TIA临床概念进展

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,TIA 临床概念的进展,黄一宁,北京大学第一医院神经科,纲要,影像学发现,定义,时间定义,组织定义 传统TIA 有DWI 改变,溶栓中的TIA,TIA的治疗,重视TIA 的意义,TIA后卒中、心梗、其它血管事件发生率很高，TIA后早期再发卒中的危险性更高,小卒中、卒中先兆、短暂性卒中、短暂性脑发作、不稳定的脑梗死,TIA 的提示 不是什么,时间,会发生卒中，而是,容易,发生卒中,病因,动脉到动脉微栓塞,血液动力学,心源性微栓塞,血管痉挛,TIA 症状和病因关系,短于30分钟,长于一小时,心源性栓子,动脉到动脉栓子,我国TIA患者颅内血管狭窄多见,62% TIA 有颅内外血管狭窄，颅内：颅外3：1,Huang YN, et al, Neurology, 1997, 48:524-525,3年有21%发生脑卒中，年轻人有血管狭窄者更容易发生脑卒中,症状超过1小时者8%有异常，也提示心源性可能,左侧肢体无力5小时,Figure 1.,A large region of DWI and ADC imaging abnormality in the right temporal lobe in a patient with a left hemiparesis that rapidly resolved within 5 hours of onset. Other slices (not shown) demonstrated frontal and parietal regions of abnormality. a, DWI image; b, ADC image; and c, baseline T2-weighted image.,眩晕、左手笨6小时后症状消失,Figure 2.,Several foci of left cerebellar DWI and ADC abnormality in a patient presenting with 6 hours of vertigo and left-arm clumsiness. Other slices (not shown) also showed foci of right cerebellar DWI abnormality. Follow-up MRI at 3 months did not show corresponding late ischemic changes on T1- or T2-weighted images. a, DWI image; b, ADC image; c, baseline T2-weighted image; and d, late (follow-up) T2-weighted image.,左侧肢体发麻无力十分钟 多部位病变,ADC 容积 (mm,3,),平均ADC强度,DWI 发现 （发病3天内检查）,21% 异常,DWI异常者比无常者出现临床表现,症状持续,1,小时 （倍),运动障碍 (16倍),失语 (25倍),3者均有，均出现核磁异常,DWI 异常者中有44%已经出现常规核磁（T2, FLAIR)异常,Ralph A. et al, stroke, 2003;34(4):932,什么是真正的 TIA,？,打假,时间定义,短暂性的、可逆的、局部的脑血液循环障碍，症状和体征在24小时内完全消失。, 24小时,Special Report from the National Institute of Neurological Disorders and Stroke: classification of cerebrovascular diseases III. Stroke. 1990; 21: 637676.,时间定义历史,1950s 首先武断地定义24小时是组织有无缺血损伤的界限,1958年,NIH 脑血管病分类定义TIA可以持续一个小时,Fisher 症状可以持续几个小时，但多数持续5-10分钟,1964 年,Acheson, Hutchinson提议一小时作为鉴别TIA或脑梗死界限,Marchall 发现3/4患者症状短于1小时,1975年 NIH 第二版分类定义24小时,临床表现,常见类型,发作持续时间短于5分钟，平均1分钟,50% TIAs 在 30分钟内自然消失,*,10% 在 30-60 分钟内恢复,60分钟内仍有症状者，仅14%在 24小时 后恢复,*Levy DE Neurology 1988;5:674-77,*Lyden P et al;2001:57:2125-2128,时间定义的挑战,大多数TIA 在10-60分钟内症状消失,80、90年代CT进步显示大于1小时者常常伴有脑实质损害,核磁进展显示小病灶,DWI显示新病灶，近半数传统TIA有持久的改变,新定义,a TIA is a brief episode of neurologic dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction.,TIA Working Group,Transient Ischemic Attack Proposal for a New Definition，NEJM 2002, Volume 347:1713-1716,组织定义TIA,短暂发作的神经功能缺失，没有持续的脑实质改变,Saver JL, Kidwell CS. Magnetic resonance imaging in transient ischemic attacks: clinical utility and insights into pathophysiology. In: Davis SA, Fisher M, Warach S, eds. Magnetic Resonance Imaging in Cerebrovascular Disease. New York, NY: Cambridge University Press. In press.,Albers GW, Caplan LR, Easton JD, Fayad PB, Mohr JP, Saver JL, Sherman DG, for the,TIA,Working Group. Transient ischemic attack: proposal for a new definition. New Engl J Med. 2002; 347: 17131716.,美国组织定义TIA的发病率,经典定义（10万）,组织定义（10万）,TIA归类梗死（10万）,2000年美国组织定义TIA,2000年美国组织定义卒中,中位数,低,高,64,37,107,43,25,72,21,12,35,120493,69660,201000,880528855491,920181,TIA需住院治疗指征：,发病2周内患者未到专科就诊者,疑有需急诊处理的潜在病因,短时间内TIA发作多于1次,TIAs -溶栓,50% TIAs 在 30分钟内自然消失*,10% 在 30-60 分钟内恢复,60分钟内仍有症状者，仅14%在 24小时 后恢复,两个排除 TIAS的原则,症状迅速改善,选择性的轻微症状,NINDS Results*,*Levy DE Neurology 1988;5:674-77,*Lyden P et al;2001:57:2125-2128,%,药物治疗,目的：,稳定动脉硬化斑块,比以往概念要复杂，不仅仅是阿司匹林！联合用药较好,他汀：降低LDL-C, 提高HDL,Fibrate: 提高HDL,降低TG,对卒中预防无效,ACEI,利尿剂,抗血小板药物,他汀治疗卒中大系列的研究,研究,药物（计量）,观察时间（年）,预后（卒中和TIA),治疗效果（相对危险性,显著性检验,4S,Simvastatin(20/40mg),5.4,Totol stroke,-30%,NS,4S,Simvastatin (20/40 mg),5.4,Stroke+TIA,-28%,P=0.033,CARE,Pravastatin (40mg),5,Stroke,-32%,P=0.030,LIPID,Pravastatin(40mg),6,Stroke,-19%,P=0.050,LIPID,Pravastatin(40mg),6,Ischemic stroke,-23%,HPS,Simvastatin(40mg),5,Stroke,-25%,P=0.0001,HPS,Simvastatin(40mg),5,Ischemic stroke,-30%,P=0.0001,HPS,Simvastatin(40mg),5,Fatal stroke,-20%,NS,PROSPER,Pravastatin (40mg),3.2,Stroke+TIA,-0.96,NS,PROSPER,Pravastatin(40mg),3.2,TIA,-25%,P=0.051,ASCOT,Atorvastatin(10mg),3.3,Stroke,-27%,P=0.0236,ACEI,Plaque with stable fibrous cap formation,:,mod. nach Ross R, N Engl J Med 340 (1999) & Falk et al., Circulation 92 (1995,),Fibrous cap,formation,Macrophage,accumulation,Formation of,necrotic core,Pathophysiology of Atherosclerosis (III),Vessel wall,Coronary plaque with lipid core,Plaque-ACE and Atherosclerosis,Major role in atherosclerotic pathways:,Endothelial,dysfunction,Thrombosis,Inflammation,Vasoconstriction,Vascular lesions,Remodeling,Plaque,rupture,Plaque-ACE,Local Mediators,VCAM,ICAM,Cytokines,Endothelin,PAI-1,Growth factors,Proteolysis,Ang II,Bradykinin NO,Clinical,Sequelae,Ang II,adapt. from Pepine C, Can J Cardiol 14; suppl D (1998),ACEI-Stroke,Ramipril:,primary composite end point 22%,Death from CVD: 26%,MI: 20%,Stroke 32%,Death from any cause: 16%,沙坦、硝苯地平、利尿药,外科介入,颈动脉内膜切除术,血管内支架,教育患者：,社区中发生TIA者，或就诊时已经恢复良好的卒中者，应该在起病14天内就诊于有专家的神经血管临床机构，接受评价和观察。,不要等待！ 小卒中、卒中前兆、短暂性脑卒中,