腦與脊髓的血管性疾病課件

腦與脊髓的血管性疾病

VASCULARDISEASES

inBRAINandSPINALCORD

Whatisit?

Howtomanageit?流行病學(xué)（Epidemiology）Annually,1,500,000to2,000,000Chinesesufferastroke.Mortality:25-30%Morbidity:60%Thecosttoindividualsandsocietyintermsofacutecareresources,rehabilitation,chroniccare,andlostproductivityisenormous.Today’stopics缺血性腦血管?。↖schemiccerebralvasculardiseases）出血性腦血管?。℉emorrhagiccerebralvasculardiseases）脊柱脊髓血管?。⊿pineandspinalcordvasculardiseases）Ischemiccerebraldisease–

ClinicalpresentationTIA(transientischemicattack一過性腦缺血發(fā)作)Infarction（腦梗死）COMMONSYMPOTOMS

ParaplegiaHomonymousemianopsia

HemisensorylossVertigoTransientmonocularblindnessDiplopiaDysphasiaFacialweaknessVisualfielddefectAtaxiaConfusionTinnitus

CAROTIDSYSTEM

VERTEBRAL-BASICSYSTEMStrokeFirstconsultationbycerebrovascularspecialistsCT、MRI、SONOGRAPHY、SPECTHemorrhagicIschemicEtiologictreatmentEtiologicdiagnosisRehabilitationProtocol

EmergencynetworkAcutestrokediagnosedInterventionaltherapySurgeryDrugtherapyMedicineRehabilitation“GreenChannelEmergency”TreatmentofIschemicStrokeMedicinemethod(Antiplatelet,anticoagulation,etal)SurgicalmethodEndarterectomySTA-MCAby-passInterventionalmethodThrombolysisAngioplasty(balloon,stent)AcuteStrokemale，29yearsold，righthemiplegiafor1/2hour，Thrombolysis1yearFollow-upStentingandfollow-upMale,63yearsold,TIACarotidStenosis–EndarterectomyMale,73-year-old,TIACarotidStenosis–AngioplastyandStentEPIMale,63yearsold，leftextremityweaknessfor3monthsMale,46yearsold,periodicdizzinessfor3months.By-passoperation

STA-MCAAnastomosisBy-pass+carotidstentingMale,56yearsold,rightextremityweakness.HighstenosisofrightICAandocclusionofleftICAHemorrhagicCerebralVascularDiseasesSubarachnoidHemorrhageandAneurysmsCerebralvascularmalformations

-arteriovenousmalformation

-cavernousangioma

-venousmalformationDural

arteriovenousfistulaMoyamoyaDiseasesIntracerebralhemorrhageSubarachnoid

HaemorrhageAneurysmal

subarachnoid

haemorrhage(SAH)isabout80.3%----Chinesegovernment:thetenth5yearsprojectresearchedresultSAHandAneurysmssubarachnoidhemorrhageSubaracnoidHemorrhage–

HuntandHessScaleScoreDefinition0

UnrupturedaneurysmAsymptomatic,ormildHA,andslightnuchalrigidity1aNoacutemeningeal/brainreaction,butwithfixed

neuroologicaldeficitModeratetosevereHA,nuchalrigidity;orCNpalsy(i.e.III,IV)3Lethargyorconfusion;mildfocaldeficit4Stupor,moderatetoseverehemiparesis5Deepcoma,decerebraterigidity,moribundappearanceAddonegradeforserioussystemicdisease(i.e.HTN,DM,Severeatherosclerosis,COPD)orseverevasospasmonarteriograpgy.DiagnosisofsubarachnoidhemorrhageLumbarpunctureCTscan.

goldstandardCLASSIFICATIONOFANEURYSMS

FUSIFORMDISSECTIONOCCULARPSEUDO-ANEURYSMEtiologyandpathogenesisDevelopmentaltheory:congenitallesions/inbornstructuralweaknessofthemusclelayeratbranchingpointsDegenerativetheory:

ruptureofinternalelasticlaminaandmediaduetoextremehemodynamicstressCurrentconcept:

degenerativedisease,triggeredbyhemodynamicstress.StructuralweaknessmayplayaroleEtiologyandpathogenesisruptureofinternalelasticlaminathinningandruptureofmedialackofelasticelementsinarterialwallconstantpulsatileflowaneurysmgrowthandruptureIntracranialAneurysm

–TreatmentEmbolizationOperationConservative

“clearneck”threateningvasospasm

posteriorcirculation

anteriorcirculationSAHFisher3hematomaneedingevacuation“noneck”HH4/5no(previous)SAHmult.SAHEMBOLIZATIONSURGERY"unclear"anatomyincreasedsurgicalriskIntracranialaneurysmsGoalofaneurysmtreatment:

toeliminatepulsatingbloodpressureinsidetheaneurysmAneurysmEmbolization2mmX2cm?

CordisNeurovascular,Inc.20033mmX4cm?

CordisNeurovascular,Inc.20034mmX7cm?

CordisNeurovascular,Inc.2003ComplexPlatinumCoilsEndovascularembolizationFemale,67yearsold,SAHOperativeclippingComplicationsafterSAHVasospasm--infarctionHydrocephalusCerebralVascularMalformation

ArteriovenousmalformationsCavernousmalformationsCarotid-cavernousfistula(CCF)VenousmalformationsTelangiectasis.Arteriovenousmalformations(AVMs)臨床表現(xiàn)64％患者在40歲之前發(fā)病(20～39歲）

主要癥狀：出血52～77%15～20歲高發(fā)癲癇28-64%神經(jīng)功能障礙20～30％頭痛60％1臨床表現(xiàn)2

據(jù)文獻(xiàn)報道：

未出血AVM的年出血率為2～4％再出血率為第一年6％以后2～4％臨床表現(xiàn)3AVM死亡病例中，大約30％因出血；每次出血的死亡率大概10～15％HeadacheIntracranialhemorrhageEpilepsypresentationArteriovenousmalformation–ClinicalNeurologicaldeficitArteriovenousmalformation–

PurposeofthetreatmentPreventionfromrehemorrhageImprovementofischemiaRemovaloftheepilepticsourceFollow-up10yearslaterGirl，age12,SAHwithepilepsyGirl，age12,SAHwithepilepsyOneyearafterembolizationPre-emboPost-emboBoy，age2，hydrocephalus2yearsafterembolizationPre-emboPre-emboPost-emboPost-opFemale，age30，multi-SAH

Boy，age14，

intracerebralhemorrhageEmbolization+surgeryMale,22yearold,

intracerebralhemorrhagePost-embolizationPost-operationWillis環(huán)不對稱3、立體定向放射治療

利用先進(jìn)的立體定向技術(shù)和計算機系統(tǒng)，對顱內(nèi)的正常組織靶電或病變組織，使用1次大劑量窄束電離射線從多方向、多角度精確地聚集于靶點上，引起放射生物學(xué)反應(yīng)，從而達(dá)到治療目的。主要方法1γ刀：γ射線（鈷60）2X刀：高能X射線（直線加速器）3質(zhì)子刀：質(zhì)子束（回旋加速器、同步加速器）病例（立體定向放射治療）放療2年后隨訪Cavernousangioma外傷性頸動脈－海綿竇瘺的定義定義外傷性頸動脈－海綿竇瘺是指由外傷引起的海綿竇段的頸內(nèi)動脈本身或其在海綿竇內(nèi)的分支破裂，與海綿竇之間形成異常的動、靜脈溝通。Carotid-cavernousfistula(CCF)臨床癥狀和體征T－CCF的分型

閉塞頸內(nèi)動脈閉塞瘺口VenousmalformationFemale,50-year-old,SAHMoyamoyaDiseaseIntracerebralhemorrhage(hypertensivehematoma)thulemusputaminal

hematomaMicrosurgicalremovaloftheclot.Percutaneouspunctureanddrainage(withthrombolyticsubstances)NationalCooperationnetworkwith150hospitals,3000casesAVMinSPINEandSPINALCORD

SpinalVascularMalformations

-ClassificationIntrathecalIntramedullary

arteriovenousmalformations(SAVMs)Intramedullary

cavernomasPerimedullary

arteriovenousfistulas(PMAVFs)SpinalDural

arteriovenousfistulas(SDAVFs)Extradural

arteriovenousmalformationsVertebralangiomasParavertebralCobb’ssyndromeKlippel-TrenaunaysyndromeRendu-Osler-Weber’ssyndromeParavertebral

arteriovenousfistulasSYMPTOMSANDSIGNSBackpainHypoesthesiaMuscleweakness(paraplegic,quadriplegic)SphincterdisturbanceIntramadulleryAVMTwoweekspost-embIntramadulleryAVMIntramadulleryAVM

POST-OPIntramadullary

cavernomaPerimedullary

ArteriovenousfistulaIPerimedullary

arteriovenousfistulaIIPerimedullary

arteriovenousfistulaIIISpinalDAVFSPINALCAVENOUSANGIOMAPOST-OPCONCLUSIONCerebrovasculardiseasesIschemicTransientischemicattack(TIA)InfarctionHemorrhagic

Subarachnoidhemorrhage(SAH)Cerebralvascularmalformations

Dural

arteriovenousfistula