李亚雄读书报告-基底动脉闭塞.ppt

1、Basilar Artery Occlusion,08级脑外科研究生 李亚雄,Introduction,约20%的缺血性卒中是椎基底动脉闭塞所致。基底动脉闭塞(basilar artery occlusionBAO)有临床表现复杂、发病凶险、病情重、预后差(90%)等特点，即使采用抗凝和降纤等治疗，患者死亡率仍然接近50,Anatomy,Etiopathogenisis,动脉粥样硬化合并狭窄 血栓栓塞 其它：颈部外伤 动脉炎 基底动脉瘤 高凝状态 药物滥用等,Clinical manifestation,临床表现取决于动脉闭塞的部位、支配的范围和侧支循环状况。 动脉粥样硬化椎基底动脉 基底动脉

2、近端和中段 颅外血栓栓子基底动脉远端,BAO,主干闭塞：反复眩晕、恶心、复视、构音障碍等，病情发展快而出现四肢瘫、昏迷、并导致死亡 分支闭塞： 脑桥腹外侧综合症 闭锁综合症 基底动脉尖综合症 等 (构音障碍、瞳孔改变、球部症状和意识障碍,Examination,实验室检查：凝血酶原时间、部分凝血活酶时间、胆固醇水平、血脂、心肌同工酶、肌钙蛋白水平 影像学检查：头颅CT（24h） MRI和MRA CTA DSA,Diagnosis,危险因素 （高血压、糖尿病） 局灶性神经功能缺损 可有反复TIA 影像学资料,Therapy,急性期治疗： 时间再通预后 一般治疗 溶栓治疗 静脉溶栓(IVT) 动脉

3、溶栓(IAT) 在BAO急性期，静脉溶栓联合机械性血栓取出术(EMT)可以明显提高闭塞血管的再通率，改善预后,Inclusion criteria,有明确的BAO的症状 CT除外脑出血 CTA证据 6h 无IVT禁忌症,Methods,Clinical signs (all three required) suggesting acute basilar artery occlusion (BAO): reduced consciousness (GCS 14) oculomotor dysfunction and/or bulbar signs hemi- or tetraparesis a

4、nd/or ataxia,Exclusion of cerebral hemorrhage on CT Evidence of BAO on CTA Treatment within six hours after symptom onset IVT (0,9 mg/kg rt-PA,Transfer to our Stroke Center(24h) (if patient was initially admitted to Community Hospital) CT and CTA Persisting BAO EMT,Intensive Care Unit 或者 CT and CTA

5、Patent Basilar Artery Intensive Care Unit,A total of 106 patients with the clinical syndrome of BAO (symptoms_24 hours) and subsequent confirmation by CT or MRA presented to our institution. Department of Neurology,University of Heidelberg,criteria of the Trial in Myocardial Infarction (TIMI) : TIMI

6、 0, complete occlusion of the BA; TIMI 1, partial recanalization but remnant occlusion; TIMI 2, incomplete recanalization with continuous BA patency but remnant thrombus; TIMI 3, complete recanalization,个体化原则 预防再闭塞： 阿司匹林 所有患者在治疗后1-7天内都复查CT或MRI 出院后随访3个月 Intravenous abciximab and intraarterial rt-PA (

7、bridging therapy,Results,IVT治疗时间窗延长到6h Bridging Therapy时间窗延长到24h 缺点：人数少，缺少大规模随机对照试验。 联合治疗前景广阔 (血管成形术/支架置入术,2009 AHA Scientific Statement,Mechanical Clot Extraction, Angioplasty and Stenting,ESO-Guidelines for Management of Ischaemic Stroke 2008,ESO-Guidelines for Management of Ischaemic Stroke 2008

8、(BAO,References,Staged Escalation Therapy in Acute Basilar Artery Occlusion: Intravenous Thrombolysis and On-Demand Consecutive Endovascular Mechanical Thrombectomy: Preliminary Experience in 16 Patients stroke. 2008;39:1496-1500,References,Therapy of Acute Basilar Artery Occlusion Intraarterial Thrombolysis Alone vs Bridging Therapy stroke. 2009;40:140-146,References,