脑血管病-1教学课件

脑血管疾病

cerebrovasculardiseases

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

CerebrovascularDiseases，CVD在脑血管病变基础上发生的局限性或弥漫性脑功能障碍thecerebraldiseasesthatareresultedfromvariouscerebrovasculardiseases急性脑血管疾病分类

classificationofacutecerebrovasculardiseases短暂性脑缺血发作（transientischemicattack，TIA）颈动脉系统internalcarotidarterysystem

TIA椎－基底动脉系统basilar-vertebralarterysystemTIA脑卒中（stroke,apoplexy,cerebrovascularaccident）蛛网膜下腔出血（subarachnoidhemorrhage）脑出血（intracerebralhemorrhage,ICH）脑梗死(cerebralinfarction)动脉粥样硬化性血栓性脑梗死(arterothromboticcerebralinfarction)脑栓塞(cerebralembolism)腔隙性脑梗死(lacunarinfarction),

等其他分类脑血管疾病

otherclassificationofcerebrovasculardiseases椎基底动脉供血不足（Vertebrobasilararterialinsufficiency）脑血管性痴呆（cerebralvasculardementia）高血压脑病（hypertensiveencephalopathy）颅内动脉瘤（intracranialaneurysm）颅内血管畸形（intracranialvascularmalformation）脑动脉炎（cerebralarteritis）颅内静脉、静脉窦血栓形成（thrombosisofvenoussinus）颅外段动、静脉疾病其他动脉疾病(otherarterialdiseases)脑的血液循环

bloodcirculationofcerebullar颈内动脉系统(internalcarotidarterysystem)椎基底动系统(basilar-vertebralartery脑组织(braintissue)静脉系统(veinsystem)静脉窦(veinsinuses)颈内静脉(internalcarotidvein)椎-基底动脉系统

vertebrobasilarcirculation椎动脉vertebralartery基底动脉basilarartery大脑后动脉posteriorcerebralartery脑的供血区域颈内动脉系统(internalcarotidartery)又称前循环,供应额、颞、顶叶和基底核等大脑半球前3/5血流providethebloodoffrontallobe,temporallobeandparietallobe,etal椎-基底动脉系统（basilar-vetebralartery)又称后循环，供应小脑、脑干、丘脑和枕、颞叶等大脑半球后2/5血液providethebloodofcerebellum,brainstem,cerebralganglion,occipitallobe,脑动脉细小分支穿通支（perforatingbranch）间脑(diencephalon)、纹状体(corpusstriatum)、内囊(internalcapsule)、脑干基底部中线旁结构皮质支（corticalbranch）

大脑半球皮质及皮质下白质与脑干的背外侧脑底动脉环大脑中动脉近端基底动脉脑动脉侧支循环

compensatorycirculationWillis环双侧颈内动脉

internalcaroticartey双侧大脑前动脉

anteriorcerebralartey双侧大脑后动脉

posteriorcerebralartery前交通动脉

anteriorcommunicatingartery双侧后交通动脉

posteriorcommunicatingartery其他侧支循环(othercompensatorycirculation)大脑前、中、后动脉皮质支在大脑表面彼此交通颈内、外动脉围绕眼耳、鼻、的深浅分支互相吻合大脑动脉皮质支与来自颈外动脉的脑膜动脉分支也存在丰富的侧支吻合分水岭脑梗死

cerebralwatershedinfarction脑血流及其调节

bloodcirculationregulation

脑血供丰富。在正常情况下，脑血流量（CBF）具有自动调节作用：CBF=（MAP-ICP）π•r4/（8η•L）。在缺血或缺氧的病理状态下，脑血管的自动调节机制紊乱，血管扩张或反应异常，脑水肿和颅内压升高，就会出现缺血区的充血和过度灌注或脑内盗血现象Inthenormalconditions,cerebralbloodflowcanautoregulate.CBFcanincreasewhilecerebralperfusionpressurerisesandcerebrovascularresistanceisdecreased.Intheischemicandhypoxicpathologicbehavior,theautoregulationmechanismsdisorder,bloodvesselsectasiaorresponseabnormality,cerebraledemaandintracranialpressurewillrise,soitappearshyperemiaandsuperperfusionorcerebralstealphenomenonintheischemicregion脑卒中(Stroke)发病率、死亡率、致残率均高与心脏病、恶性肿瘤构成人类三大致死病因不但危害中老年人健康，而且发病有年轻化趋势给社会和家庭带来沉重的负担morbidity,mortalityandmutilationrateofstrokearehigh流行病学epidemiology我国城市脑血管病的年发病率、死亡率和时点患病率分别为219/10万、116/10万和719/10万农村地区分别为185/10万、142/10万和394/10万分类classification一级预防：防发生first-levelprevention:preventoccurrence二级预防：防复发second-levelprevention:preventrecidivation三级预防：发病后治疗third-levelprevention:

thetherapyaftermorbility一级预防(primaryprevention)指发病前的预防，即通过早期改变不健康的生活方式，积极主动地控制各种危险因素，从而达到脑卒中不发生或推迟发病年龄的目的脑卒中危险因素riskfactors

可干预性mayintervene：高血压(hypertension)、心脏病(heartdieases)、糖尿病(diabetes)、血脂异常(hyperlipemia)、高同型半胱氨酸血症、短暂性脑缺血发作(historicstroke)、吸烟(smoking)、酗酒(heavyalcoholconsumption)、肥胖、无症状性劲动脉狭窄、口服避孕药物、肺炎衣原体感染、情绪应激、抗凝治疗等不可干预性non-intervention：年龄、性别、种族、遗传因素等脑卒中主要症状和体征

singsandsymptoms起病突然(onstesuddenly)全脑症状(wholebrainsymptom)局灶性症状和体征(focalsingsandsymptoms)颈内动脉系统表现

(internalcarotidartery)椎-基底动脉系统表现(basilar-vetebralartery)脑膜刺激征(meningealirritationsign)短暂性脑缺血发作transientischemicattack临床表现

clinicalsituation＞50岁

patientsolderthan50,

常伴有动脉硬化、高血压、糖尿病、冠心病等

accomplywithangiosclerosis,hypertension,diabetes,coronaryarterydisease发病突然，迅速出现局限性神经功能障碍

acuteonsetofaneurologicdeficit持续时间短，＜24小时

neurologicdeficitpersistsforless24hours不留后遗症

noresidual可反复发作

recurrentattacks颈内动脉系统TIA

TIAofinternalcarotidartery短暂性偏侧或单肢无力transienthemiparesis面部、单肢或偏身麻木hemisensorydisturbances同向偏盲或单眼一过性失明homonymoushemianopiaortransientocellanaeacroisa失语aphasia椎－基底动脉系统TIA

TIAofvertebrobasilarcirculation眩晕（vertigo）、复视（diplopia）、吞咽困难（acataposis）、共济失调（ataxia）交叉性瘫痪（crossedparalysis）跌倒发作（dropattack）、短暂全面性遗忘症（transientglobalamnesiaTGA）、双眼视力障碍发作（theonsetofbinocularvisiondisorders）诊断

approachtodiagnosis中老年患者senior突然出现局限性神经功能障碍

acuteonsetofaneurologicdeficit24小时完全恢复

completerecoveryin24hoursCT、MRI（－）TCD监测鉴别诊断

differentialdiagnosis部分性癫痫（partepilepsy）梅尼埃病（Menieredisease）颅内占位性病变（intracranialspaceoccupyinglesion）治疗

treatment药物治疗(drugtreatment)抗血小板聚集(antiplatelettherapy)Asprin50~150mg，po，Qd噻氯匹定（ticlopidine)氯吡格雷(clopidogrel)双嘧达莫(dipyridamole,DPA)奥扎格雷(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钙拮抗剂：尼莫地平、盐酸氟桂嗪（nimodipine、flunarizine）其他（others）中药治疗（tranditionalmedicinetreatment）扩血管治疗：罂粟碱、倍他司丁、烟酸（papaverine、betahistine、nicotinicacid）治疗

treatment病因治疗(etilogicaltreatment)手术治疗(surgery)管腔狭窄＞70%，伴反复TIA，可考虑介入治疗或颈动脉内膜剥除术预后

prognosis脑梗死cerebralinfarction反复发作recurrentattacks自行缓解releasewithouttreatment缺血性脑卒中cerebralischemicstroke缺血性脑卒中

cerebralischemicstroke,CIS由于脑部血液供应障碍，缺血、缺氧引起的局限性脑组织的缺血性坏死或脑软化又称脑梗死（cerebralinfarction,CI),临床常见类型有动脉粥样硬化性血栓性脑梗死、脑栓塞和腔隙性梗死等。脑梗死约占全部脑卒中的80％Cerebralischemicstrokeisagaincalledcerebralinfarction,whichiscausedbyinsufficientinflowofblood,thenischemiaandhypoxiacauselocalcerebraltissue’sischemicnecrosisorencephalomalacia

动脉粥样硬化性血栓性脑梗死

arterothromboticcerebralinfarction通常是指脑动脉的主干或其皮层支因动脉粥样硬化等血管病变，导致的官腔狭窄或闭塞并进而发生学栓形成，造成脑局部供血区血流中断，发生脑组织缺血、缺氧、软化坏死，出现相应的神经系统症状和体征thevesseldiseasesarecausedbycerebralarterialstems’oritscortexbranches’atherosclerosisandvariousarteritis,whichcausevesselconstrictionoremphraxisandthenformthrombosisandlocalbloodflowbreaks.Socerebraltissueischemia,hypoxia,softeningandnecrosis,whichcausecorrespondingnervoussystemsymptomsandsigns.

病因

etiopathogenisis脑动脉粥样硬化cerebralatherosclerosis高血压hypertension糖尿病diabetes

血脂异常hyperlipemia脑动脉炎cerebralarteritis结缔组织疾病connectivetissuediseases先天性血管畸形congenitalvascularmalformation真性红细胞增多症polycythemiarubravera血高凝状态hypercoagulabalestate血小板增多症thrombocythemia发病机制

nosogenesis脑梗死(cerebralinfarction)灶形成机制脑血流障碍(cerebralbloodflowdisorder)神经细胞缺血性损害(nervecellischemiadamage)能量代谢障碍(energymetabolismdisorder)和酸中毒(acidosis)兴奋性氨基酸（excitatoryaminoacid)毒性和钙超载(calciumoverload)磷脂降解(phospholipiddegradation)和脂类介导的毒性作用自由基(freeradical)损伤缺血性脑水肿(ischemicbrainedema)一氧化碳(nitricoxide)毒性即早基因(immediateearlygenes)、神经营养因子(neurotrophicfactors)和热休克蛋白(heatshockprotein)等基因表达改变细胞因子再灌注时间窗

reperfusiontimewindow超早期治疗的关键是抢救缺血半暗带，采取脑保护措施减轻再灌注损伤，目前普遍把脑缺血的超早期治疗时间窗定为6小时之内Thekeytotherapyistosalvageischemicpenumbraintheultra-earlierperiodandtakeactionstoreducereperfusiondamadge.Atpresent,cerebralischemictherapytimewindowintheultra-earlierperiodissettledwithin6hours临床表现

clinicalmanifestation老年人(senior)有动脉粥样硬化、高血压、糖尿病或冠心病史(withangiosclerosis,hypertension,diabetes,coronaryarterydisease)常在安静或睡眠中起病(onsetatquietorsleep)一般无头痛、呕吐、昏迷等全脑症状(noheadache、vomit、coma）颈内动脉系统脑梗死临床表现(clinicalmanifestation)颈内动脉血栓形成（internalcarotidarterythrombosis）大脑中动脉血栓形成(middlecerebralarterythrombosis)大脑前动脉血栓形成(anteriorcerebralarterythrombosis)椎-基底动脉系统脑梗死(basilar-vetebralarterysysteminfarction)大脑后动脉血栓形成(posteriorcerebralarterythrombosis)椎动脉血栓形成(vetebralarterythrombosis)延髓背外侧综合征(Wallenbergsyndrome)基底动脉血栓形成(basilararterythrombosis)脑桥腹外侧综合征(Millard-Gublersyndrome)闭锁综合征(locked-insymdrome)基底动脉尖综合征(topofthebasilararterysyndrome)辅助检查

auxiliaryexamination血常规BR和生化检查CTMRI血管造影(cerebralarteriography)

DSA、CTA、MRAB超、TCDSPECT、PETCSF急性期一般治疗

generaltreatmentinacutestage维持呼吸功能(retainrespiratoryfunction)调整血压(adjustedbloodpressure)控制血糖(controlbloodsugar)控制体温(controlbodytemperature)预防并发症(precautioncomplication)营养支持(nutritionalsupport)急性期溶栓治疗

thrombolysistreatment溶栓时间窗（timewindow)起病3小时内，3~6小时可慎重选择病例，6小时后疗效不佳，并有较大出血危险适应征(indcation)年龄小于75岁瘫痪肢体肌力3级以下无明显意识障碍用药时血压低于180/110mmHg禁忌征(taboo)有出血倾向、大面积脑梗死、严重心、肝、肾疾病者常用药物(generaldrug)组织型纤维蛋白溶解酶原激活剂(tPA)尿激酶(UK)链激酶(SK)溶栓治疗有颅内或身体其他部位出血的危险，有的可导致死亡其他治疗

(othertreatment)抗凝治疗(anticoagulation)降纤治疗（defibrase）抗血小板聚集(antiplateletaggregation)治疗脑保护治疗(brainconservation)神经保护剂压低温治疗脱水降颅压(dehydration)血液稀释疗法(hemodilution)中医中药治疗(Chinesecrudedrug)外科介入治疗(surgery)卒中单元（strokeunit,SU）康复期治疗

treatmentinconvalescencestage康复治疗convalescentcare二级预防second-levelprevention脑栓塞cerebralembolism脑栓塞

cerebralembolism是指各种栓子随血流进人颅内动脉系统使血管腔急性闭塞引起相应供血区脑组织缺血坏死及脑功能障碍Cerebralembolism—cerebraltissueischemia,necrosisandcerebralfunctiondisordersthatarecausedbyvariousembolienteringcraniumarterysystemfollowingbloodflowandmakingbloodvesselacutelyemphraxis病因

etiopathogenisis心源性脑栓塞(Cardiogeniccerebralembolism)心房颤动AF心脏瓣膜病和心内膜病感染性心内膜炎心肌梗死、心肌病心脏手术先天性心脏病心脏肿瘤非心源性脑栓塞(nonCardiogeniccerebralembolism)原因不明(unknownaetiology)临床表现

clinicalmanifestation任何年龄均可发病，青壮年多见。活动中突然起病，数秒或数分达高峰，是发病最急的脑卒中，且多为完全性卒中Cerebralembolismcanbefoundatanyage,butmostofthemisatyoungprimeofone’slife.Theonsetsuddenlystartsatactivities,achievespeaksafterafewsecondorminutes.Itistheacuteststrokeamongallstrokes,andmostofthemarecompletedstrokes局限性神经缺失症状与栓塞动脉供血区的功能相对应Limitednervedeletionsymptomsarecorrespondedwithembolismarterysufficientbloodregions大多数病人有栓子来源的原发病Mostofpatientstroubleproepisodethatembolicomefrom诊断及鉴别诊断

diagnosisanddifferentialdiagnosis根据病史和临床表现，诊断不难。应注意与脑血栓形成、脑出血的鉴别Accordingtohisteryandclinicalmanifestatio