《神经病学》（英文）课件3.Cerebrovascular Disease

,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,脑血管疾病,Cerebrovascular,Disease(CVD),Department of Neurology,2nd hospital of Harbin Medical University,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。,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,。,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.,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),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,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,),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）,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。,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,Heart diseases and blood kinetics changes,Hypertention,or hypotension,Atrial,fibrillation, Rheumatic heart disease, arrhythmias etc,.,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.,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 factors,Smoking and alcohol,Hyperlipidmia,Others: food,symptomless,ICA bruit, overweight, drug abuse, contraceptive,，,age, sex, family history, race, etc.,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,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-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),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,),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,),Clinical features,Clinical types,Complete stroke: reaches peak within several hours,(,24h and recovering within 3ws,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 features,General features:,Usually, the patients are awake and alert except for those with a large area of CI or infarction in brainstem.,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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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,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 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 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,。,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 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 findings,Cerebral angiography,：,MRA, DSA,Blood tests and ECG:,Serum glucose, cholesterol and lipid ,hemorheology,.,TCD and CSF,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 differentiation,Differential diagnosis:,Cerebral hemorrhage,cerebral embolism,Other structural brain lesions: tumor,abscess, etc.,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。,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,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,Thrombolytic,agents :,Urokinase,(UK),Straptokinase,(SK), recombinant tissue,plasminogen,activator (,rt,-PA),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,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。,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,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,。,Treatment,Surgical treatment,General treatment,ICU: monitoring ECG, Bp, R, P, etc.,Antiedema,agents,Preventing infection,Physical therapy and rehabilitation,Preventive measures,腔隙性脑梗塞,-,Lacunar,Infarction,Concept,：,Small penetrating arteries located deep,in the brain may become occluded as a result of changes in the vessel wall induced by chronic hypertension and atherosclerosis.,是指发生在大脑半球深部白质及脑干的缺血性微梗死因脑组织缺血、坏死、液化并由吞噬细胞移走而形成,腔隙,，占脑梗死的。,多见于基底节区、放射冠、丘脑、脑干等部位,。,腔隙性脑梗塞,-,Lacunar,Infarction,Common types:,纯运动性卒中,(,Pure motor,hemiparesis, PMH,),纯感觉性卒,(,Pure sensory stroke, PSS,),共济失调性轻偏瘫,(,Ataxic-,hemiparesis, AH,),构音障碍,-,手笨拙综合征,(,Dysarthric,- clumsy hand syndrome, DCHS,),感觉运动性卒中,(,Sensorimotor,stroke, SMS),腔隙状态,(,Lacunar,state,),脑栓塞,-Cerebral embolism,Concept,Etiology and mechanism,Clinical findings,Investigative studies,Diagnosis and differentiation,Treatment and prognosis,脑栓塞,-Cerebral embolism,Concept,：,embolism produces stroke when cerebral arteries occluded by the distal passage of thrombus from the heart,aortic arch, or large cerebral arteries.,脑栓塞指各种栓子随血流进入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。,脑栓塞,-Cerebral embolism,Etiology,心源性,(,Cardiogenic,),非心源性,(,non-,cardiogenic,),来源不明,(,source unknown,),Pathology,多见于颈内动脉系统，尤其是左侧大脑中动脉，病理上与脑血栓形成基本相同。但栓子常为多发切易破碎。,Clinical findings,发病急骤，症状在数秒或数分钟内达高峰，是血管病中最快的,多属完全性中风，栓塞部位继发血栓时病情可逐渐进展,可有头痛、局灶性癫痫和不同程度的意识障碍,神经系统定位体征,原发病的症状和体征,易发生梗塞后出血,Laboratory Findings,CT, MRI,:,indicate ischemic Infarct or hemorrhagic infarct,MRA,shows the,stenosis,of large cerebral arteries.,CSF examination:,Can be normal, or with increased ICP. Red blood cells can be seen grossly,or under microscope.,Laboratory Findings,ECG:,心律失常,(,arrhythmia,),、,心肌梗塞,(,myocardical,infarction, MI,),等,Ultrasonography,Echocardiography,Cerebral angiography,Diagnosis and differentiation,诊断：急骤起病，有定位体征，有栓子来源,鉴别诊断：,与脑出血、脑血栓鉴别,有局限性癫痫者应与其它引起癫痫的疾病鉴别,.,Treatment and prognosis,Treatment,：,Antiedema,and increased ICP,Recurrence prevention treatment:,emboli originated disease treatment.,Vasodilation,agents,Treatment and prevention,Treatment,：,others,prognosis,:,mortality -,5%15%.,Die from severe cerebral edema,herniation, respiratory system infection, and heart failure.,Majority of Survivors will have severe disability,本课重点,TIA,的临床特点，颈内动脉和椎,-,基底动脉,TIA,的最常见的表现及特有症状,脑血栓形成的常见病因，好发部位，临床特点及治疗重点,腔隙性脑梗死的常见临床类型几表现,脑栓塞的常见病因、临床特点及鉴别诊断,谢 谢,2002.5.1,