脑血管疾病CerebrovascularDiseaseCVD课件

,单击此处编辑母版标题样式,*,*,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,可编辑,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,可编辑,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2020/9/14,#,脑血管疾病,Cerebrovascular,Disease(CVD),Department of Neurology,2nd hospital of Kunming Medical University,脑血管疾病Cerebrovascular Disease,1,Section 1 Introduction,Definition,CVD:,The term of CVD designates any abnormality of the brain resulting from various pathological process of the blood vessels.,脑血管病是各种脑血管病变引起脑部疾病的总称。,Section 1 Introduction,2,Definition,Stroke:,The stroke,is a syndrome characterized by the acute onset of a neurologic deficit that reflects focal/diffused involvement of the CNS and is the result of a disturbance of the cerebral circulation.,脑卒中是指急性起病 、迅速出现局限性或弥漫性脑功能缺失征象的脑血管性事件,。,Definition,3,Epidemiology:,CVD,is the third most common cause of death after heart disease and cancer.,Incidence,: 100300/100,000,morbidity,: 100740/100,000,mortality,: 50100/100,000,About 50%70% of survivors shows disability in different degree.,Epidemiology:,4,Classification of CVD,According to,the lasting time of neurologic deficit:,TIA (24h).,According to the severity of,neurologic deficit:,minor stroke,major stroke,silent stroke,According to the pathological features:,ischemic stroke,hemorrhagic stroke,(see table 8-1),Classification of CVDAccording,5,脑部的血液供应,-Blood supply in brain,颈内动脉系统,-,internal carotid artery,(ICA) S.,眼动脉,-,ophthalmic artery,后交通动脉,-,post communicating artery,脉络膜前动脉,-,anterior choroidal artery,大脑前动脉,-,anterior cerebral artery,(ACA),大脑中动脉,-,middle cerebral artery,(MCA,),供应眼部及大脑半球前,3/5,部分即额叶、颞叶、顶叶及基地节的血液,见图,the circle of Willis,环,见图脑基底部动脉,脑部的血液供应-Blood supply in brain颈,6,椎,-,基底动脉系统,-,vertebral-basilar artery S.,椎动脉,(VA):,Which is divided into,anterior spinal artery,(,脊髓前动脉,),posterior spinal artery,(,脊髓后动脉,),medullary artery,(,延髓动脉,),posterior inferior cerebellar artery,(,小脑后下动脉,),椎-基底动脉系统-vertebral-basilar art,7,基底动脉,(BA):,Which has branches of,anterior inferior cerebellar artery,（小脑前下动脉）,branches of pons,（脑桥支）,internal auditory artery,（内听动脉）,superior cerebellar,artery,（小脑上动脉）,基底动脉(BA): Which has branches o,8,大脑后动脉,(posterior cerebral artery, PCA) ,which is the terminal division of BA,椎基底动脉系统供应脑干,小脑及大脑 半球后,2/5,部分即枕叶及颞叶的基底面，枕叶的内侧及丘脑等。,大脑后动脉 (posterior cerebral arte,9,Etiology of CVD,Vascular disorder,Atherosclerosis,Inflammatory disorders (TB,syphilitic arteritis, SLE, etc.),Congenital vascular malformation (aneurysm, AVM ),Lesions of any cause,Etiology of CVD Vascular diso,10,Etiology of CVD,Heart diseases and blood kinetics changes,Hypertention or hypotension,Atrial fibrillation, Rheumatic heart disease, arrhythmias etc,.,Etiology of CVDHeart diseases,11,Changes in blood constituent and hemodynamics,Increase in blood viscosity,Abnormality in blood coagulation mechanism,Others,Such as emboli of air , fat, cancer cells. Blood vessel spasm, trauma, etc.,Changes in blood constituent a,12,Risk factors,Several factors are known to increase the liability to stroke. The most important of these are:,Hypertention,Heart diseases,Diabetes,TIA or stroke history,Risk factorsSeveral factors ar,13,Risk factors,Smoking and alcohol,Hyperlipidmia,Others: food, symptomless ICA bruit, overweight, drug abuse, contraceptive,，,age, sex, family history, race, etc.,Risk factorsSmoking and alcoho,14,Section 2 Transient Ischemic Attack, TIA (,短暂性脑缺血发作,),Concept,Etiology and mechanism,Clinical findings,Investigative studies,Diagnosis and differentiation,Treatment and prevention,Section 2 Transient Ischemic,15,TIA-Concept,TIA is brief, repeated, reversible episodes of focal ischemic neurologic disturbance. The duration of which should be less than 24h (usually lasting about several min to 1h).,Repeated TIAs of uniform type are more often a warning sign of ischemic stroke.,TIA-ConceptTIA is brief, repea,16,脑血管疾病CerebrovascularDiseaseCVD课件,17,TIA-Clinical findings,Age of onset, 5070, male female,Basic features:,Transient episode,(30 seconds-metabolic change, 1 min - cease of neuron activity, 5min - cerebral infarct.,Ischemic penumbra (,缺血半暗带,）,time window (6h),PathophysiologyBlood flow bloc,49,Pathophysiology,Reperfusion damage: possible mechanisms:,自由基 (,free radical,),形成及其瀑布式反应,神经细胞内钙超载(,calcium overload,),EAA,毒性作用,(,toxic effect of excitatory amino acid,),酸中毒,(,acidosis,),PathophysiologyReperfusion dam,50,Types,大面积脑梗死（,a large area CI,）,分水岭脑梗死,(,cerebral watershed infarction, CWSI,),出血性脑梗死,(,hemorrhagic infarct, HI,),多发性脑梗死,(,multiple infarct, MI,),Types大面积脑梗死（a large area CI）,51,Clinical features,Clinical types,Complete stroke: reaches peak within several hours,(,24h and recovering within 3ws,Clinical features Clinical typ,52,THANK YOU,SUCCESS,2024/8/28,53,可编辑,THANK YOUSUCCESS2023/9/353,Clinical features,General features:,Middle-aged or elderly people (caused by Atherosclerosis), youth or middle-aged people (caused by arteritis).,Stroke onset at quiet state and reaches the peak within several hours to 12 days.,Clinical featuresGeneral featu,54,Clinical features,General features:,Usually, the patients are awake and alert except for those with a large area of CI or infarction in brainstem.,Clinical featuresGeneral featu,55,Clinical syndromes of CI,Occlusion syndrome of carotid artery,Carotid artery occlusion may be asymptomatic,.,Symptomatic occlusion results in syndromes follow,:,Transient monocular blindness caused by ipsilateral retinal artery ischemia.,Horners sign,.,Clinical syndromes of CIOcclus,56,Clinical syndromes of CI,Occlusion syndrome of carotid artery,Carotid artery or ophthalmic artery bruit and a weakened pulse in carotid artery.,Contralateral hemiplegia, hemisensory deficit, and homonymous hemianopia.,Aphasia, if dominant hemisphere involvement,.,Clinical syndromes of CIOcclus,57,Clinical syndromes of CI,Oclusion syndrome of,MCA,主干闭塞 (,Occlusion in stem):,is a severe stroke syndrome which combines the features of superior and inferior division stroke.,三偏症状,(,contralateral hemiparesis, hemisensory deficit, and homonymous hemianopia,).,Clinical syndromes of CIOclusi,58,Clinical syndromes of CI,Oclusion syndrome of MCA,失语症,、,体象障碍 (,globle aphasia, if dominant hemisphere is involved, and body image disturbence,),意识障碍、,颅内压增高、脑疝可导致死亡,(,disturbence of consciousness, increased ICP, and herniation,),Clinical syndromes of CIOclusi,59,Clinical syndromes of CI,Oclusion syndrome,of MCA,皮层支闭塞(,occlusion in superior division),中枢性面舌瘫和偏瘫，偏瘫上肢重于下肢 (,contralateral hemiparesis that affects the face, hand, and arm but less severe in the leg,).,Clinical syndromes of CIOclusi,60,Clinical syndromes of CI,Oclusion syndrome,of,MCA,皮层支闭塞(,occlusion in superior division),伴感觉障碍，主要是皮质感觉障碍 (,contralateral hemisensory deficit,mainly shows cortical sensory deficit,),失语,、,体象障碍 (,aphasia and body image disturbence,),Clinical syndromes of CIOclusi,61,Clinical syndromes of CI,Oclusion syndrome,of MCA,深穿支闭塞,(occlusion in inferior division),对侧偏瘫,(,contralateral hemiparesis, upper and lower limbs evenly affected,),对侧偏身,感觉障碍及偏盲,(,contralateral hemisensory deficit and homonymous hemianopia,),可有失语,(,dominant hemisphere involved,),Clinical syndromes of CIOclusi,62,Clinical syndromes of CI,Occlusion syndrome of,ACA,主干闭塞(,occlusion in stem),中枢性面舌瘫、偏瘫下肢重于上肢(挑扁担样,瘫,),(,Shoulde-pole-carry-like,),伴轻度感觉障碍,尿便障碍或尿急(旁中央小叶损), (,incontinence , paracentral lobule is affected,),Clinical syndromes of CIOcclus,63,Clinical syndromes of CI,Occlusion syndrome of,ACA,主干闭塞 (,occlusion in stem),精神症状 (,psychiatric symptom,) (,颞极与胼胝体受,累，,temporal pole andcorpus callosum are affected,)，,常可见强握、,吸,吮反射 (额叶病变,),(,grasp reflex, suck reflex are common signs, lision in frontal lobe,).,Clinical syndromes of CIOcclus,64,Clinical syndromes of CI,Occlusion syndrome of ACA,皮层支闭塞(,occlusion in superior division),对侧偏瘫，下肢重于上肢 (,sensorimotor deficit of the opposite leg and foot and , to less degree, of the shoulder and arm,),Clinical syndromes of CIOcclus,65,Clinical syndromes of CI,Occlusion syndrome of ACA,深穿支闭塞 (,occlusion in inferior division),面、舌、肩瘫 (,contralateral paresis includes face, lingua, shoulder,),Clinical syndromes of CIOcclus,66,Clinical syndromes of CI,Occlusion,syndrome of,PCA,主干闭塞,(,occlusion in stem )：,对侧偏盲、偏瘫及偏身感觉障碍(较轻),丘脑综合症 (,thalamic syndrome,),主侧半球病变可有失读症(,alexia,).,Clinical syndromes of CIOcclus,67,Clinical syndromes of CI,Occlusion,syndrome of PCA,皮层支闭塞（,occlusion in superior division,）,对侧同向性偏盲(,contralateral homonymous hemianopia,)、,象限盲(,quadrant hemianopia,)、,皮质盲(,cortical blidness, bilateral involvment,),Clinical syndromes of CIOcclus,68,Clinical syndromes of CI,Occlusion,syndrome of PCA,皮层支闭塞（,occlusion in superior division,）,主侧颞下动脉闭塞时可见视觉性失认症,(,visual agnosia,),和颜色失认(,achromatopsia,),主侧半球顶枕动脉闭塞可有,对侧偏盲，,失语,。,Clinical syndromes of CIOcclus,69,Clinical syndromes of CI,PCA occlusion,syndrome,深穿支闭塞 (,occlusion in,inferior division),丘脑穿通动脉闭塞,：,红核综合征（,Claude syndrome,),丘脑综合征(,thalamic syndrome,):,snesory loss, spontaneous pain and dysesthesias, choreoathetosis, intention tremor, spasm of hand, mild hemiparesis.,Clinical syndromes of CIPCA oc,70,Clinical syndromes of CI,PCA occlusion,syndrome,深穿支闭塞 (,occlusion in,inferior division),中脑分支闭塞：,Weber syndrome,: third nerve palsy ad contralateral hemiplegia.,Clinical syndromes of CIPCA oc,71,Clinical syndromes of CI,Syndrome of vertebral- basilar artery occlusion,主干闭塞：广泛脑干梗死。,Shows symptoms of cranial nerves, pyramidal tract, and cerebellum.,Clinical syndromes of CISyndro,72,Clinical syndromes of CI,Syndrome of vertebral- basilar artery occlusion,基底动脉尖综合征（,Top of the basilar Syndrome,）,:,Abnormality in eye movement and pupils,disturbance of consciousness (loss of consciousness),homonymous hemianopia or cortical blindness,severe memory disorder,Clinical syndromes of CISyndro,73,Clincal syndromes of CI,Syndrome of vertebral- basilar artery occlusion,脑干分支闭塞,Weber syndrome,Millard-Gubler syndrome,Foville syndrome,Clincal syndromes of CISyndrom,74,Clincal syndromes of CI,Syndrome of vertebral- basilar artery occlusion,小脑后下动脉闭塞-延髓背外侧综合症(,Wallenberg syndrome),眼球震颤 (,nystagmus,),交叉性感觉障碍 (,crossed sensory deficit,),球麻痹,(,bulbar paralysis,),病灶侧,Horner,征 (,ipslateral Hornor sign,),病灶侧小脑性共济失调 (,ipslateral cerebellar ataxia,),Clincal syndromes of CISyndrom,75,Clincal syndromes of CI,Syndrome of vertebral- basilar artery occlusion,闭锁综合征(,Locked -in syndrome):,基底动脉分支双侧闭塞,Cerebellar infarction,由小脑上动脉,(,superior cerebellar artery),、,小脑后下动脉,(,posterior inferior cerebellar artery),、,小脑前下动脉闭塞,(,anterior inferior cerebellar artery),所致,。,Clincal syndromes of CISyndrom,76,Laboratory findings,CT scan,：,normal at the day of onset of the stroke, shows the low density of the infarct after 2448h. CT is preferred for initial diagnosis since it can make the critical distinction between ischemia and hemorrhage,(,见图 ),Laboratory findingsCT scan：nor,77,Laboratory findings,MRI,：,may be superior to CT scan for demonstrating early ischemic infarcts, showing ischemic stroke in brainstem or cerebellum and detecting thrombosis occlusion of venous sinuses.,Laboratory findingsMRI：may be,78,Laboratory findings,Cerebral angiography,：,MRA, DSA,Blood tests and ECG:,Serum glucose, cholesterol and lipid ,hemorheology.,TCD and CSF,Laboratory findingsCerebral an,79,Diagnosis and differentiation,Diagnosis,diagnosis can be made,depending on the clinical features,(,Patients presenting with focal central nervous system dysfunction of sudden onset, Lasting more than 24h,),CT and MRI changes,Diagnosis and differentiationD,80,Diagnosis and differentiation,Differential diagnosis:,Cerebral hemorrhage,cerebral embolism,Other structural brain lesions: tumor,abscess, etc.,Diagnosis and differentiationD,81,脑出血和脑梗塞的鉴别要点 脑出血 脑梗塞,1.,发病年龄,60,岁以下 多,60,岁以上,2.TIA,史 多无 常有,3.,起病状态 活动中 安静状态或睡眠中,4.,起病速度 急,(,分、时,),较缓,(,时、日,)5.,血压 明显增高 正常或增高,6.,全脑症状 明显 多无,7.,意识障碍 较重 较轻或无,8.,颈强直 可有 无,9.,头颅,CT,高密度病灶 低密度病灶,10.,脑脊液 血性,洗肉水样 无色透明,其中最重要的是,2,、,3.,两条。,脑出血和脑梗塞的鉴别要点,82,Treatment,急性期治疗（,Treatment in acute stage,）,治疗原则： 超早期治疗,-,力争溶栓；,综合保护治疗；,个体化治疗；,整体化治疗；,对危险因素及时予以预防性干预措施。,Treatment急性期治疗（Treatment in ac,83,Treatment,超早期溶栓治疗,目的：溶解血栓；迅速恢复梗死区血流灌注；减轻神经元损伤。（,6h,）,complications:,Hemorrhage, reperfusion damage and brain edema, reocclusion.,Treatment超早期溶栓治疗,84,Treatment,超早期溶栓治疗,Thrombolytic agents :Urokinase (UK), Straptokinase (SK), recombinant tissue plasminogen activator (rt-PA),Treatment超早期溶栓治疗,85,Treatment,超早期溶栓治疗,Indications:,Age 75,no disturbance of consciousness,within 6h(or 12h for progressive stroke) of onset,Bp 200/120mmHg,no hemorrhage shown on CT scanning,exclusion of TIA,no other hemorrhagic diseases,Treatment超早期溶栓治疗,86,Treatment,Antiplatelet agents,The regime is as described in the section of TIA.,Anticoagulation agents:,to prevent the progression of thrombosis. The agents used are the same as mentioned in the section of TIA.,Fibrinogen degradation therapy:,降纤酶,(Defibrase),巴曲酶,(Batroxobin),安洛克酶,(Ancrod),和引激酶。,TreatmentAntiplatelet agents,87,Treatment,Neuroprotective agents:,抗自由基：,V-E V-C,甘露醇 激素等,抑制脑代谢,急性期时应降低脑代谢，减少脑细胞耗氧量使缺血区血流量增加,钙离子拮抗剂：西比灵 尼莫地平等,亚低温,胰岛素维持血糖正常低限水平,TreatmentNeuroprotective agent,88,Treatment,Other forms of medical treatment: such as therapies aimed at improving blood flow:,hemodilution, metabolic improving agents-ATP, Co-A,脑活素等,。,TreatmentOther forms of medica,89,Treatment,Surgical treatment,General treatment,ICU: monitoring ECG, Bp, R, P, etc.,Antiedema agents,Preventing infection,Physical therapy and r