隐源性卒中-课件

隐源性卒中

（CryptogenicStrokes）

北美和欧洲研究2023/6/632023/6/63CS定义的演变1988年，Mohr在《新英格兰医学杂志》最先提出CS这一概念，并将其定义为“缺乏已知危险因素的卒中”。MohrJP．NEnslJMed，1988，318(18)：1197-1198．1989年，Sacco等注意到40％的脑梗死患者经过积极排查后仍不能明确其原因，将这类脑梗死称为CS。SaecoRL，etal.AnnNeurol，1989，25(4)：382-3901993年，Adams等进一步将原因不明型的缺血性卒中分为3种情况：①未接受全面评价者；②发现两种或多种可能的病因，但不能明确哪种病因是脑梗死的实际原因——此种情况被称为两种或多种病因亚型（(twoormorecauses，TMC)；③经过积极排查后仍找不到原因的缺血性卒中。(TOASTcriteria）AdamsHPJr，etal.Stroke，1993，24(1)：35-41．2023/6/6CS定义的演变2009年，Timsit和Breuilly等明确将CS定义为，尽管经过积极排查，仍有部分脑梗死缺乏可以解释其发生的原因，称之为隐源性脑梗死。TimsitS，BreuillyC．PresseMed，2009，38(12)：1832—1842．2014年，Hart等建议用ESUS（Embolicstrokesofundeterminedsource）HartRG,etal.LancetNeurol2014;13:429–382023/6/6Potentialsourcesof

thromboembolismunderlyingESUSMinor-riskpotentialcardioembolicsources*（50%）Mitralvalve（二尖瓣）•Myxomatousvalvulopathywithprolapse（伴脱垂的粘液瘤样心瓣膜病）•Mitralannularcalcification（二尖瓣环形钙化）Aorticvalve(主动脉瓣）Aorticvalvestenosis（主动脉瓣狭窄）•Calcificaorticvalve（主动脉瓣钙化）Non-atrialfibrillationatrialdysrhythmiasandstasis•Atrialasystoleandsick-sinussyndrome（房性停博和病窦综合征）•Atrialhigh-rateepisodes•AtrialappendagestasiswithreducedflowvelocitiesorspontaneousechodensitiesAtrialstructuralabnormalities（房间隔异常）•Atrialseptalaneurysm（房中隔动脉瘤）•ChiarinetworkLeftventricle（左心室）•Moderatesystolicordiastolicdysfunction(globalorregional)（中度收缩期或舒张期功能障碍）•Ventricularnon-compaction•Endomyocardialfibrosis（心内膜心肌纤维化）2023/6/6Potentialsourcesof

thromboembolismunderlyingESUSCovertparoxysmalatrialfibrillation（隐匿性阵发性房颤）（10~20%）Cancer-associated•Covertnon-bacterialthromboticendocarditis•TumourembolifromoccultcancerArteriogenicemboli（15%）（动脉源性栓塞）•Aorticarchatheroscleroticplaques•Cerebralarterynon-stenoticplaqueswithulcerationParadoxicalembolism（反常栓塞）•Patentforamenovale（卵园孔未闭）（25%）•Atrialseptaldefect（房间隔缺损）•Pulmonaryarteriovenousfistula（肺动静脉动瘘）*Minor-risksourcesaremoreoftenincidentallypresentthanisthestrokecausewhenidentifiedinanindividualstrokepatient,areassociatedwithaloworuncertainrateofinitialstroke,andconsequentlycause-effectrelationandmanagementimplicationsareusuallyunclear.2023/6/67CriteriafordiagnosisofESUDStrokedetectedbyCTorMRIthatisnotlacunarAbsenceofextracranialorintracranialatherosclerosiscausing≥50%luminalstenosisinarteriessupplyingtheareaofischaemiaNomajor-riskcardioembolicsourceofembolismNootherspecificcauseofstrokeidentified(eg,arteritis,dissection,migraine/vasospasm,drugmisuse)2023/6/6ProposeddiagnosticassessmentforESUDBrainCTorMRI12-leadECGPrecordialechocardiography(transoesophagealechocardiography)Cardiacmonitoringfor≥24hwithautomatedrhythmdetectionImagingofboththeextracranialandintracranialarteriessupplyingtheareaofbrainischaemia(catheter,MR,orCTangiography,orcervicalduplexplustranscranialdopplerultrasonography)2023/6/6StrokerecurrenceratesThereportedrateofrecurrentstrokevarieswidely,of3–6%peryearvaryingcriteriafordiagnosisnon-standardisedantithrombotictreatmentvaryingprognosticfactors(particularlymeanpatientage)Youngpatients(averageagemid-40s)withPFO:1–2%peryearwhengivenasprin.olderpatientswithPFO:14%peryearinonereport2023/6/6AntithrombotictherapyforsecondarystrokepreventioninESUSTheonlyrandomisedassessmentofanticoagulationincryptogenicstrokeisthesubgroupanalysisoftheWarfarin-AspirinRecurrentStrokeStudy(WARSS)donebetween1993and2000.2206patients,30and85yearswithrecent(<30days)ischaemicstrokewhowererandomlyassignedtoaspirin325mgperdayoradjusted-dosewarfarin(targetinternationalnormalisedratio[INR]1·4–2·82023/6/611theprimaryoutcomeofischaemicstrokeordeath:15·0%warfarinversus16·5%aspirinover2years.the2yearrateofrecurrentischaemicstrokeordeathwas12%withwarfarinversus18%withaspirin(HR0·66,95%CI0·4–1·2).WARSSsubgroupsupportthenotionthatanticoagulation2023/6/6TheoralfactorXainhibitorsapixabanandrivaroxaban,andtheoraldirectthrombininhibitordabigatran,areatleastasefficaciousaswarfarinforpreventionofstrokeinpatientswithatrialfibrillation,andhavesignificantlylowerratesofintracranialbleeding.NorandomisedtrialshavetestedanticoagulantsinpatientswithcryptogenicstrokesassociatedwithPFO.Littleisknownabouttherelativeefficacyofanticoagulantversusantiplatelettherapyforsecondarystrokepreventionforarteriogenicembolismtothebrain,butavailabledatasupportgreaterefficacyofanticoagulants.2023/6/6Guidelinerecommendationsforsecondarypreventionrecommendantiplatelettherapy2008AmericanCollegeofChestPhysiciansguideline2008AmericanHeartAssociationguidelinedonotcommentspecificallyoncryptogenicstroke,butrecommendantiplatelettherapyforpatientswithnon-cardioembolicischaemicstroke.TheEuropeanStrokeOrganisationguidelinethe2011AmericanHeartAssociationrevisedguidelinethe2012AmericanCollegeofChestPhysiciansguidelinethe2010CanadianBestPracticeRecommendationsforStrokeCare2023/6/6CS诊断思路强调：费用一疗效比适当、常见病的不漏诊和可治性疾病的确诊。临床上应该重点考虑以下4种疾病：卵圆孔未闭(patentforamenoval，PF0)动脉夹层主动脉粥样硬化斑块形成Fabry病2023/6/6卵圆孔未闭PFO是目前最受到关注的CS的病因，43.9%HandkeM,etal.NEnglJMed2007;357:2262-2268诊断：TEE和TCD的发泡试验，这2种检查的敏感度和特异度都在90％以上。对于55岁以下的CS患者TCD或者TEE检查是必要的项目。大的PF0或合并房间隔动脉瘤的PF0，推荐介入（Amplatzeroccluderdevice）或手术治疗，降低卒中的复发。2023/6/616PFO和通过PFO的深静脉血栓

导致了4.5%-5%卒中发生2023/6/6卵园孔未闭的筛查TCD2023/6/618PFO诊断方法比较2014国际卒中大会（ISC）2023/6/6MagneticresonanceimagingscanshowingmultiplesmallischemiclesionsonFLAIRsequence.2023/6/6动脉夹层青年卒中，动脉夹层是重点考虑的诊断外伤、颈部按摩或过伸动作，迅速的转头，剧烈的Valsalva动作都可以引起颅内、外血管的夹层出现。典型的病史，结合动脉影像的线样征、火焰征、波纹征、双腔征、活瓣征、半月征，可以对患者作出诊断。一些没有明确病史的患者，也可以根据影像学检查结果直接作出高度怀疑的诊断。治疗一般以抗凝为主，也可以抗血小板治疗2023/6/6主动脉粥样硬化斑块形成对于55岁以上的患者，优先考虑的诊断一些患者经过仔细检查也没有发现颅内、外血管和心脏的病变，并且排除了腔隙性脑梗死的可能，要进行TEE检查和CTA检查对于升主动脉内膜中膜厚度超过4mm的患者，其卒中的发生率很高发现低回声、有溃疡或出血的斑块，其造成卒中的可能性更大。治疗ASA2023/6/6如何提高主动脉弓病变检出率？JNeurolNeurosurgPsychiatry2010;81:1306e1311TEE2023/6/6CE-CTA84岁老年男性，主动脉弓多层螺旋CT(矢状位重建)

箭头所指为5mm厚主动脉弓处动脉粥样硬化斑块，伴有钙化以及低密度成分2023/6/624TEE与多层螺旋CT（MSCT）从急性缺血性卒中前瞻性研究的150例患者中选择30例病因不明的患者TEE共检测出8位患者(29.6%)存在主动