensory deficit)失语失语、体象障碍体象障碍(aphasia and body image disturbence)第59页/共102页Clinical syndromes of CIOclusion syndrome of MCA深穿支闭塞深穿支闭塞(occlusion in inferior division)对侧偏

21、瘫对侧偏瘫(contralateral hemiparesis,upper and lower limbs evenly affected)对侧偏身对侧偏身感觉障碍及偏盲感觉障碍及偏盲(contralateral hemisensory deficit and homonymous hemianopia)可有失语可有失语(dominant hemisphere involved)第60页/共102页Clinical syndromes of CIOcclusion syndrome of ACA 主干闭塞主干闭塞(occlusion in stem)中枢性面舌瘫、偏瘫下肢重于上肢中枢性面舌瘫、

22、偏瘫下肢重于上肢(挑扁担样挑扁担样瘫瘫)(Shoulde-pole-carry-like),伴轻度感觉障碍伴轻度感觉障碍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),(incontinence,paracentral lobule is affected)第61页/共102页Clinical syndromes of CIOcclusion syndrome of ACA 主干闭塞主干闭塞(occlusion in stem)精神症状精神症状(psychiatric symptom)(颞极与胼胝颞极与胼胝体受体受累，累，temporal pole andcorpus callosu

23、m are affected)，常可见强握、常可见强握、吸吸吮反射吮反射(额叶病额叶病变变)(grasp reflex,suck reflex are common signs,lision in frontal lobe).第62页/共102页Clinical syndromes of CIOcclusion syndrome of ACA 皮层支闭塞皮层支闭塞(occlusion in superior division)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

24、degree,of the shoulder and arm)第63页/共102页Clinical syndromes of CIOcclusion syndrome of ACA 深穿支闭塞深穿支闭塞(occlusion in inferior division)面、舌、肩瘫面、舌、肩瘫(contralateral paresis includes face,lingua,shoulder)第64页/共102页Clinical syndromes of CIOcclusion syndrome of PCA主干闭塞主干闭塞(occlusion in stem)：对侧偏盲、偏瘫及偏身感觉障碍对

25、侧偏盲、偏瘫及偏身感觉障碍(较较轻轻)丘脑综合症丘脑综合症(thalamic syndrome)主侧半球病变可有失读症主侧半球病变可有失读症(alexia).第65页/共102页Clinical syndromes of CIOcclusion syndrome of PCA皮层支闭塞（皮层支闭塞（occlusion in superior division）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 invo

26、lvment)第66页/共102页Clinical syndromes of CIOcclusion syndrome of PCA皮层支闭塞（皮层支闭塞（occlusion in superior division）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)主侧半球顶枕动脉闭塞可有主侧半球顶枕动脉闭塞可有对侧偏盲，对侧偏盲，失语失语。第67页/共102页Clinical syndromes of CIPCA occlusion syndrome深穿支闭塞深穿支闭塞(occlusion

27、 in inferior division)丘脑穿通动脉闭塞丘脑穿通动脉闭塞：红核综合征红核综合征（Claude syndrome)丘脑综合征丘脑综合征(thalamic syndrome):snesory loss,spontaneous pain and dysesthesias,choreoathetosis,intention tremor,spasm of hand,mild hemiparesis.第68页/共102页Clinical syndromes of CIPCA occlusion syndrome深穿支闭塞深穿支闭塞(occlusion in inferior divi

28、sion)中脑分支闭塞：中脑分支闭塞：Weber syndrome:third nerve palsy ad contralateral hemiplegia.第69页/共102页Clinical syndromes of CISyndrome of vertebral-basilar artery occlusion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.第70页/共102页Clinical syndromes of CISyndrome of verteb

29、ral-basilar artery occlusion基底动脉尖综合征（基底动脉尖综合征（Top of the basilar Syndrome）:Abnormality in eye movement and pupilsdisturbance of consciousness(loss of consciousness)homonymous hemianopia or cortical blindnesssevere memory disorder第71页/共102页Clincal syndromes of CISyndrome of vertebral-basilar artery o

30、cclusion脑干分支闭塞脑干分支闭塞Weber syndromeMillard-Gubler syndromeFoville syndrome第72页/共102页Clincal syndromes of CISyndrome of vertebral-basilar artery occlusion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)眼球震颤眼球震颤(nystagmus)交叉性感觉障碍交叉性感觉障碍(crossed sensory deficit)球麻痹球麻痹(bulbar paralysis)病灶侧病灶侧Horner

31、征征(ipslateral Hornor sign)病灶侧小脑性共济失调病灶侧小脑性共济失调(ipslateral cerebellar ataxia)第73页/共102页Clincal syndromes of CISyndrome of vertebral-basilar artery occlusion闭锁综合征闭锁综合征(Locked-in syndrome):基底动脉分支双侧闭塞基底动脉分支双侧闭塞Cerebellar infarction 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

32、 cerebellar artery)、小脑小脑前下动脉闭塞前下动脉闭塞(anterior inferior cerebellar artery)所致所致。第74页/共102页Laboratory findingsCT scan：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 ischem

33、ia and hemorrhage (见图见图)第75页/共102页Laboratory findingsMRI：may be superior to CT scan for demonstrating early ischemic infarcts,showing ischemic stroke in brainstem or cerebellum and detecting thrombosis occlusion of venous sinuses.第76页/共102页Laboratory findingsCerebral angiography：MRA,DSABlood tests a

34、nd ECG:Serum glucose,cholesterol and lipid,hemorheology.TCD and CSF第77页/共102页Diagnosis and differentiationDiagnosisdiagnosis can be made depending on the clinical features(Patients presenting with focal central nervous system dysfunction of sudden onset,Lasting more than 24h)CT and MRI changes第78页/共

35、102页Diagnosis and differentiationDifferential diagnosis:Cerebral hemorrhagecerebral embolismOther structural brain lesions:tumor,abscess,etc.第79页/共102页 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 安静状态或安静状态或睡眠中睡眠中4.4.起病速度起病速度 急急(

36、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。第80页/共102页Treatment急性期治疗（急性期治疗（Treatment in acute stage）治治疗原则：疗原则：超早期治疗超早期治疗-力争溶栓；力争溶栓；综合保

37、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施。对危险因素及时予以预防性干预措施。第81页/共102页Treatment超早期溶栓治疗超早期溶栓治疗目的：溶解血栓；迅速恢复梗死区血流灌注；减轻神目的：溶解血栓；迅速恢复梗死区血流灌注；减轻神经元损伤。（经元损伤。（6h）complications:Hemorrhage,reperfusion damage and brain edema,reocclusion.第82页/共102页Treatment超早期溶栓治疗超早期溶栓治疗Thrombolytic agents:Urokinase(UK

38、),Straptokinase(SK),recombinant tissue plasminogen activator(rt-PA)第83页/共102页Treatment超早期溶栓治疗超早期溶栓治疗Indications:Age 75 no disturbance of consciousnesswithin 6h(or 12h for progressive stroke)of onset Bp 200/120mmHgno hemorrhage shown on CT scanningexclusion of TIAno other hemorrhagic diseases 第84页/共1

39、02页TreatmentAntiplatelet agentsThe regime is as described in the section of TIA.Anticoagulation agents:to prevent the progression of thrombosis.The agents used are the same as mentioned in the section of TIA.Fibrinogen degradation therapy:降纤降纤酶酶(Defibrase),巴曲酶巴曲酶(Batroxobin),安洛克酶安洛克酶(Ancrod)和引激酶。和引激

40、酶。第85页/共102页TreatmentNeuroprotective agents:抗自由基：抗自由基：V-E V-C 甘露醇甘露醇 激素等激素等抑制脑代谢抑制脑代谢急性期时应降低脑代谢，减少脑细胞耗氧量使缺血区血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流量增加钙离子拮抗剂：西比灵钙离子拮抗剂：西比灵 尼莫地平等尼莫地平等亚低温亚低温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第86页/共102页TreatmentOther forms of medical treatment:such as therapies aimed at improving blood f

41、low:hemodilution,metabolic improving agents-ATP,Co-A,脑活素等脑活素等。第87页/共102页TreatmentSurgical treatmentGeneral treatmentICU:monitoring ECG,Bp,R,P,etc.Antiedema agentsPreventing infectionPhysical therapy and rehabilitationPreventive measures第88页/共102页腔隙性脑梗塞-Lacunar InfarctionConcept：Small penetrating art

42、eries located deep in the brain may become occluded as a result of changes in the vessel wall induced by chronic hypertension and atherosclerosis.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。第89

43、页/共102页腔隙性脑梗塞-Lacunar InfarctionCommon types:纯运动性卒中纯运动性卒中(Pure motor hemiparesis,PMH)纯感觉性卒纯感觉性卒(Pure sensory stroke,PSS)共济失调性轻偏瘫共济失调性轻偏瘫(Ataxic-hemiparesis,AH)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)感觉运动性卒中感觉运动性卒中(Sensorimotor stroke,SMS)腔隙状态腔隙状态(Lacunar state)第90页/共102页脑栓塞脑栓塞-Cer

44、ebral embolismConceptEtiology and mechanismClinical findingsInvestigative studiesDiagnosis and differentiationTreatment and prognosis第91页/共102页脑栓塞脑栓塞-Cerebral embolismConcept：embolism produces stroke when cerebral arteries occluded by the distal passage of thrombus from the heart,aortic arch,or larg

45、e cerebral arteries.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。第92页/共102页脑栓塞-Cerebral embolismEtiology心源性心源性(Cardiogenic)非心源性非心源性(non-cardiogenic)来源不明来源不明(source unknown)Pathology 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。

46、但栓子常为多发切易破碎。相同。但栓子常为多发切易破碎。第93页/共102页Clinical findings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，栓塞部位继发血栓时病情可逐渐进展可逐渐进展可有头痛、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神经系统定位体征神经系统定位体征原发病的症状和体征原发病的症状和体征易发生梗塞后出血易发生梗塞后出血第94页/共102页Laboratory Findings CT,MRI:indicate ischemic

47、 Infarct or hemorrhagic infarctMRA shows the stenosis of large cerebral arteries.CSF examination:Can be normal,or with increased ICP.Red blood cells can be seen grossly or under microscope.第95页/共102页Laboratory FindingsECG:心律失常心律失常(arrhythmia)、心肌梗塞、心肌梗塞(myocardical infarction,MI)等等UltrasonographyEcho

48、cardiographyCerebral angiography第96页/共102页Diagnosis and differentiation诊断：急骤起病，有定位体征，有栓子来源诊断：急骤起病，有定位体征，有栓子来源鉴别诊断：鉴别诊断：与脑出血、脑血栓鉴别与脑出血、脑血栓鉴别有局限性癫痫者应与其它引起癫痫的疾病鉴别有局限性癫痫者应与其它引起癫痫的疾病鉴别.第97页/共102页Treatment and prognosisTreatment：Antiedema and increased ICPRecurrence prevention treatment:emboli originated

49、disease treatment.Vasodilation agents第98页/共102页Treatment and preventionTreatment：othersprognosis:mortality-5%15%.Die from severe cerebral edema,herniation,respiratory system infection,and heart failure.Majority of Survivors will have severe disability第99页/共102页本课重点TIATIA的临床特点，颈内动脉和椎的临床特点，颈内动脉和椎-基底动脉基底动脉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脑血栓形成的常见病因，好发部位，临床特点及治疗重点脑血栓形成的常见病因，好发部位，临床特点及治疗重点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脑栓塞的常见病因、临床特点及鉴别诊断脑栓塞的常见病因、临床特点及鉴别诊断第100页/共102页第101页/共102页感谢您的观看！第102页/共102页