卒中中西医结合治疗最新进展课件

,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,*,脑卒中中西医结合诊断与治疗,The burden of Stroke,A common condition,3,rd,cause of death worldwide,1,(after MI and cancer),Accounts for 12% of deaths,2,nd,cause of death within the next 10 years in developing countries,2,nd,cause of dementia,1,st,cause of severe disability the western world,A major health problem,中风概念,Stroke; 卒中;,中风 - 缺血性中风（,ischemic stroke,） 出血性中风(,hemorrhagic stroke,),小中风(mini-stroke); TIA,脑卒中（中风）即“脑血管意外”，指因脑血管阻塞或破裂引起的脑血流循环障碍和脑组织功能或结构损害的疾病。可以分为缺血性脑卒中（中风）和出血性脑卒中（中风）两大类。,缺血性脑卒中（中风），“脑梗死”，主要包括脑血栓形成和脑栓塞两种。脑血栓形成是由于动脉狭窄，管腔内逐渐形成血栓而最终阻塞动脉所致；脑栓塞是由于血栓脱落或其它栓子进入血流中阻塞脑动脉所引起。,出血性脑卒中（中风）根据出血部位的不同分为脑出血和蛛网膜下腔出血。是由于脑内动脉破裂，血液溢出到脑组织内；蛛网膜下腔出血是脑表面或脑底部的血管破裂，血液直接进入容有脑脊液的蛛网膜下腔和脑池中。,不论是缺血性脑卒中（中风）还是出血性脑卒中（中风），都会造成不同范围、不同程度的脑组织损害，因而产生多种多样的神经精神症状，严重的还会危及生命，治愈后很多病人留有后遗症。,-摘自雅虎知识堂,NINDS Stroke Information Page,What is Stroke?,A stroke occurs when the blood supply to part of the brain is suddenly interrupted or when a blood vessel in the brain bursts, spilling blood into the spaces surrounding brain cells. Brain cells die when they no longer receive oxygen and nutrients from the blood or there is sudden bleeding into or around the brain.,The symptoms of a stroke include sudden numbness or weakness, especially on one side of the body; sudden confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble with walking, dizziness, or loss of balance or coordination; or sudden severe headache with no known cause. There are two forms of stroke:,ischemic,- blockage of a blood vessel supplying the brain, and,hemorrhagic,- bleeding into or around the brain.,What is Transient Ischemic Attack?,Synonym(s):,Mini-Strokes,A transient ischemic attack (TIA) is a transient stroke that lasts only a few minutes. It occurs when the blood supply to part of the brain is briefly interrupted. TIA symptoms, which usually occur suddenly, are similar to those of stroke but do not last as long. Most symptoms of a TIA disappear within an hour, although they may persist for up to 24 hours.,Symptoms can include: numbness or weakness in the face, arm, or leg, especially on one side of the body; confusion or difficulty in talking or understanding speech; trouble seeing in one or both eyes; and difficulty with walking, dizziness, or loss of balance and coordination.,Definition and Evaluation of Transient Ischemic Attack,A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the InterdisciplinaryCouncil on Peripheral Vascular Disease,2009TIA新概念,definition of transient ischemic attack (TIA): a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. (,脑、脊髓或视网膜局灶性缺血引起的、未伴发急性梗死的短暂性神经功能障碍。),Patients with TIAs are at high risk of early stroke, and their risk may be stratified by clinical scale, vessel imaging, and diffusion magnetic resonance imaging. Diagnostic recommendations include: TIA patients should undergo neuroimaging evaluation within 24hours of symptom onset, preferably with magnetic resonance imaging, including diffusion sequences; noninvasive imaging of the cervical vessels should be performed and noninvasive imaging of intracranial vessels is reasonable; electrocardiography should occur as soon as possible after TIA and prolonged cardiac monitoring and echocardiography are reasonable in patients in whom the vascular etiology is not yet identified; routine blood tests are reasonable; and it is reasonable to hospitalize patients with TIA if they present within 72 hours and have an ABCD2 score _3, indicating high risk of early recurrence, or the evaluation cannot be rapidly completed on an outpatient basis.,(,Stroke,. 2009;40:2276-2293.),金匮要略：提出中风病名。在经在络、中脏中腑区别。,卒中-素问本病论日：“久而化郁，即大风摧拉，折损鸣乱。民病卒中偏痹，手足不仁。,明 楼英医学纲目 卷之十肝胆部 首提卒中病名。,现代中风病概念,中风病是在气血内虚的基础上，因劳倦内伤、忧思恼怒、嗜食厚味及烟酒等诱因，引起脏腑阴阳失调，气血逆乱，直冲犯脑，导致脑脉痹阻或血溢脑脉之外，临床以突然昏仆、半身不遂、口舌歪斜、言语謇涩或不语、偏身麻木为主症，具有起病急、变化快的特点，好发于中老年人的一种常见病。,相当于脑卒中，从病理上分为缺血性中风和出血性中风。,缺血性中风和出血性中风？,出血性中风和缺血性中风的病因病机，现代医学传入我国之前，中医并无区分，即古代中医对中风并未认识到象现今所分脑络瘀阻和血瘀脉外之不同。因而两种不同的中风的中医治疗并无差异。,晚清时期，伴随现代医学的传入，中医逐渐接受了西医的观点，其中晚清张山雷、张锡纯为主要代表，张锡纯医学衷中参西录脑贫血证和脑充血证即大体相当缺血性脑血管病和出血性脑血管病。自此脑出血治疗认识上始有不同。,诊断与鉴别诊断,1.疾病诊断,（1）临床表现：神识昏蒙、半身不遂、口舌歪斜、言语謇涩或不语、偏身麻木；或出现头痛、眩晕、瞳神变化、饮水发呛、目偏不瞬、共济失调等。,（2）急性起病，渐进加重，或骤然起病，即刻达到高峰。,（3）发病前多有诱因，常有先兆症状。,（4）发病年龄多在40岁以上。,具备以上临床表现，结合起病形式、诱因、先兆症状、年龄即可诊断；影像学检查（CT或MRI）可助明确诊断。,2.病类诊断,（1）中经络：中风病而无神识昏蒙者。,（2）中脏腑：中风病而有神识昏蒙者,。,3.分期标准？,急性期：发病4周以内,恢复期: 发病半年以内,后遗症期: 发病半年以上,中国分期中西医一致,脑卒中的临床分期,英国皇家医学会指南,1周,1周-6月,6月后,早期,中期,晚期,病理分期,脑缺血性病变的病理分期,（神经病学第六版教材人民卫生出版社）,：1、超早期（06小时）2、急性期（624小时）3、坏死期（2448小时）4、软化期（3d3w）5、恢复期（34w后）,脑卒中分类,脑卒中的分类,脑卒中可分为出血性卒中和缺血性卒中两大类。,（一） 缺血性中风,1 动脉粥样硬化性血栓性脑梗死（脑血栓形成）,2 脑栓塞, 心源性, 动脉源性, 脂肪性, 其他,3 腔隙性脑梗死,4 颅内异常血管网症,5 出血性梗死,6 无症状梗死,7 其他,8 原因未明,（二）,出血性中风,1,蛛网膜下腔出血,动脉瘤破裂出血,血管畸形,颅内异常血管网症,其他,原因未明,2,脑出血,高血压脑出血,脑血管畸形和动脉瘤出血,继发于梗死的出血,肿瘤性出血,血液病源性出血,淀粉样脑血管病出血,动脉炎性出血,药物性出血,其他,原因未明,CT,MRI/MRA/Fmr,DSA,TCD,SPECT,PET,Xe-CT,辅助诊断,Brott, T. et al. N Engl J Med 2000;343:710-722,CT Scan of the Brain of a Patient with Confusion, Left Hemiparesis, and Left Hemisensory Loss 50 Minutes, 3 Hours, and 25 Hours after the Onset of Stroke,MRI示例,小脑梗死,脑干出血,DSA图例,DSA示例,烟雾病,缺血性中風分-,TOAST,分,（,Trial of in acute stroke treatment,TOAST，1993,）,目前國際上較廣泛使用的：,1.,大动脉粥样硬化性卒中（LAA,Large-artery atherosclerosis),2. 心源性栓 (CE Cardioembolism),3.,小动脉闭塞性卒中或腔隙性卒中（SAA,Small-artery occlusion；lacune),4.,其他原因所致的缺血性卒中（SOE,Stroke of other determined etiology),5. 原因未明之,卒中,(,SUE,Stroke of undetermined etiology)。,TOAST Classification of Subtypes of Acute Ischemic Stroke,Large-artery atherosclerosis (embolus/thrombosis)*,Cardioembolism (high-risk/medium-risk)*,Small-vessel occlusion (lacune)*,Stroke of other determined etiology*,Stroke of undetermined etiology,a. Two or more causes identified,b. Negative evaluation,c. Incomplete evaluation,牛,津郡,社,区卒中,研究,分,型,（,Oxfordshire community stroke project,OCSP，1991,）,不,依,赖,影,像,学结果，,常,规,CT,、,MRI,尚,未,能发现病,灶,时,就,可；,根,据,临床表,现迅速分,型,，并,提,示,闭塞,血管和,梗,死,灶,的大,小,和部位，,临床,简,单,易,行，对指导治疗、,评,估预后有重要,价,值,。,OCSP,临床,分,型,标准：,1,、完全前,循,环,梗,死（,TACI,）,：,表,现为三,联,征,，即完全大脑中动,脉,（,MCA,）,综,合,征,的,表,现,：,大脑,较,高级神经活动,障碍,（意,识,障碍,、失,语,、失算、,空,间,定,向,力,障碍,等,）；同,向偏,盲,；对,侧,三,个,部位（,面,、上,肢,与,下,肢,）,较严,重的,运,动和（或）,感觉,障碍,。,多,为,MCA,近,段,主,干,，,少,数为,颈,内动,脉,虹,吸,段,闭塞,引起,的大,片,脑,梗,死。,2,、部分前,循,环,梗,死（,PACI,）,：,有以上三,联,征,中的,两个,，或只有高级神经活动,障碍,，或,感觉运,动,缺损较,TACI,局,限,。,提,示是,MCA,远,段,主,干,、各级分,支,或,ACA,及分,支,闭塞,引起,的中、,小,梗,死。,3,、后,循,环,梗,死（,POCI,）,：,表,现为各种不同程度的,椎,-,基,动,脉,综,合,征,：可表,现为同,侧,脑神经,瘫,痪,及对,侧,感觉运,动,障碍,；,双,侧,感觉运,动,障碍,；,双眼协,同活动及,小,脑,功,能,障碍,，无,长,束征,或视,野,缺损等,。为,椎,-,基,动,脉,及分,支,闭塞,引起,的大,小,不,等,的脑,干,、,小,脑,梗,死。,4,、,腔隙,性梗,死（,LACI,）,：,表,现为,腔隙,综,合,征,，,如纯,运,动,性轻,偏,瘫,、,纯,感觉,性,脑卒中、,共,济失调,性轻,偏,瘫,、,手,笨拙,-,构,音,不,良综,合,征,等,。大,多,是,基底,节或脑,桥,小穿,通,支,病变,引起,的,小,腔隙灶,OCSP分型的CT表现,TACI,PACI,POCI,LACI,Physiologic Subtypes of Thrombosis-Related Ischemic Stroke,Cerebral Embolism Formation,In addition to thrombotic occlusion at the site of cerebral artery atherosclerosis, ischemic infarction can be produced by emboli arising from proximally situated atheromatus lesions to vessels located more distal in the arterial tree Mohr JP, Sacco RL. In: Barnett HJM, et al (eds). Stroke. Pathophysiology, Diagnosis, and Management. New York: Churchill Livingstone, 1992:271.,A small clot may break off from a larger thrombus and be carried to other places in the bloodstream. When the embolus reaches an artery too narrow to pass through and becomes lodged, blood flow distal to the fragment ceases, resulting in infarction of distal brain tissue due to lack of nutrients and oxygen.,As a cause of stroke, embolism accounts for approximately 32% of cases.,Cellular Changes During Ischemia,Cellular Injury During Ischemia,The Ischemic Penumbra,In the core zone, which is an area of severe ischemia (blood flow below 10% to 25%), the loss of inadequate supply of oxygen and glucose results in rapid depletion of energy stores. Severe ischemia can result in necrosis of neurons and also of supporting cellular elements (glial cells) within the severely ischemic area.,Brain cells within the penumbra, a rim of mild to moderately ischemic tissue lying between tissue that is normally perfused and the area in which infarction is evolving, may remain viable for several hours. That is because the penumbral zone is supplied with blood by collateral arteries anastomosing with branches of the occluded vascular tree (see inset). However, even cells in this region will die if reperfusion is not established during the early hours since collateral circulation is inadequate to maintain the neuronal demand for oxygen and glucose indefinitely.,Edema Formation,Ischemic brain edema is a combination of two major types of edema: cytotoxic (cellular) and vasogenic,Cytotoxic edema is characterized by swelling of all the cellular elements of the brain (shown). In the presence of acute cerebral ischemia, neurons, glia (indicated by astrocytes), and endothelial cells swell within minutes of hypoxia due to failure of ATP-dependent ion (sodium and calcium) transport. With the rapid accumulation of sodium within cells, water follows to maintain osmotic equilibrium. Increased intracellular calcium activates phospholipases and the release of arachidonic acid, leading to the release of oxygen-derived free radicals and infarction.,Vasogenic edema (not shown) is characterized by an increase in extracellular fluid volume due to increased permeability of brain capillary endothelial cells to macromolecular serum proteins (e.g., albumin). Normally, the entry of plasma protein-containing fluid into the extracellular space is limited by tight endothelial cell junctions, but in the presence of massive injury there is increased permeability of brain capillary endothelial cells to large molecules. Vasogenic edema can displace the brain hemisphere and, when severe, lead to cerebral herniation.,Acute hypoxia initially causes cytotoxic edema, followed within the next hours to days by the development of vasogenic edema as infarction develops (Fishman, 1992). The delayed onset of vasogenic edema suggests that time is needed for the defects in endothelial cell function and permeability to develop.,脑出血,脑,出,血是指,非外,伤,性,脑,实,质,内的,出,血。发病率为,60,80/10,万人口,/,年，在我国占,急,性,脑血管病的,30%,左,右,。,急,性,期病死率约为,30%,40%,，是,急,性,脑血管病中,最,高的。,大脑,半,球,出,血约占,80%,，脑,干,和,小,脑,出,血约占,20%,。,脑,CT,扫描,是,诊断,脑,出,血,最,有,效最,迅速的,方,法,。,Qureshi, A. I. et al. N Engl J Med 2001;344:1450-1460,Rapid Expansion of Hematoma,Qureshi, A. I. et al. N Engl J Med 2001;344:1450-1460,Most Common Sites and Sources of Intracerebral Hemorrhage,诊断,1,、,临床特,点,（,1,）,多,在动,态,下,急,性起,病；,（,2,）,突,发,局灶,性,神经,功,能,缺损症,状，,常,伴,有,头痛,、,呕吐,，,可,伴,有血,压增,高、意,识,障碍,和脑,膜,刺,激,征,。,2,、,辅,助,检,查,（,1,）血,液检,查,：可,有,白细,胞,增,高，血,糖,升高,等,；,（,2,）,影,像,学,检,查,：,头,颅,CT,扫描,：,是,诊断,脑,出,血,可靠,的方,法,，,可准确,显示脑,出,血的部位、,出,血,量,、占位,效应,、是,否,破,入,脑,室,或,蛛,网,膜,下,腔,及,周围,脑,组,织,受,损,的,情况,。,急性期血,肿,灶,为高,密,度,影,，,边,界,清,楚,，,CT,值,为,75,80Hu,；在血,肿,被,吸收,后显示为低,密,度,影,。,头,颅,MRI,检,查,：,脑,出,血后随着时间的,延,长,，完,整红细,胞,内的,含氧,血,红蛋白,（,HbO2,）,逐,渐,转,变为,去氧,血,红蛋白,（,DHb,）及,正,铁,血,红蛋白,（,MHb,），,红细,胞破,碎,后，,正,铁,血,红蛋白,析出,呈,游离,状,态,，,最,终,成为,含铁,血,黄,素。上,述,演,变过程从血,肿,周围,向,中心发展，因此,出,血后的不同时期血,肿,的,MRI,表,现,也,各,异,。对,急,性,期脑,出,血的,诊断,CT,优,于,MRI,，,但,MRI,检,查能,更准确,地显示血,肿演,变过程，对,某,些,脑,出,血患者的病因,探,讨,会,有所,帮,助,，,如,能,较好,地,鉴,别,瘤,卒中，发现,AVM,及动,脉,瘤,等,。,脑血管,造影,（,DSA,）,：,中,青,年,非,高血,压性,脑,出,血，或,CT,和,MRI,检,查,怀疑,有血管,异常,时，,应进,行脑血管,造影,检,查。脑血管,造影可,清,楚,地显示,异常,血管及显示,出造影剂外,漏,的,破裂,血管和部位。,（,3,）,腰,穿检,查,：,脑,出,血,破,入,脑,室,或,蛛,网,膜,下,腔,时，,腰,穿,可见,血,性,脑,脊,液,。在,没,有条件或不能,进,行,CT,扫描,者，,可进,行,腰,穿检,查,协,助,诊断,脑,出,血，,但,阳,性,率,仅,为,60%,左,右,。对大,量,的脑,出,血或脑,疝,早期，,腰,穿,应,慎,重，以,免,诱,发脑,疝,。,各部位脑,出,血的,临床,诊断,要点,1,、,壳,核,出,血,：,是,最常见,的脑,出,血，约占,50%,60%,，,出,血经,常,波,及内,囊,。,（,1,）对,侧,肢,体,偏,瘫,，,优,势,半,球,出,血,常出,现失,语,。,（,2,）对,侧,肢,体,感觉,障碍,，主要是,痛,、,温,觉,减,退,。,（,3,）对,侧偏,盲,。,（,4,）,凝,视,麻,痹,，呈,双眼,持续性,向,出,血,侧,凝,视。,（,5,）,尚可出,现失用、体,像,障碍,、,记忆,力和计算力,障碍,、意,识,障碍,等,。,2,、,丘,脑,出,血,：,约占,20%,。,（,1,）,丘,脑,性,感觉,障碍,：,对,侧半,身,深浅,感觉,减,退,，,感觉,过,敏,或,自,发,性,疼,痛,。,（,2,）,运,动,障碍,：出,血,侵,及内,囊,可出,现对,侧,肢,体,瘫,痪,，,多,为,下,肢,重于上,肢,。,（,3,）,丘,脑,性,失,语,：,言,语,缓,慢,而不,清,、重,复言,语,、发,音困,难,、,复,述差,，,朗读,正常,。,（,4,）,丘,脑,性,痴呆,：,记忆,力,减,退,、计算力,下,降、,情,感,障碍,、人,格,改变。,（,5,）,眼球,运,动,障碍,：,眼球,向,上,注,视,麻,痹,，,常,向,内,下,方,凝,视。,3,、脑,干出,血,：,约占,10%,，,绝,大,多,数为脑,桥,出,血，,偶,见,中脑,出,血，,延,髓,出,血极为,罕,见,。,（,1,）中脑,出,血,：,突,然,出,现,复,视、,眼,睑,下,垂,；,一,侧,或,两,侧,瞳,孔扩,大、,眼球,不同,轴,、,水平,或,垂,直,眼,震,、同,侧,肢,体,共,济失调，,也可表,现,Weber,或,Benedikt,综,合,征,；,严,重者很快,出,现意,识,障碍,、,去,大脑强,直,。,（,2,）脑,桥,出,血,：,突,然头痛,、,呕吐,、,眩晕,、,复,视、,眼球,不同,轴,、,交,叉,性,瘫,痪,或,偏,瘫,、四,肢瘫,等,。,出,血,量较,大时，患者很快,进,入,意,识,障碍,、,针,尖,样,瞳,孔,、,去,大脑强,直,、,呼,吸,障碍,，,多,迅速死亡，并,可,伴,有高,热,、大,汗,、,应,激,性,溃疡,等,；,出,血,量较少,时,可表,现为一,些,典,型,的,综,合,征,，,如,Foville,、,Millard-Gubler,和,闭,锁,综,合,征,等,。,（,3,）,延,髓,出,血,：,突,然,意,识,障碍,，血,压下,降，,呼,吸,节,律,不,规则,，心,律,紊乱,，,继,而死亡；,轻,者,可表,现为不,典,型,的,Wallenberg,综,合,征,。,4,、,小,脑,出,血,：,约占,10%,。,（,1,）,突,发,眩晕,、,呕吐,、后,头,部,疼,痛,，无,偏,瘫,。,（,2,）有,眼,震,、,站,立,和行,走,不,稳,、,肢,体,共,济失调、,肌,张,力降低及,颈项,强,直,。,（,3,）,头,颅,CT,扫描,示,小,脑,半,球,或,蚓,部高,密,度,影,及四脑,室,、脑,干,受,压,。,5,、脑,叶,出,血,：,约占,5%,10%,。,（,1,）,额,叶,出,血,：,前,额,痛,、,呕吐,、,痫,性,发,作较多见,；,对,侧偏,瘫,、,共,同,偏,视、,精,神,障碍,；,优,势,半,球,出,血时,可出,现,运,动,性,失,语,。,（,2,）,顶,叶,出,血,：,偏,瘫,较轻,，而,偏侧,感觉,障碍,显,著,；,对,侧,下,象限,盲,；,优,势,半,球,出,血时,可出,现,混,合性,失,语,。,（,3,）,颞,叶,出,血,：,表,现为对,侧,中,枢,性面,舌,瘫,及上,肢,为主的,瘫,痪,；,对,侧,上,象限,盲,；,优,势,半,球,出,血时,可出,现,感觉,性,失,语,或,混,合性,失,语,；,可,有,颞,叶,癫痫,、,幻嗅,、,幻,视。,（,4,）,枕,叶,出,血,：,对,侧,同,向,性,偏,盲,，并有,黄,斑,回,避,现,象,可,有一过,性,黑矇,和视,物,变,形,；,多,无,肢,体,瘫,痪,。,6,、脑,室,出,血,：,约占,3%,5%,。,（,1,）,突,然头痛,、,呕吐,，迅速,进,入,昏迷,或,昏迷,逐,渐,加,深,。,（,2,）,双,侧,瞳,孔,缩,小,，四,肢,肌,张,力,增,高，病,理,反,射阳,性,，早期,出,现,去,大脑强,直,，脑,膜,刺,激,征,阳,性,。,（,3,）,常出,现,丘,脑,下,部,受,损,的,症,状及体,征,，,如,上,消,化,道,出,血、中,枢,性,高,热,、大,汗,、,应,激,性,溃疡,、,急,性,肺,水,肿,、血,糖增,高、,尿,崩,症等,。,（,4,）脑,脊,液,压,力,增,高，呈血,性,。,（,5,）,轻,者,仅,表,现,头痛,、,呕吐,、脑,膜,刺,激,征,阳,性,，无,局,限,性,神经体,征,。,临床,上,易,误,诊,为,SAH,，,需,通过,头,颅,CT,扫描,来,确定,诊断,。,脑,出,血的病因,1,、高血,压性,脑,出,血,（,1,）,50,岁,以上者,多见,。,（,2,）有高血,压,病,史,。,（,3,）,常见,的,出,血部位是,壳,核,、,丘,脑、,小,脑和脑,桥,。,（,4,）无,外,伤,、,淀粉,样,血管病,等,脑,出,血,证,据。,2,、脑血管,畸,形,出,血,（,1,）年,轻,人,多见,。,（,2,）,常见,的,出,血部位是脑,叶,。（,3,）,影,像,学,可,发现血管,异常影,像,。,（,4,）,确,诊需,依,据脑血管,造影,。,3,、脑,淀粉,样,血管病,（,1,）,多见,于老年患者或,家族性,脑,出,血的患者。,（,2,）,多,无高血,压,病,史,。,（,3,）,常见,的,出,血部位是脑,叶,，,多,发者,更,有,助,于,诊断,。,（,4,）,常,有,反复,发,作,的脑,出,血病,史,。,（,5,）,确定,诊断需,做,病,理组,织,学,检,查。,脑,出,血的病因,4,、,溶栓,治疗所致脑,出,血,（,1,）近期,曾,应,用,溶栓,药物,。,（,2,）,出,血,多,位于脑,叶,或,原,有的脑,梗,死病,灶,附,近。,5,、,抗凝,治疗所致脑,出,血,（,1,）近期,曾,应,用,抗凝,剂,治疗。,（,2,）,常见,脑,叶,出,血。,（,3,）,多,有,继续出,血的,倾,向,。,6,、,瘤,卒中,（,1,）脑,出,血前即有神经系统,局灶,症,状。,（,2,）,出,血,常,位于高血,压,脑,出,血的,非,典,型,部位。,（,3,）,影,像,学上早期,出,现血,肿,周围,明显,水,肿,。,蛛,网,膜,下,腔,出,血,原,发,性,蛛,网,膜,下,腔,出,血（,subarachnoid hemorrhage,，,SAH,）是指脑,表面,血管,破裂,后,血,液,流,入,蛛,网,膜,下,腔,而,言,。年发病率为,5,20/10,万，,常见,病因为,颅,内动,脉,瘤,其,次,为脑血管,畸,形,，,还,有高血,压性,动,脉,硬,化，,也可见,于动,脉,炎,、脑,底,异常,血管,网,、结,缔,组,织,病、血,液,病、,抗凝,治疗并发,症等,。,一、,诊断,（一）,临床特,点,蛛,网,膜,下,腔,出,血的,临床表,现主要,取,决,于,出,血,量,、积血部位、脑,脊,液循,环,受,损,程度,等,。,1,、,起,病,形,式,：多,在,情,绪,激,动或用力,等情况下,急骤,发病。,2,、主要,症,状,：,突,发,剧,烈头痛,，,持续,不能,缓,解,或,进,行,性,加重；,多,伴,有,恶,心、,呕吐,；,可,有,短暂,的意,识,障碍,及,烦躁,、,谵妄,等,精,神,症,状，,少,数,出,现,癫痫,发,作,。,3,、主要体,征,：,脑,膜,刺,激,征,明显，,眼,底,可见,玻璃,膜,下出,血，,少,数,可,有,局灶,性,神经,功,能,缺损,的,征,象,，,如轻,偏,瘫,、失,语,、动,眼,神经,麻,痹,等,。,Subarachnoid Hemorrhage,临床,分级,（,1,）一,般,采,用,Hunt,和,Hess,分级,法,（,表,1,）对动,脉,瘤,性,SAH,的,临床,状,态,进,行分级以,选择,手术,时,机,和,判,断,预后。,表,1 Hunt,和,Hess,分级,法,分类 标准,0级 未破裂动脉瘤,I级 无症状或轻微头痛,II级 中-重度头痛，脑膜刺激征、颅神经麻痹,III级 嗜睡、意识混浊、轻度局灶神经体征,IV级 昏迷、中或重度偏瘫、有早期去脑强直或自主神经功能紊乱,V级 深昏迷、去大脑强直、频死状态,SAH的主要并发,症,包括,再,出,血、脑血管,痉挛,、,急,性非,交,通,性,脑积,水,和,正常,颅,压,脑积,水等,。,（,1,）,再,出,血,：,以,5,11,天,为高,峰,，,81%,发生在,1,月,内。,颅,内动,脉,瘤,初,次出,血后的,24,小,时内,再,出,血率,最,高，约为,4.1%,，至第,14,天,时,累,计为,19%,。,临床表,现为,：,在经治疗病,情,稳,定好,转,的,情况下,，,突,然,发生,剧,烈头痛,、,恶,心,呕吐,、意,识,障碍,加重、,原,有,局灶,症,状和体,征,重新,出,现,等,。,（,2,）血管,痉挛,：,通,常,发生在,出,血后第,1,2,周,，,表,现为病,情,稳,定,后,再,出,现神经系统,定,位体,征,和意,识,障碍,，因脑血管,痉挛,所致,缺,血,性,脑,梗,死所,引起,，,腰,穿,或,头,颅,CT,检,查无,再,出,血,表,现。,（,3,）,急,性非,交,通,性,脑积,水：,指,SAH,后,1,周,内发生的,急,性,或,亚,急,性,脑,室,扩,大所致的脑积,水,，,机,制主要为脑,室,内积血，,临床表,现主要为,剧,烈,的,头痛,、,呕吐,、脑,膜,刺,激,征,、意,识,障碍,等,，,复,查,头,颅,CT,可,以,诊断,。,（,4,）,正常,颅,压,脑积,水：出,现于,SAH,的,晚,期，,表,现为,精,神,障碍,、,步,态,异常,和,尿,失,禁,。,辅,助,检,查,1,、,头,颅,CT,：,诊断,SAH,的,首,选,，,CT,显示,蛛,网,膜,下,腔,内高,密,度,影可,以,确,诊,SAH,。,根,据,CT,结果,可,以初,步,判,断,或,提,示,颅,内动,脉,瘤,的位,置,：如,位于,颈,内动,脉,段,常,是,鞍,上,池,不对,称,积血；大脑中动,脉,段,多见外,侧,裂,积血；前,交,通动,脉,段,则,是前间,裂,基底,部积血；而,出,血在,脚,间,池,和,环,池,，一,般,无动,脉,瘤,。动,态,CT,检,查,还,有,助,于了,解,出,血的,吸收情况,，有无,再,出,血、,继,发脑,梗,死、脑积,水,及其程度,等,。,2,、脑,脊,液,（,CSF,）,检,查,：,通,常,CT,检,查已,确,诊,者，,腰,穿,不,作,为,临床常,规检,查。,如,果,出,血,量少,或者,距起,病时间,较长,，,CT,检,查,可,无,阳,性,发现，而,临床可,疑,下,腔,出,血,需,要行,腰,穿检,查,CSF,。,均,匀,血,性,脑,脊,液,是,蛛,网,膜,下,腔,出,血的,特,征,性表,现，,且,示新,鲜,出,血，,如,CSF,黄,变或者发现,吞噬,了,红细,胞,、,含铁,血,黄,素或,胆红质,结,晶,的,吞噬,细,胞,等,，,则,提,示已存在不同时间的,SAH,。,辅,助,检,查,3,、脑血管,影,像,学,检,查,：,有,助,于发现,颅,内的,异常,血管。,（,1,）脑血管,造影,（,DSA,）,：,是,诊断,颅,内动,脉,瘤,最,有,价,值,的方,法,，,阳,性,率达,95%,，,可,以,清,楚,显示动,脉,瘤,的位,置,、大,小,、与,载,瘤,动,脉,的,关,系、有无血管,痉挛,等,。条件,具,备,、病,情,许,可,时,应,争,取尽,早行全脑,DSA,检,查以,确定出,血,原,因和,决,定,治疗方,法,、,判,断,预后。,但由,于血管,造影可,加重神经,功,能,损,害，,如,脑,缺,血、动,脉,瘤再,次,破裂,出,血,等,，因此,造影,时,机宜,避,开脑血管,痉挛,和,再,出,血的高,峰,期，即,出,血,3,天,内或,3,周,后,进,行为,宜,。,（,2,）,CT,血管成,像,（,CTA,）和,MR,血管成,像,（,MRA,）,：,是无,创,性,的脑血管显,影,方,法,，主要用于有动,脉,瘤,家族,史,或,破裂,先,兆,者的,筛,查，动,脉,瘤,患者的随,访,以及,急,性,期不能,耐受,DSA,检,查的患者。,4,、其,他：,经,颅,超,声,多普,勒,（,TCD,）动,态检,测,颅,内主要动,脉,流速是及时发现脑血管,痉挛,（,CVS,）,倾,向,和,痉挛,程度的,最,灵,敏,的方,法,；,局,部脑血流测,定,用以,检,测,局,部脑,组,织,血流,量,的变化，,可,用于,继,发脑,缺,血的,检,测。,卒中的治疗-缺血性卒中篇,脑,梗,死的治疗不能一,概,而论，,应,根,据不同的病因、发病,机,制、,临床类,型,、发病时间,等确定,针,对,性,强的治疗方,案,，,实施,以分,型,、分期为,核,心的,个,体化治疗。在一,般,内,科支持,治疗的,基础,上，,可,酌,情,选,用改,善,脑,循,环,、脑,保,护,、,抗,脑,水,肿,降,颅,压等措施,。通,常,按,病程,可,分为,急,性,期（,1,个,月,），,恢,复,期（,2,6,个,月,）和后,遗症,期（,6,个,月,以后）。重点是,急,性,期的分,型,治疗，,腔隙,性,脑,梗,死不,宜,脱,水,，主要是改,善,循,环,；大、中,梗,死,应,积极,抗,脑,水,肿,降,颅,压,，防,止,脑,疝,形,成。在,6,小,时的时间,窗,内有,适,应证,者,可,行,溶栓,治疗。,中国脑血管病指南,(一)内科综合支持治疗：应特别注意血压的调控(参见第九章),(二)抗脑水肿、降颅高压(参见第九章),(三)改善脑血循环,脑梗死是缺血所敌，恢复或改善缺血组织的灌注成为治疗的重心，应贯彻于全过程，以保持良好的脑灌注压。,卒中服务及卒中单元,建议,建议所有卒中患者都在卒中单元内接受治疗 (I 类证据，A 级建议),建议医疗卫生技术系统要确保一旦需要，急性卒中患者能够获得高技术的内外科医疗(III 类证据，B 级建议),建议建立包括远程医疗在内的临床网络，提高高技术专科医师卒中医疗的可及性(II 类，B 级建议),Acute Stroke Unit: Multidisciplinary Team,Neurologist, on site,neurosurgeon, on duty,neuropsychiatrist, on call,Internist/cardiologist,Specialist nurses,Other consultants as required,Physiotherapists,Speech and occupational therapists,Neuropsychologists,Social workers,ESO 2008 指南 特殊治疗,建议,发病3小时内的缺血性卒中患者，静脉应用rtPA(0.9mg/kg体重，最大剂量90mg)，其10%剂量推注，余量持续60分钟输注(I类证据，A级建议)。,急性缺血性卒中发病超过3小时，静脉应用rtPA仍可能有效(I类证据，B级建议)，但不建议常规临床应用。,应用多模式影像标准可能有助于溶栓患者的筛选，但不建议常规临床应用(III类证据，C级建议)。,溶栓前将血压控制于185/110mmHg(IV类证据，优良临床实践)。,卒中发生时有痫性发作的患者，如果神经功能缺损与急性脑缺血有关，可以静脉使用rtPA (IV类证据，优良临床实践)。,尽管超出现行的欧洲标签范围，建议80岁有选择性的患者仍可静脉应用rtPA(III类证据，C级建议)。,6h时间窗内的急性大脑中动脉闭塞患者，动脉内治疗可作为一个治疗选项(II类证据，B级建议)。,符合筛选标准的急性基底动脉闭塞患者，可应用动脉内溶栓治疗(III类证据，B级建议)。即使超过3小时，仍可应用静脉溶栓治疗(III类证据，B级建议)。,建议缺血性卒中发病后48小时内给予阿司匹林(160325mg负荷剂量)治疗(I类证据，A级建议),如果计划溶栓或已经溶栓，建议24小时内不要启用阿司匹林或其他抗栓治疗(IV类证据,优良临床实践)。,急性缺血性卒中急性期内不建议使用其他抗血小板药物（单用或联用）(III类证据，C级建议)。,不建议使用糖蛋白-IIb-IIIa抑制剂(I类证据，A级建议)。,不建议急性缺血性卒中患者早期应用普通肝素(UFH)、低分子量肝素或类肝素(I类证据，A级建议)。,目前尚没有使用神经保护剂治疗缺血性卒中的建议(I 类证据，A 级建议)。,Specific treatment: thrombolysisRecommendations,-,Update,Guidelines January,2009,New Elements,.,Intravenous rtPA (0.9 mg/kg body weight, maximum 90 mg), with 10% of the dose given as a bolus followed by a 60minute infusion, is recommended within 4.5 hours of onset of ischaemic stroke,(Class I, Level A), although treatment between 3 and 4.5h is currently not included in the European labelling.,ESO2008指南 一般治疗,建议,建议对严重神经功能缺损的患者，间断性监测神经功能状态、脉搏、血压、体温以及氧饱和度72小时,(IV类证据，优良临床实践)。,建议