腦與脊髓的血管性疾病

VASCULARDISEASES

inBRAINandSPINALCORD

Whatisit?

Howtomanageit?流行病學（Epidemiology）Annually,1,500,000to2,000,000Chinesesufferastroke.Mortality:25-30%Morbidity:60%Thecosttoindividualsandsocietyintermsofacutecareresources,rehabilitation,chroniccare,andlostproductivityisenormous.Today’stopics缺血性腦血管病（Ischemiccerebralvasculardiseases）出血性腦血管病（Hemorrhagiccerebralvasculardiseases）脊柱脊髓血管病（Spineandspinalcordvasculardiseases）Ischemiccerebraldisease–

ClinicalpresentationTIA(transientischemicattack一過性腦缺血發作)Infarction（腦梗死）COMMONSYMPOTOMS

ParaplegiaHomonymousemianopsia

HemisensorylossVertigoTransientmonocularblindnessDiplopiaDysphasiaFacialweaknessVisualfielddefectAtaxiaConfusionTinnitus

CAROTIDSYSTEM

VERTEBRAL-BASICSYSTEMStrokeFirstconsultationbycerebrovascularspecialistsCT、MRI、SONOGRAPHY、SPECTHemorrhagicIschemicEtiologictreatmentEtiologicdiagnosisRehabilitationProtocol

EmergencynetworkAcutestrokediagnosedInterventionaltherapySurgeryDrugtherapyMedicineRehabilitation“GreenChannelEmergency”TreatmentofIschemicStrokeMedicinemethod(Antiplatelet,anticoagulation,etal)SurgicalmethodEndarterectomySTA-MCAby-passInterventionalmethodThrombolysisAngioplasty(balloon,stent)AcuteStrokemale，29yearsold，righthemiplegiafor1/2hour，Thrombolysis1yearFollow-upStentingandfollow-upMale,63yearsold,TIACarotidStenosis–EndarterectomyMale,73-year-old,TIACarotidStenosis–AngioplastyandStentEPIMale,63yearsold，leftextremityweaknessfor3monthsMale,46yearsold,periodicdizzinessfor3months.By-passoperation

STA-MCAAnastomosisBy-pass+carotidstentingMale,56yearsold,rightextremityweakness.HighstenosisofrightICAandocclusionofleftICAHemorrhagicCerebralVascularDiseasesSubarachnoidHemorrhageandAneurysmsCerebralvascularmalformations

-arteriovenousmalformation

-cavernousangioma

-venousmalformationDural

arteriovenousfistulaMoyamoyaDiseasesIntracerebralhemorrhageSubarachnoid

HaemorrhageAneurysmal

subarachnoid

haemorrhage(SAH)isabout80.3%----Chinesegovernment:thetenth5yearsprojectresearchedresultSAHandAneurysmssubarachnoidhemorrhageSubaracnoidHemorrhage–

HuntandHessScaleScoreDefinition0

UnrupturedaneurysmAsymptomatic,ormildHA,andslightnuchalrigidity1aNoacutemeningeal/brainreaction,butwithfixed

neuroologicaldeficitModeratetosevereHA,nuchalrigidity;orCNpalsy(i.e.III,IV)3Lethargyorconfusion;mildfocaldeficit4Stupor,moderatetoseverehemiparesis5Deepcoma,decerebraterigidity,moribundappearanceAddonegradeforserioussystemicdisease(i.e.HTN,DM,Severeatherosclerosis,COPD)orseverevasospasmonarteriograpgy.DiagnosisofsubarachnoidhemorrhageLumbarpunctureCTscan.

goldstandardCLASSIFICATIONOFANEURYSMS

FUSIFORMDISSECTIONOCCULARPSEUDO-ANEURYSMEtiologyandpathogenesisDevelopmentaltheory:congenitallesions/inbornstructuralweaknessofthemusclelayeratbranchingpointsDegenerativetheory:

ruptureofinternalelasticlaminaandmediaduetoextremehemodynamicstressCurrentconcept:

degenerativedisease,triggeredbyhemodynamicstress.StructuralweaknessmayplayaroleEtiologyandpathogenesisruptureofinternalelasticlaminathinningandruptureofmedialackofelasticelementsinarterialwallconstantpulsatileflowaneurysmgrowthandruptureIntracranialAneurysm

–TreatmentEmbolizationOperationConservative

“clearneck”threateningvasospasm

posteriorcirculation

anteriorcirculationSAHFisher3hematomaneedingevacuation“noneck”HH4/5no(previous)SAHmult.SAHEMBOLIZATIONSURGERY"unclear"anatomyincreasedsurgicalriskIntracranialaneurysmsGoalofaneurysmtreatment:

toeliminatepulsatingbloodpressureinsidetheaneurysmAneurysmEmbolization2mmX2cm?

CordisNeurovascular,Inc.20033mmX4cm?

CordisNeurovascular,Inc.20034mmX7cm?

CordisNeurovascular,Inc.2003ComplexPlatinumCoilsEndovascularembolizationFemale,67yearsold,SAHOperativeclippingComplicationsafterSAHVasospasm--infarctionHydrocephalusCerebralVascularMalformation

ArteriovenousmalformationsCavernousmalformationsCarotid-cavernousfistula(CCF)VenousmalformationsTelangiectasis.Arteriovenousmalformations(AVMs)臨床表現64％患者在40歲之前發病(20～39歲）

主要癥狀：出血52～77%15～20歲高發癲癇28-64%神經功能障礙20～30％頭痛60％1臨床表現2

據文獻報道：

未出血AVM的年出血率為2～4％再出血率為第一年6％以后2～4％臨床表現3AVM死亡病例中，大約30％因出血；每次出血的死亡率大概10～15％HeadacheIntracranialhemorrhageEpilepsypresentationArteriovenousmalformation–ClinicalNeurologicaldeficitArteriovenousmalformation–

PurposeofthetreatmentPreventionfromrehemorrhageImprovementofischemiaRemovaloftheepilepticsourceFollow-up10yearslaterGirl，age12,SAHwithepilepsyGirl，age12,SAHwithepilepsyOneyearafterembolizationPre-emboPost-emboBoy，age2，hydrocephalus2yearsafterembolizationPre-emboPre-emboPost-emboPost-opFemale，age30，multi-SAH

Boy，age14，

intracerebralhemorrhageEmbolization+surgeryMale,22yearold,

intracerebralhemorrhagePost-embolizationPost-operationWillis環不對稱3、立體定向放射治療

利用先進的立體定向技術和計算機系統，對顱內的正常組織靶電或病變組織，使用1次大劑量窄束電離射線從多方向、多角度精確地聚集于靶點上，引起放射生物學反應，從而達到治療目的。主要方法1γ刀：γ射線（鈷60）2X刀：高能X射線（直線加速器）3質子刀：質子束（回旋加速器、同步加速器）病例（立體定向放射治療）放療2年后隨訪Cavernousangioma外傷性頸動脈－海綿竇瘺的定義定義外傷性頸動脈－海綿竇瘺是指由外傷引起的海綿竇段的頸內動脈本身或其在海綿竇內的分支破裂，與海綿竇之間形成異常的動、靜脈溝通。Carotid-cavernousfistula(CCF)臨床癥狀和體征T－CCF的分型

閉塞頸內動脈閉塞瘺口VenousmalformationFemale,50-year-old,SAHMoyamoyaDiseaseIntracerebralhemorrhage(hypertensivehematoma)thulemusputaminal

hematomaMicrosurgicalremovaloftheclot.Percutaneouspunctureanddrainage(withthrombolyticsubstances)NationalCooperationnetworkwith150hospitals,3000casesAVMinSPINEandSPINALCORD

SpinalVascularMalformations

-ClassificationIntrathecalIntramedullary

arteriovenousmalformations(SAVMs)Intramedullary

cavernomasPerimedullary

arteriovenousfistulas(PMAVFs)SpinalDural

arteriovenousfistulas(SDAVFs)Extradural

arteriovenousmalformationsVertebralangiomasParavertebralCobb’ssyndromeKlippel-TrenaunaysyndromeRendu-Osler-Weber’ssyndromeParavertebral

arteriovenousfistulasSYMPTOMSANDSIGNSBackpainHypoesthesiaMuscleweakness(paraplegic,quadriplegic)SphincterdisturbanceIntramadulleryAVMTwoweekspost-embIntramadulleryAVMIntramadulleryAVM

POST-OPIntramadullary

cavernomaPerimedullary

ArteriovenousfistulaIPerimedullary

arteriovenousfistulaIIPerimedullary

arteriovenousfistulaIIISpinalDAVFSPINALCAVENOUSANGIOMAPOST-OPCONCLUSIONCerebrovasculardiseasesIschemicTransientischemicattack(TIA)InfarctionHemorrhagic

Subarachnoidhemorrhage(SAH)Cerebralvascularmalformations

Dural

arteriovenousfistula