神经精神病学课件：缺血性脑卒中

脑血管病CerebrovasculardiseaseStroke

IschemicStrokeHemorrhagicStrokeCharacteristicsAcuteonsetNeurologicdeficitsPersists>24hoursAdisturbanceofthecerebralcirculation

缺血性脑卒中IschemicStrokeIschemicStrokeDefinitionClassification临床分型：OCSP分型病因分型：Toast分型病理生理分型：脑血栓形成，脑栓塞，血流动力学机制（低灌注）所致的脑梗死（10%—20%）

CircleofwillisOCSP分型1、完全前循环梗死2、部分前循环梗死3、后循环梗死4、腔隙性梗死Anteriorcerebralartery(ACA)Anteriorcerebralartery(ACA)1、分出前交通动脉前主干闭塞2、分出前交通动脉后远端闭塞3、皮质支闭塞4、深穿支闭塞weaknessoftheoppositelegwithorwithoutsensoryinvolvement

Incontinence(尿失禁）possiblecognitiveimpairmentFrontallobeTemporallobeParietallobe

CerebralstructuresaffectedbyMCAocclusion

Middlecerebralartery（MCA）1、主干闭塞2、皮层支闭塞3、深穿支闭塞(纹状体内囊梗死)ContralateralhemiplegiaHemisensory

lossContralateralhemianopsiaGlobalaphasiaorneglectEyeandheaddeviationtowardlesionin

acutestageInternalcarotidartery（ICA）InternalcarotidarteryACAMCAOAArchofaorta(middlecerebralartery)(anteriorcerebralartery)(ophthalmicartery)

OcclusionAsymptomatic（慢性闭塞）TIAormonocularblindnessNeurologicalsymptoms:monoparesisorhemiparesis

hemisensorydisturbance

impairmentofspeechorlanguage

transientmonocularblindnessorvisualfielddefects

apraxia(失用)Internalcarotidartery（ICA）SubclavianarteryVertebralarteryPCABasilarartery(posteriorcerebralartery)Vertbrobasilarartery（VBA）Vertbrobasilarartery（VBA）severevertigo,nausea,vomitingcranialnervepalsies:dysphagia(呑咽困难),diplopia(复视)crossedsensorimotordeficits

ipsilateralcerebellarataxia(共济失调)visualfieldloss,gazepalsies

Wallenberg‘ssyndrome(延髓，小脑后下PICA)vertigo,nystagmus(眼震)，nausea,vomitingcrossedsensorydeficitipsilateralataxiaipsilateralHorner’ssyndromeipsilateralvocalcordparalysis,hoarseness,dysphagia,dysarthria,andhiccup

Vertbrobasilarartery（VBA）

“locked-insyndrome”(桥脑，基底动脉)

completebilateralparalysismotionlessandmutecanperceivesensorystimuliverticalcomponentsof3rdand4thnervefunctionmaybespared

Vertbrobasilarartery（VBA）

Webersyndrome(中脑，基底动脉)Ipsilateralthird(oculomotor，动眼神经)nervepalsyContralateralhemiplegiaVertbrobasilarartery（VBA）1、皮层支闭塞2、双侧闭塞3、近端闭塞midbrainsyndrome;thalamicsyndrome;choreaorhemiballismus(偏身投掷)hemisensorydisturbance.homonymoushemianopiacorticalblindnessPosteriorcerebralartery（PCA）IschemicStrokeDefinitionClassification临床分型：OCSP分型病因分型：TOAST分型病理生理分型：脑血栓形成，脑栓塞，血流动力学机制（低灌注）所致的脑梗死（10%—20%）

大动脉粥样硬化型（排除在血管狭窄50%基础上合并的心源性栓塞）心源性栓塞型小动脉闭塞型（腔隙综合症）其他少见类型（血管炎，血管畸形，夹层动脉瘤，肌纤维营养不良，卵圆孔未闭等）不明原因型Etiology:TOASTCerebralthrombosis

(脑血栓形成)不稳定斑块脱落附壁血栓形成严重狭窄引起下游低灌注（有争议）

PathogenesisAbnormalCBFisthebasalconditionofinfarction1）lowerthan20ml/(100gbraintissue.min)--cerebrocyteelectricactionstop2）lowerthan10ml/(100gbraintissue.min)--neurocytemembranedysfunction

Ischemicpenumbra(缺血性半暗带)ReperfusiondamageNeurocyteischemicdamagePathogenesisBloodtests（血脂、同型半胱氨酸，纤维蛋白原，凝血功能）

血压、血糖监测心电图，心脏彩超，经食道彩超，发泡实验外周动脉血管B超（颈动脉，下肢动脉）颅内血管检查（头颈MRA，CTA,或DSA）影像学检查（CT，MR平扫+DWI）其它少见原因筛查(ANCA,抗心磷脂抗体，梅毒等)

AssistantTest●Computedtomographyscan(CTscan)

AssistantTest●Magneticresonanceimaging(MRI)

AssistantTestDSA

AssistantTest:angiographyAssistantTest:angiographyTCDB超

AssistantTest:ultrosoundTreatment●Accuratediagnosisiskey!ACTScanmustbedonetoruleoutahemorrhagicstrokebeforeinitiationofanytreatment.Treatment吸氧和通气支持维持血压稳定，早期保持脑灌注，防止血压过低引起低灌注控制血糖防止脑水肿预防应激性溃疡其他对症支持治疗（发热、感染、容量）

Treatment:Supportivecare●

goalofthrombolysisrestoreCBFrescueischemicpenumbraTreatment:thrombolysis（溶栓）●Timewindow:3~6h●Inclusioncriteria

◆

age<75y

◆arterothromboticinfarctionwithin3~6h

◆

SBP<185;DBP<110

◆nohemorragictendency

◆nomassivehypodensityonCT

●Thrombolyticdrugs◆

urokinase(UK)

◆

streptokinase(SK)

◆

tissueplasminogenactivator(tPA)

●Administrativemodality◆

intraartery

◆intravenous●Sideeffect◆hemorrhageTreatment:thrombolysis（溶栓）Treatment:thrombolysis1、抗血小板治疗（阿司匹林+氯吡格雷）2、强化降脂治疗（他汀类药物）3、抗凝治疗（华法林、低分子肝素）4、脑细胞保护剂

Treatment

TreatmentOthercytoprotectivetherapy

Defibrase(降纤酶)batoxobin(巴曲酶)glutamatereceptorantagonists(谷氨酸受体拮抗剂)counteracteffectsoffreeradicals(抗自由基效应)gangliosides(神经节苷酯)neuronotrophicgrowthfactors(神经营养生长因子)中药：丹参，川芎●Surgicaltherapy◆

interventionaltherapyangioplasty(血管成形)intralumenalstents(血管内支架)

◆

endarterectomy(动脉内膜切除术)●

Rehabilitation(康复)

Treatment大动脉粥样硬化型（排除在血管狭窄50%基础上合并的心源性栓塞）心源性栓塞型小动脉闭塞型（腔隙综合症）其他少见类型（血管炎，血管畸形，夹层动脉瘤，肌纤维营养不良，卵圆孔未闭等）不明原因型Etiology:TOASTCerebralembolism（脑栓塞）●Etiology◆

Airembolism:lunginjury,etc.◆

Fatembolism:associatedwithbonefracture.◆MostcommoncauseofTIAismicroembolismfromatheroscleroticplaques.◆

Approximately70%ofembolicomefromtheheart

Cerebralembolism

（脑栓塞）Cardiogenicembolus（心瓣膜病或心内膜病）infeciveendocarditis

nonbacterialendocarditis

mitralvalveprolapse(脱垂)left-ventriclemural(附壁)thrombus

congestivecardiomyopathy

CerebralembolismCardiogenicembolus●

Arrhythmia

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Atrialfibrillation

◆

Sick-sinussyndrome

CerebralembolismCardicsurgery

●

Congenitalheartdisease

●

Hearttumor◆Pathologysimilartothosewitharterothrombosis.◆Commoninvolvedartery◆Theischemiaoftenaccompaniedbyhemorrhage◆Mutipleembolism:cardiogenicembolusmaycausemutipleembolism,orrelapse.

Cerebralembolism:pathology◆

Decreasedlevelofconsciousnessatonsetof

stroke◆

Suddenonsetofsymptomsandsignsthataremaximalatonset◆Rapidrecoveryfrommajorhemisphericdeficits◆Symptomsreflectinginvolvementofdifferentvascularterritoriesofthebrain◆CorticaldeficitinvolvingmainlytheMCAandthePCAandtheirbranches◆Usuallycompaniedbyheartdisease

Cerebralembolism:clinicalfeaturesCerebralembolism:therapytherapyforcerebralembolism

issimilartothearterothromboticinfarctionmentionedabovetherapyforheartdisease

anticogulation大动脉粥样硬化型（排除在血管狭窄50%基础上合并的心源性栓塞）心源性栓塞型小动脉闭塞型（腔隙综合症）其他少见类型（血管炎，血管畸形，夹层动脉瘤，肌纤维营养不良，卵圆孔未闭等）不明原因型Etiology:TOASTlacunarinfarction

DistinctclinicalsyndromesSmallpenetratingarteries(microathroma微小动脉硬化,lipohylinosis透明样变,embolism，小血管弥散障碍)Infarcts1cmorsmallerBasalganglia,internalcapsule,thalamus,brainstemMRfarmoresensitvethanCTCT

MR

lacunarinfarction

◆puremotorhemiparesis◆puresensorystroke◆motorandsensorystroke

◆ataxichemiparesis

◆dysarthria-clumsyhandsyndrome

lacunarinfarction：clinicalpresentation●Diagnosis◆

hypertensionhistory