腦與脊髓的血管性疾病課件

腦與脊髓的血管性疾病

VASCULARDISEASES

inBRAINandSPINALCORD

腦與脊髓的血管性疾病

VASCULARDISEASES

Whatisit?

Howtomanageit?Whatisit?

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

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

COMMONSYMPOTOMS

ParaplegiaHomonymousemianopsiaHemisensorylossVertigoTransientmonocularblindnessDiplopiaDysphasiaFacialweaknessVisualfielddefectAtaxiaConfusionTinnitus

CAROTIDSYSTEM

VERTEBRAL-BASICSYSTEMCOMMONSYMPOTOMSCAROTIDSYSTEMStrokeFirstconsultationbycerebrovascularspecialistsCT、MRI、SONOGRAPHY、SPECTHemorrhagicIschemicEtiologictreatmentEtiologicdiagnosisRehabilitationProtocol

StrokeFirstconsultationbyceEmergencynetworkAcutestrokediagnosedInterventionaltherapySurgeryDrugtherapyMedicineRehabilitation“GreenChannelEmergency”EmergencynetworkAcutestrokeTreatmentofIschemicStrokeMedicinemethod(Antiplatelet,anticoagulation,etal)SurgicalmethodEndarterectomySTA-MCAby-passInterventionalmethodThrombolysisAngioplasty(balloon,stent)TreatmentofIschemicStrokeMeAcuteStrokemale，29yearsold，righthemiplegiafor1/2hour，AcuteStrokemale，29yearsold，ThrombolysisThrombolysis1yearFollow-upStentingandfollow-up1yearFollow-upStentingandfMale,63yearsold,TIACarotidStenosis–EndarterectomyMale,63yearsold,TIACarotidMale,73-year-old,TIACarotidStenosis–AngioplastyandStentMale,73-year-old,TIACarotid腦與脊髓的血管性疾病課件EPIMale,63yearsold，leftextremityweaknessfor3monthsEPIMale,63yearsold，leftext腦與脊髓的血管性疾病課件Male,46yearsold,periodicdizzinessfor3months.Male,46yearsold,periodicdBy-passoperationBy-passoperation

STA-MCAAnastomosisSTA-MCAAnastomosis腦與脊髓的血管性疾病課件By-pass+carotidstentingMale,56yearsold,rightextremityweakness.HighstenosisofrightICAandocclusionofleftICABy-pass+carotidstentingMale腦與脊髓的血管性疾病課件HemorrhagicCerebralVascularDiseasesSubarachnoidHemorrhageandAneurysmsCerebralvascularmalformations

-arteriovenousmalformation

-cavernousangioma

-venousmalformationDuralarteriovenousfistulaMoyamoyaDiseasesIntracerebralhemorrhageHemorrhagicCerebralVascularSubarachnoidHaemorrhageAneurysmalsubarachnoidhaemorrhage(SAH)isabout80.3%----Chinesegovernment:thetenth5yearsprojectresearchedresultSubarachnoidHaemorrhageAneurySAHandAneurysmsSAHandAneurysms腦與脊髓的血管性疾病課件subarachnoidhemorrhagesubarachnoidhemorrhageSubaracnoidHemorrhage–

HuntandHessScaleScoreDefinition0

UnrupturedaneurysmAsymptomatic,ormildHA,andslightnuchalrigidity1aNoacutemeningeal/brainreaction,butwithfixedneuroologicaldeficitModeratetosevereHA,nuchalrigidity;orCNpalsy(i.e.III,IV)3Lethargyorconfusion;mildfocaldeficit4Stupor,moderatetoseverehemiparesis5Deepcoma,decerebraterigidity,moribundappearanceAddonegradeforserioussystemicdisease(i.e.HTN,DM,Severeatherosclerosis,COPD)orseverevasospasmonarteriograpgy.SubaracnoidHemorrhage–

HuntDiagnosisofsubarachnoidhemorrhageLumbarpunctureCTscan.

goldstandardDiagnosisofsubarachnoidhemoCLASSIFICATIONOFANEURYSMS

FUSIFORMDISSECTIONOCCULARPSEUDO-ANEURYSMCLASSIFICATIONOFANEURYSMSEtiologyandpathogenesisDevelopmentaltheory:congenitallesions/inbornstructuralweaknessofthemusclelayeratbranchingpointsDegenerativetheory:

ruptureofinternalelasticlaminaandmediaduetoextremehemodynamicstressCurrentconcept:

degenerativedisease,triggeredbyhemodynamicstress.StructuralweaknessmayplayaroleEtiologyandpathogenesisDevelEtiologyandpathogenesisruptureofinternalelasticlaminathinningandruptureofmedialackofelasticelementsinarterialwallconstantpulsatileflowaneurysmgrowthandruptureEtiologyandpathogenesisruptuIntracranialAneurysm

–TreatmentEmbolizationOperationConservativeIntracranialAneurysm

–Treat

“clearneck”threateningvasospasm

posteriorcirculation

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

toeliminatepulsatingbloodpressureinsidetheaneurysmGoalofaneurysmtreatment:AneurysmEmbolizationAneurysmEmbolization2mmX2cm?CordisNeurovascular,Inc.20033mmX4cm?CordisNeurovascular,Inc.20034mmX7cm?CordisNeurovascular,Inc.2003ComplexPlatinumCoils2mmX2cm?CordisNeurovasculaEndovascularembolizationEndovascularembolization腦與脊髓的血管性疾病課件Female,67yearsold,SAHOperativeclippingFemale,67yearsold,SAHOperaComplicationsafterSAHVasospasm--infarctionHydrocephalusComplicationsafterSAHVasospaCerebralVascularMalformation

ArteriovenousmalformationsCavernousmalformationsCarotid-cavernousfistula(CCF)VenousmalformationsTelangiectasis.CerebralVascularMalformationArteriovenousmalformations(AVMs)Arteriovenousmalformations(A腦與脊髓的血管性疾病課件腦與脊髓的血管性疾病課件臨床表現(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)64％患者在40歲之前發(fā)病(20～39歲）1臨床表現(xiàn)2

據(jù)文獻(xiàn)報(bào)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)2據(jù)文獻(xiàn)報(bào)道：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％臨床表現(xiàn)3HeadacheIntracranialhemorrhageEpilepsypresentationArteriovenousmalformation–ClinicalNeurologicaldeficitHeadacheIntracranialhemorrhagArteriovenousmalformation–

PurposeofthetreatmentPreventionfromrehemorrhageImprovementofischemiaRemovaloftheepilepticsourceArteriovenousmalformation–

腦與脊髓的血管性疾病課件腦與脊髓的血管性疾病課件腦與脊髓的血管性疾病課件腦與脊髓的血管性疾病課件Follow-up10yearslaterFollow-up10yearslaterGirl，age12,SAHwithepilepsyGirl，age12,SAHwithepilepsyGirl，age12,SAHwithepilepsyGirl，age12,SAHwithepilepsyOneyearafterembolizationOneyearafterembolizationPre-emboPost-emboBoy，age2，hydrocephalusPre-emboPost-emboBoy，age2，hyd2yearsafterembolization2yearsafterembolizationPre-emboPre-emboPost-emboPost-opFemale，age30，multi-SAHPre-emboPre-emboPost-emboPost-

Boy，age14，

intracerebralhemorrhageBoy，age14，

intracerebralhemoEmbolization+surgeryMale,22yearold,intracerebralhemorrhageEmbolization+surgeryMale,22Post-embolizationPost-embolization腦與脊髓的血管性疾病課件Post-operationPost-operationWillis環(huán)不對(duì)稱Willis環(huán)不對(duì)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(jì)算機(jī)系統(tǒng)，對(duì)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(diǎn)上，引起放射生物學(xué)反應(yīng)，從而達(dá)到治療目的。3、立體定向放射治療利用先進(jìn)的立體定向技術(shù)和計(jì)算機(jī)腦與脊髓的血管性疾病課件主要方法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）主要方法1γ刀：γ射線（鈷60）2X刀：高能X射線（直病例（立體定向放射治療）病例（立體定向放射治療）放療2年后隨訪放療2年后隨訪CavernousangiomaCavernousangioma外傷性頸動(dòng)脈－海綿竇瘺的定義定義外傷性頸動(dòng)脈－海綿竇瘺是指由外傷引起的海綿竇段的頸內(nèi)動(dòng)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(dòng)、靜脈溝通。外傷性頸動(dòng)脈－海綿竇瘺的定義定義外傷性頸動(dòng)脈－海綿竇瘺Carotid-cavernousfistula(CCF)Carotid-cavernousfistula(CCF臨床癥狀和體征臨床癥狀和體征T－CCF的分型T－CCF的分型

閉塞頸內(nèi)動(dòng)脈閉塞頸內(nèi)動(dòng)脈腦與脊髓的血管性疾病課件閉塞瘺口閉塞瘺口腦與脊髓的血管性疾病課件VenousmalformationFemale,50-year-old,SAHVenousmalformationFemale,50-MoyamoyaDiseaseMoyamoyaDiseaseIntracerebralhemorrhage(hypertensivehematoma)thulemusputaminalhematomaIntracerebralhemorrhagethulemMicrosurgicalremovaloftheclot.MicrosurgicalremovalofthecPercutaneouspunctureanddrainage(withthrombolyticsubstances)PercutaneouspunctureanddraiNationalCooperationnetworkwith150hospitals,3000casesNationalCooperationnetworkwAVMinSPINEandSPINALCORD

AVMinSPINEandSPINALCORD

SpinalVascularMalformations

-ClassificationIntrathecalIntramedullaryarteriovenousmalformations(SAVMs)IntramedullarycavernomasPerimedullaryarteriovenousfistulas(PMAVFs)SpinalDuralarteriovenousfistulas(SDAVFs)ExtraduralarteriovenousmalformationsVertebralangiomasParavertebralCobb’ssyndromeKlippel-TrenaunaysyndromeRendu-Osler-Weber’ssyndromeParavertebralarteriovenousfistulasSpinalVascularMalformationsSYMPTOMSANDSIGNSBackpainHypoesthesiaMuscleweakness(paraplegic,quadriplegic)SphincterdisturbanceSYMPTOMSANDSIGNSBackpainIntramadulleryAVMIntramadulleryAVMTwoweekspost-embTwoweekspost-embIntramadulleryAVMIntramadulleryAVMIntramadulleryAVM

IntramadulleryAVMPOST-OPPOST-OPIntramadullarycavernomaIntramadullarycavernomaPerimedullaryArteriovenousfistulaIPerimedullaryPerimedullaryarteriovenousfistulaIIPerimedullaryPerimedullaryarteriovenousfistulaIIIPerimedullarySpinalDAVFSpinalDAVFSPINALCAVENOUSANGIOMASPINALCAVENOUSANGIOMAPOST-OPPOST-OPCONCLUSIONCONCLUSIONCerebrovasculardiseasesIschemicTransientischemicattack(TIA)InfarctionHemorrhagic