脑与脊髓的血管性疾病课件

脑与脊髓的血管性疾病

VASCULARDISEASES

inBRAINandSPINALCORD

Whatisit?

Howtomanageit?流行病学（Epidemiology）Annually,1,500,000to2,000,000Chinesesufferastroke.Mortality:25-30%Morbidity:60%Thecosttoindividualsandsocietyintermsofacutecareresources,rehabilitation,chroniccare,andlostproductivityisenormous.Today’stopics缺血性脑血管病（Ischemiccerebralvasculardiseases）出血性脑血管病（Hemorrhagiccerebralvasculardiseases）脊柱脊髓血管病（Spineandspinalcordvasculardiseases）Ischemiccerebraldisease–

ClinicalpresentationTIA(transientischemicattack一过性脑缺血发作)Infarction（脑梗死）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)临床表现64％患者在40岁之前发病(20～39岁）

主要症状：出血52～77%15～20岁高发癫痫28-64%神经功能障碍20～30％头痛60％1临床表现2

据文献报道：

未出血AVM的年出血率为2～4％再出血率为第一年6％以后2～4％临床表现3AVM死亡病例中，大约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环不对称3、立体定向放射治疗

利用先进的立体定向技术和计算机系统，对颅内的正常组织靶电或病变组织，使用1次大剂量窄束电离射线从多方向、多角度精确地聚集于靶点上，引起放射生物学反应，从而达到治疗目的。主要方法1γ刀：γ射线（钴60）2X刀：高能X射线（直线加速器）3质子刀：质子束（回旋加速器、同步加速器）病例（立体定向放射治疗）放疗2年后随访Cavernousangioma外伤性颈动脉－海绵窦瘘的定义定义外伤性颈动脉－海绵窦瘘是指由外伤引起的海绵窦段的颈内动脉本身或其在海绵窦内的分支破裂，与海绵窦之间形成异常的动、静脉沟通。Carotid-cavernousfistula(CCF)临床症状和体征T－CCF的分型

闭塞颈内动脉闭塞瘘口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