腦血管病-1教學(xué)課件

腦血管疾病

cerebrovasculardiseases

WenpingGu,MD.PhD.NeurologyDepartment,XiangyaHospital,centralsouthUniversity腦血管疾病

CerebrovascularDiseases，CVD在腦血管病變基礎(chǔ)上發(fā)生的局限性或彌漫性腦功能障礙thecerebraldiseasesthatareresultedfromvariouscerebrovasculardiseases急性腦血管疾病分類

classificationofacutecerebrovasculardiseases短暫性腦缺血發(fā)作（transientischemicattack，TIA）頸動(dòng)脈系統(tǒng)internalcarotidarterysystem

TIA椎－基底動(dòng)脈系統(tǒng)basilar-vertebralarterysystemTIA腦卒中（stroke,apoplexy,cerebrovascularaccident）蛛網(wǎng)膜下腔出血（subarachnoidhemorrhage）腦出血（intracerebralhemorrhage,ICH）腦梗死(cerebralinfarction)動(dòng)脈粥樣硬化性血栓性腦梗死(arterothromboticcerebralinfarction)腦栓塞(cerebralembolism)腔隙性腦梗死(lacunarinfarction),

等其他分類腦血管疾病

otherclassificationofcerebrovasculardiseases椎基底動(dòng)脈供血不足（Vertebrobasilararterialinsufficiency）腦血管性癡呆（cerebralvasculardementia）高血壓腦?。╤ypertensiveencephalopathy）顱內(nèi)動(dòng)脈瘤（intracranialaneurysm）顱內(nèi)血管畸形（intracranialvascularmalformation）腦動(dòng)脈炎（cerebralarteritis）顱內(nèi)靜脈、靜脈竇血栓形成（thrombosisofvenoussinus）顱外段動(dòng)、靜脈疾病其他動(dòng)脈疾病(otherarterialdiseases)腦的血液循環(huán)

bloodcirculationofcerebullar頸內(nèi)動(dòng)脈系統(tǒng)(internalcarotidarterysystem)椎基底動(dòng)系統(tǒng)(basilar-vertebralartery腦組織(braintissue)靜脈系統(tǒng)(veinsystem)靜脈竇(veinsinuses)頸內(nèi)靜脈(internalcarotidvein)椎-基底動(dòng)脈系統(tǒng)

vertebrobasilarcirculation椎動(dòng)脈vertebralartery基底動(dòng)脈basilarartery大腦后動(dòng)脈posteriorcerebralartery腦的供血區(qū)域頸內(nèi)動(dòng)脈系統(tǒng)(internalcarotidartery)又稱前循環(huán),供應(yīng)額、顳、頂葉和基底核等大腦半球前3/5血流providethebloodoffrontallobe,temporallobeandparietallobe,etal椎-基底動(dòng)脈系統(tǒng)（basilar-vetebralartery)又稱后循環(huán)，供應(yīng)小腦、腦干、丘腦和枕、顳葉等大腦半球后2/5血液providethebloodofcerebellum,brainstem,cerebralganglion,occipitallobe,腦動(dòng)脈細(xì)小分支穿通支（perforatingbranch）間腦(diencephalon)、紋狀體(corpusstriatum)、內(nèi)囊(internalcapsule)、腦干基底部中線旁結(jié)構(gòu)皮質(zhì)支（corticalbranch）

大腦半球皮質(zhì)及皮質(zhì)下白質(zhì)與腦干的背外側(cè)腦底動(dòng)脈環(huán)大腦中動(dòng)脈近端基底動(dòng)脈腦動(dòng)脈側(cè)支循環(huán)

compensatorycirculationWillis環(huán)雙側(cè)頸內(nèi)動(dòng)脈

internalcaroticartey雙側(cè)大腦前動(dòng)脈

anteriorcerebralartey雙側(cè)大腦后動(dòng)脈

posteriorcerebralartery前交通動(dòng)脈

anteriorcommunicatingartery雙側(cè)后交通動(dòng)脈

posteriorcommunicatingartery其他側(cè)支循環(huán)(othercompensatorycirculation)大腦前、中、后動(dòng)脈皮質(zhì)支在大腦表面彼此交通頸內(nèi)、外動(dòng)脈圍繞眼耳、鼻、的深淺分支互相吻合大腦動(dòng)脈皮質(zhì)支與來(lái)自頸外動(dòng)脈的腦膜動(dòng)脈分支也存在豐富的側(cè)支吻合分水嶺腦梗死

cerebralwatershedinfarction腦血流及其調(diào)節(jié)

bloodcirculationregulation

腦血供豐富。在正常情況下，腦血流量（CBF）具有自動(dòng)調(diào)節(jié)作用：CBF=（MAP-ICP）π?r4/（8η?L）。在缺血或缺氧的病理狀態(tài)下，腦血管的自動(dòng)調(diào)節(jié)機(jī)制紊亂，血管擴(kuò)張或反應(yīng)異常，腦水腫和顱內(nèi)壓升高，就會(huì)出現(xiàn)缺血區(qū)的充血和過(guò)度灌注或腦內(nèi)盜血現(xiàn)象Inthenormalconditions,cerebralbloodflowcanautoregulate.CBFcanincreasewhilecerebralperfusionpressurerisesandcerebrovascularresistanceisdecreased.Intheischemicandhypoxicpathologicbehavior,theautoregulationmechanismsdisorder,bloodvesselsectasiaorresponseabnormality,cerebraledemaandintracranialpressurewillrise,soitappearshyperemiaandsuperperfusionorcerebralstealphenomenonintheischemicregion腦卒中(Stroke)發(fā)病率、死亡率、致殘率均高與心臟病、惡性腫瘤構(gòu)成人類三大致死病因不但危害中老年人健康，而且發(fā)病有年輕化趨勢(shì)給社會(huì)和家庭帶來(lái)沉重的負(fù)擔(dān)morbidity,mortalityandmutilationrateofstrokearehigh流行病學(xué)epidemiology我國(guó)城市腦血管病的年發(fā)病率、死亡率和時(shí)點(diǎn)患病率分別為219/10萬(wàn)、116/10萬(wàn)和719/10萬(wàn)農(nóng)村地區(qū)分別為185/10萬(wàn)、142/10萬(wàn)和394/10萬(wàn)分類classification一級(jí)預(yù)防：防發(fā)生first-levelprevention:preventoccurrence二級(jí)預(yù)防：防復(fù)發(fā)second-levelprevention:preventrecidivation三級(jí)預(yù)防：發(fā)病后治療third-levelprevention:

thetherapyaftermorbility一級(jí)預(yù)防(primaryprevention)指發(fā)病前的預(yù)防，即通過(guò)早期改變不健康的生活方式，積極主動(dòng)地控制各種危險(xiǎn)因素，從而達(dá)到腦卒中不發(fā)生或推遲發(fā)病年齡的目的腦卒中危險(xiǎn)因素riskfactors

可干預(yù)性mayintervene：高血壓(hypertension)、心臟病(heartdieases)、糖尿病(diabetes)、血脂異常(hyperlipemia)、高同型半胱氨酸血癥、短暫性腦缺血發(fā)作(historicstroke)、吸煙(smoking)、酗酒(heavyalcoholconsumption)、肥胖、無(wú)癥狀性勁動(dòng)脈狹窄、口服避孕藥物、肺炎衣原體感染、情緒應(yīng)激、抗凝治療等不可干預(yù)性non-intervention：年齡、性別、種族、遺傳因素等腦卒中主要癥狀和體征

singsandsymptoms起病突然(onstesuddenly)全腦癥狀(wholebrainsymptom)局灶性癥狀和體征(focalsingsandsymptoms)頸內(nèi)動(dòng)脈系統(tǒng)表現(xiàn)

(internalcarotidartery)椎-基底動(dòng)脈系統(tǒng)表現(xiàn)(basilar-vetebralartery)腦膜刺激征(meningealirritationsign)短暫性腦缺血發(fā)作transientischemicattack臨床表現(xiàn)

clinicalsituation＞50歲

patientsolderthan50,

常伴有動(dòng)脈硬化、高血壓、糖尿病、冠心病等

accomplywithangiosclerosis,hypertension,diabetes,coronaryarterydisease發(fā)病突然，迅速出現(xiàn)局限性神經(jīng)功能障礙

acuteonsetofaneurologicdeficit持續(xù)時(shí)間短，＜24小時(shí)

neurologicdeficitpersistsforless24hours不留后遺癥

noresidual可反復(fù)發(fā)作

recurrentattacks頸內(nèi)動(dòng)脈系統(tǒng)TIA

TIAofinternalcarotidartery短暫性偏側(cè)或單肢無(wú)力transienthemiparesis面部、單肢或偏身麻木hemisensorydisturbances同向偏盲或單眼一過(guò)性失明homonymoushemianopiaortransientocellanaeacroisa失語(yǔ)aphasia椎－基底動(dòng)脈系統(tǒng)TIA

TIAofvertebrobasilarcirculation眩暈（vertigo）、復(fù)視（diplopia）、吞咽困難（acataposis）、共濟(jì)失調(diào)（ataxia）交叉性癱瘓（crossedparalysis）跌倒發(fā)作（dropattack）、短暫全面性遺忘癥（transientglobalamnesiaTGA）、雙眼視力障礙發(fā)作（theonsetofbinocularvisiondisorders）診斷

approachtodiagnosis中老年患者senior突然出現(xiàn)局限性神經(jīng)功能障礙

acuteonsetofaneurologicdeficit24小時(shí)完全恢復(fù)

completerecoveryin24hoursCT、MRI（－）TCD監(jiān)測(cè)鑒別診斷

differentialdiagnosis部分性癲癇（partepilepsy）梅尼埃?。∕enieredisease）顱內(nèi)占位性病變（intracranialspaceoccupyinglesion）治療

treatment藥物治療(drugtreatment)抗血小板聚集(antiplatelettherapy)Asprin50~150mg，po，Qd噻氯匹定（ticlopidine)氯吡格雷(clopidogrel)雙嘧達(dá)莫(dipyridamole,DPA)奧扎格雷(ozagrel)80mg，ivgtt，bid抗凝(anticoagulation)肝素(heparin)100mg+5%葡萄糖500ml，ivgtt，10~20滴/min低分子肝素(lowmolecularweightheparin)4000IU，腹壁皮下注射，bidWarfarin鈣拮抗劑：尼莫地平、鹽酸氟桂嗪（nimodipine、flunarizine）其他（others）中藥治療（tranditionalmedicinetreatment）擴(kuò)血管治療：罌粟堿、倍他司丁、煙酸（papaverine、betahistine、nicotinicacid）治療

treatment病因治療(etilogicaltreatment)手術(shù)治療(surgery)管腔狹窄＞70%，伴反復(fù)TIA，可考慮介入治療或頸動(dòng)脈內(nèi)膜剝除術(shù)預(yù)后

prognosis腦梗死cerebralinfarction反復(fù)發(fā)作recurrentattacks自行緩解releasewithouttreatment缺血性腦卒中cerebralischemicstroke缺血性腦卒中

cerebralischemicstroke,CIS由于腦部血液供應(yīng)障礙，缺血、缺氧引起的局限性腦組織的缺血性壞死或腦軟化又稱腦梗死（cerebralinfarction,CI),臨床常見(jiàn)類型有動(dòng)脈粥樣硬化性血栓性腦梗死、腦栓塞和腔隙性梗死等。腦梗死約占全部腦卒中的80％Cerebralischemicstrokeisagaincalledcerebralinfarction,whichiscausedbyinsufficientinflowofblood,thenischemiaandhypoxiacauselocalcerebraltissue’sischemicnecrosisorencephalomalacia

動(dòng)脈粥樣硬化性血栓性腦梗死

arterothromboticcerebralinfarction通常是指腦動(dòng)脈的主干或其皮層支因動(dòng)脈粥樣硬化等血管病變，導(dǎo)致的官腔狹窄或閉塞并進(jìn)而發(fā)生學(xué)栓形成，造成腦局部供血區(qū)血流中斷，發(fā)生腦組織缺血、缺氧、軟化壞死，出現(xiàn)相應(yīng)的神經(jīng)系統(tǒng)癥狀和體征thevesseldiseasesarecausedbycerebralarterialstems’oritscortexbranches’atherosclerosisandvariousarteritis,whichcausevesselconstrictionoremphraxisandthenformthrombosisandlocalbloodflowbreaks.Socerebraltissueischemia,hypoxia,softeningandnecrosis,whichcausecorrespondingnervoussystemsymptomsandsigns.

病因

etiopathogenisis腦動(dòng)脈粥樣硬化cerebralatherosclerosis高血壓hypertension糖尿病diabetes

血脂異常hyperlipemia腦動(dòng)脈炎cerebralarteritis結(jié)締組織疾病connectivetissuediseases先天性血管畸形congenitalvascularmalformation真性紅細(xì)胞增多癥polycythemiarubravera血高凝狀態(tài)hypercoagulabalestate血小板增多癥thrombocythemia發(fā)病機(jī)制

nosogenesis腦梗死(cerebralinfarction)灶形成機(jī)制腦血流障礙(cerebralbloodflowdisorder)神經(jīng)細(xì)胞缺血性損害(nervecellischemiadamage)能量代謝障礙(energymetabolismdisorder)和酸中毒(acidosis)興奮性氨基酸（excitatoryaminoacid)毒性和鈣超載(calciumoverload)磷脂降解(phospholipiddegradation)和脂類介導(dǎo)的毒性作用自由基(freeradical)損傷缺血性腦水腫(ischemicbrainedema)一氧化碳(nitricoxide)毒性即早基因(immediateearlygenes)、神經(jīng)營(yíng)養(yǎng)因子(neurotrophicfactors)和熱休克蛋白(heatshockprotein)等基因表達(dá)改變細(xì)胞因子再灌注時(shí)間窗

reperfusiontimewindow超早期治療的關(guān)鍵是搶救缺血半暗帶，采取腦保護(hù)措施減輕再灌注損傷，目前普遍把腦缺血的超早期治療時(shí)間窗定為6小時(shí)之內(nèi)Thekeytotherapyistosalvageischemicpenumbraintheultra-earlierperiodandtakeactionstoreducereperfusiondamadge.Atpresent,cerebralischemictherapytimewindowintheultra-earlierperiodissettledwithin6hours臨床表現(xiàn)

clinicalmanifestation老年人(senior)有動(dòng)脈粥樣硬化、高血壓、糖尿病或冠心病史(withangiosclerosis,hypertension,diabetes,coronaryarterydisease)常在安靜或睡眠中起病(onsetatquietorsleep)一般無(wú)頭痛、嘔吐、昏迷等全腦癥狀(noheadache、vomit、coma）頸內(nèi)動(dòng)脈系統(tǒng)腦梗死臨床表現(xiàn)(clinicalmanifestation)頸內(nèi)動(dòng)脈血栓形成（internalcarotidarterythrombosis）大腦中動(dòng)脈血栓形成(middlecerebralarterythrombosis)大腦前動(dòng)脈血栓形成(anteriorcerebralarterythrombosis)椎-基底動(dòng)脈系統(tǒng)腦梗死(basilar-vetebralarterysysteminfarction)大腦后動(dòng)脈血栓形成(posteriorcerebralarterythrombosis)椎動(dòng)脈血栓形成(vetebralarterythrombosis)延髓背外側(cè)綜合征(Wallenbergsyndrome)基底動(dòng)脈血栓形成(basilararterythrombosis)腦橋腹外側(cè)綜合征(Millard-Gublersyndrome)閉鎖綜合征(locked-insymdrome)基底動(dòng)脈尖綜合征(topofthebasilararterysyndrome)輔助檢查

auxiliaryexamination血常規(guī)BR和生化檢查CTMRI血管造影(cerebralarteriography)

DSA、CTA、MRAB超、TCDSPECT、PETCSF急性期一般治療

generaltreatmentinacutestage維持呼吸功能(retainrespiratoryfunction)調(diào)整血壓(adjustedbloodpressure)控制血糖(controlbloodsugar)控制體溫(controlbodytemperature)預(yù)防并發(fā)癥(precautioncomplication)營(yíng)養(yǎng)支持(nutritionalsupport)急性期溶栓治療

thrombolysistreatment溶栓時(shí)間窗（timewindow)起病3小時(shí)內(nèi)，3~6小時(shí)可慎重選擇病例，6小時(shí)后療效不佳，并有較大出血危險(xiǎn)適應(yīng)征(indcation)年齡小于75歲癱瘓肢體肌力3級(jí)以下無(wú)明顯意識(shí)障礙用藥時(shí)血壓低于180/110mmHg禁忌征(taboo)有出血傾向、大面積腦梗死、嚴(yán)重心、肝、腎疾病者常用藥物(generaldrug)組織型纖維蛋白溶解酶原激活劑(tPA)尿激酶(UK)鏈激酶(SK)溶栓治療有顱內(nèi)或身體其他部位出血的危險(xiǎn)，有的可導(dǎo)致死亡其他治療

(othertreatment)抗凝治療(anticoagulation)降纖治療（defibrase）抗血小板聚集(antiplateletaggregation)治療腦保護(hù)治療(brainconservation)神經(jīng)保護(hù)劑壓低溫治療脫水降顱壓(dehydration)血液稀釋療法(hemodilution)中醫(yī)中藥治療(Chinesecrudedrug)外科介入治療(surgery)卒中單元（strokeunit,SU）康復(fù)期治療

treatmentinconvalescencestage康復(fù)治療convalescentcare二級(jí)預(yù)防second-levelprevention腦栓塞cerebralembolism腦栓塞

cerebralembolism是指各種栓子隨血流進(jìn)人顱內(nèi)動(dòng)脈系統(tǒng)使血管腔急性閉塞引起相應(yīng)供血區(qū)腦組織缺血壞死及腦功能障礙Cerebralembolism—cerebraltissueischemia,necrosisandcerebralfunctiondisordersthatarecausedbyvariousembolienteringcraniumarterysystemfollowingbloodflowandmakingbloodvesselacutelyemphraxis病因

etiopathogenisis心源性腦栓塞(Cardiogeniccerebralembolism)心房顫動(dòng)AF心臟瓣膜病和心內(nèi)膜病感染性心內(nèi)膜炎心肌梗死、心肌病心臟手術(shù)先天性心臟病心臟腫瘤非心源性腦栓塞(nonCardiogeniccerebralembolism)原因不明(unknownaetiology)臨床表現(xiàn)

clinicalmanifestation任何年齡均可發(fā)病，青壯年多見(jiàn)。活動(dòng)中突然起病，數(shù)秒或數(shù)分達(dá)高峰，是發(fā)病最急的腦卒中，且多為完全性卒中Cerebralembolismcanbefoundatanyage,butmostofthemisatyoungprimeofone’slife.Theonsetsuddenlystartsatactivities,achievespeaksafterafewsecondorminutes.Itistheacuteststrokeamongallstrokes,andmostofthemarecompletedstrokes局限性神經(jīng)缺失癥狀與栓塞動(dòng)脈供血區(qū)的功能相對(duì)應(yīng)Limitednervedeletionsymptomsarecorrespondedwithembolismarterysufficientbloodregions大多數(shù)病人有栓子來(lái)源的原發(fā)病Mostofpatientstroubleproepisodethatembolicomefrom診斷及鑒別診斷

diagnosisanddifferentialdiagnosis根據(jù)病史和臨床表現(xiàn)，診斷不難。應(yīng)注意與腦血栓形成、腦出血的鑒別Accordingtohisteryandclinicalmanifestatio