急性脑梗死[医术材料]

1、11 12 是由于局部脑血流中断引起,时间超过 2小时，DWI上有表现。 占脑卒中的85%。 85% 预后是好的，15%的缺血脑卒中 预后差，死亡率高。 13 脑动脉粥样硬化脑动脉粥样硬化：高血压、高血脂、 吸烟 小血管玻璃样变小血管玻璃样变：高血压、糖尿病 低灌注性脑梗死低灌注性脑梗死：动脉狭窄 心源性脑栓塞心源性脑栓塞：冠心病、风心病 血管炎血管炎：SLE、 结核、螺旋体动脉炎 其它：其它：避孕药。 14 OCSP：按临床症状分：完全前循环、部 分前循环、完全后循环、腔隙性脑梗死 ASCO：A-动脉硬化，S-小血管，C-心源 性，O-其它 15 血脂、糖代谢、HCY 心脏、血管彩超 头颅C

2、T及CT A 头颅MRI及MRA DSA 16 17 OCSP 完全前循环：完全前循环：意识障碍、眼球凝视、语言 障碍加偏瘫（皮层枝加深穿支） 部分前循环部分前循环：皮层枝或深穿支 完全后循环完全后循环：四肢瘫痪、眩晕、意识障碍 腔隙性脑梗死腔隙性脑梗死：21型，常见有5型。 18 19 脑梗死的急性期治疗脑梗死的急性期治疗 超早期溶栓治疗超早期溶栓治疗 抗栓治疗抗栓治疗 他汀类药物他汀类药物 抗高血压药物抗高血压药物 控制高血糖控制高血糖 抗炎抗炎 神经保护剂神经保护剂 脱水问题脱水问题 110 超早期溶栓治疗超早期溶栓治疗 111 抗栓治疗抗栓治疗 The annualized rates

3、 of total Major bleeding events Secondary stroke prevention of antithrombotics Am J Cardiol. 2009，15;103(8):1107-12. 112 Design 13 studies follow-up： or =1 year to compare：aspirin ( or =325 mg/day), clopidogrel, anticoagulants (warfarin and other vitamin K antagonists), aspirin plus clopidogrel, and

4、 aspirin plus extended-release dipyridamole (ER-DP) 113 Total bleeding rate 4.8%-aspirin ( or =325 mg/day) 2.9% - clopidogrel 3.6%- aspirin plus ER-DP 10.1% - aspirin plus clopidogrel 16.8%- anticoagulation 114 Major bleeding rate 1% - aspirin ( or =325 mg/day) 0.85%-clopidogrel 0.93%-aspirin plus E

5、R-DP 1.7%-aspirin plus clopidogrel 2.5%-anticoagulation 115 Conclusion The combination of aspirin and clopidogrel is associated with significantly greater bleeding than either aspirin ( or =325 mg/day) or clopidogrel alone. Aspirin plus ER-DP has a greater bleeding rate than clopidogrel but a lower

6、rate than aspirin ( or =2 medications with different mechanisms of action will be necessary RAAS have proven to be excellent therapeutic targets A number of antiatherosclerotic effects have been attributed to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers combination ther

7、apy with these agents has become the focus of recent clinical trials Am Heart J. 2009 Jun;157(6 Suppl):S24-30 126 Cumulative proportions of patients prescribed new medication new statin (adding) clopidogrel new BP lowering med. 2 new BP lowering med. EXPRESS study, Rothwell et al, Lancet 2007;370:14

8、32-42 127 ACEIs clinical evidence suggests that ACEIs added to standard therapy reduce CV mortality, MI, and stroke in a broad population of patients at high risk for ischemic events. 128 ARBs and ischemic stroke prevention The Study on Cognition and Prognosis in the Elderly (SCOPE) assessed the eff

9、ect of candesartan therapy on CV events in elderly patients. SCOPE trial assessed the effect of candesartan therapy on CV events in elderly patients. Active treatment was associated with a significant reduction in nonfatal stroke (28%, P = .04 vs placebo) and total stroke (24%, P = .056 vs placebo).

10、 129 PRoFESS trial limitations Diastolic BP (80 mmHg) in the first month post- stroke may have been too low in at least one third of the population Baseline systolic blood pressure less than 130 mmHg, because a high dose of telmisartan was given after a very short post-stroke delay (median 15 days)

11、130 Combination ACEI/ARB therapy Combination therapy resulted in a 2.4/1.4- mm Hg greater decrease in BP compared with ramipril alone A growing number of studies indicate that ARBs and ACEIs provide stroke protection beyond their ability to reduce 131 Meta-analysis 4 randomized clinical trials inclu

12、ding 426 patients.94% had ischemic stroke Fluoroquinolones in 2 and tetracycline or a combination of beta-lactam antibiotic with beta- lactamase inhibitor in 1 Within 24 hours Duration for between 3 and 5 days Arch Neurol. 2009 Sep;66(9):1076-81 Preventive antibiotics in patients with acute stroke 1

13、32 控制高血糖控制高血糖 133 Management of hyperglycemia in critically ill patients A better long-term outcome was shown in patients who suffered from MI and who underwent meticulous blood glucose control 1,548 surgical intensive care patients had been randomly allocated to either the conventional approach (in

14、sulin infusion started only when blood glucose levels exceeded 12 mmol/L) or intensive insulin therapy (insulin infused to maintain blood glucose at a level of 4.5-6.1 mmol/L 80 110 mg/dL) Intensive insulin therapy reduced intensive care mortality by more than 40% Mesotten D, Van den Berghe G. Clini

15、cal potential of insulin therapy in critically ill patients. Drugs 2003;63:625-636 134 Intravenous insulin is feasible and achieves euglycemia in stroke Gray et al. Stroke 2004;35:122 Bruno et al.Neurology 2004;62:1441 135 Glucose-Potassium-Insulin infusion in the management of post stroke hyperglycemia: the UK Glucose Insulin in Stroke Trial (GIST-UK). Lancet N