腦血管疾病

CerebrovascularDisease

(CVD)DepartmentofNeurology2ndhospitalofHarbinMedicalUniversitySection1IntroductionDefinitionCVD:

ThetermofCVDdesignatesanyabnormalityofthebrainresultingfromvariouspathologicalprocessofthebloodvessels.

腦血管病是多種腦血管病變引起腦部疾病旳總稱。DefinitionStroke:

Thestroke

isasyndromecharacterizedbytheacuteonsetofaneurologicdeficitthatreflectsfocal/diffusedinvolvementoftheCNSandistheresultofadisturbanceofthecerebralcirculation.

腦卒中是指急性起病、迅速出現不足或彌漫性腦功能缺失征象旳腦血管性事件。Epidemiology:CVDisthethirdmostcommoncauseofdeathafterheartdiseaseandcancer.Incidence:100~300/100,000morbidity:100~740/100,000mortality:50~100/100,000About50%~70%ofsurvivorsshowsdisabilityindifferentdegree.

ClassificationofCVDAccordingtothelastingtimeofneurologicdeficit:TIA(<24h)stroke(>24h).Accordingtotheseverityofneurologicdeficit:minorstrokemajorstrokesilentstrokeAccordingtothepathologicalfeatures:ischemicstrokehemorrhagicstroke(seetable8-1)腦部旳血液供給-Bloodsupplyinbrain頸內動脈系統

-internalcarotidartery(ICA)S.

眼動脈-ophthalmicartery后交通動脈-postcommunicatingartery脈絡膜前動脈-anteriorchoroidalartery

大腦前動脈-anteriorcerebralartery(ACA)

ci-mca-1.jpg供給眼部及大腦半球前3/5部分即額葉、顳葉、頂葉及基地節旳血液見圖thecircleofWillis環見圖腦基底部動脈椎-基底動脈系統-vertebral-basilararteryS.椎動脈(VA):Whichisdividedinto

anteriorspinalartery(脊髓前動脈)posteriorspinalartery(脊髓后動脈)medullaryartery(延髓動脈)posteriorinferiorcerebellarartery(小腦后下動脈)基底動脈(BA):Whichhasbranchesof

anteriorinferiorcerebellarartery（小腦前下動脈）branchesofpons（腦橋支）internalauditoryartery（內聽動脈）superiorcerebellar

artery（小腦上動脈）大腦后動脈

(posteriorcerebralartery,PCA),

whichistheterminaldivisionofBA椎基底動脈系統供給腦干,小腦及大腦半球后2/5部分即枕葉及顳葉旳基底面，枕葉旳內側及丘腦等。EtiologyofCVD

VasculardisorderAtherosclerosisInflammatorydisorders(TB,syphiliticarteritis,SLE,etc.)Congenitalvascularmalformation(aneurysm,AVM)Lesionsofanycause

EtiologyofCVDHeartdiseasesandbloodkineticschangesHypertentionorhypotensionAtrialfibrillation,Rheumaticheartdisease,arrhythmiasetc.ChangesinbloodconstituentandhemodynamicsIncreaseinbloodviscosityAbnormalityinbloodcoagulationmechanismOthersSuchasemboliofair,fat,cancercells.Bloodvesselspasm,trauma,etc.

RiskfactorsSeveralfactorsareknowntoincreasetheliabilitytostroke.Themostimportantoftheseare:Hypertention HeartdiseasesDiabetes TIAorstrokehistory

RiskfactorsSmokingandalcoholHyperlipidmiaOthers:food,symptomlessICAbruit,overweight,drugabuse,contraceptive，age,sex,familyhistory,race,etc.Section2

TransientIschemicAttack,TIA

(短暫性腦缺血發作)ConceptEtiologyandmechanismClinicalfindingsInvestigativestudiesDiagnosisanddifferentiationTreatmentandpreventionTIA-ConceptTIAisbrief,repeated,reversibleepisodesoffocalischemicneurologicdisturbance.Thedurationofwhichshouldbelessthan24h(usuallylastingaboutseveralminto1h).RepeatedTIAsofuniformtypearemoreoftenawarningsignofischemicstroke.TIA-ClinicalfindingsAgeofonset,50~70,male>femaleBasicfeatures:Transientepisode(<24h)

Reversibleresolvecompletelyrepeatedanduniformtype

ClinicalfeaturesofcarotidarteryTIACommonsymptom/sign:

weaknessofoppositelimbs.(對側單肢無力或輕偏癱)。Characteristicsymptom/sign:

ophthalmicarterycrossingparalysis（眼動脈交叉癱)Horner’scrossingparalysis（Horner氏交叉癱)Aphasia(dominanthemisphereisinvolved)ClinicalfeaturesofcarotidarteryTIAPossiblesymptoms:contralateralsinglelimb-orhemi-sensorydeficitcontralateralhomonymoushemianopiaTIAofVertebra-basilararteryCommonsymptom/sign:

vertigo,dysequilibrium,usuallynotinnitus(眩暈，平衡失調，多不伴有耳鳴)Characteristicsymptom/sign:dropattack（跌倒發作）transientglobalamnesia（TGA,短暫性全方面性遺忘）

bioccularvisiondisorder

(雙眼視力障礙)

TIAofVertebral-basilararteryPossiblesymptom/sign:swallowingdisorder,dysarthria/dysphagia(吞咽障礙、構音不清)incoordination(共濟失調)disturbenceofconsciousnesswith/withoutsmallpupils(意識障礙伴或不伴瞳孔縮小)

TIAofVertebral-basilararteryPossiblesymptom/sign:unilateral/bilateralfacial/perioralnumbnessorcrossingsensorydeficit(一側或雙側面部/口周麻木或交叉性感覺障礙)extraocularpalsyordiplopia(眼外肌麻痹或復視)crossedparalysis(交叉性癱瘓)TIASymptomsRelated

toCerebralCirculationTIA-DiagnosisanddifferentiationDiagnosis:

mainlydependuponhistory.ButthecausesofTIAareveryimportant.differentiation:partialseizure(不足癲癇)MéniereDisease(美尼耳氏病)Heartdiseases:Adams-stokessyndrome,severearrhythmia,etc.Management

DiagnosisofCarotidStenosisInvestigativestudyBloodTest:Bloodcount,ESR,bloodglucose,etc.EEG,CTorMIRECG,CardiacUltralsoundCarotidDuplexUltrasoundOthersTIA-treatmentandpreventionTreatmentintermsofetiologyDrugsforprevention

Antiplateletagents:Aspirin(ASA),Ticlopidine,Dipyridamole,Clopidogre

Anticoagulationtherapy:肝素(heparin)，低分子肝素(lowermoleculeheparin)，華法林(warfarin)TIA-treatmentandpreventionDrugsforprevention

Others:Chinesetraditionalmedicines,vasodilatationagents,bloodvolumeenlargementdosesandsurgicaltreatment（carotidendoarterectomy,intralumenalstents）CerebralprotectiveagentsPrognosis1/3willdevelopintocerebralInfarctionafterward1/3recurrence1/3resolvedSummarythemostimportantpartsneedtobeemphasizedare:

clinicalfindings,diagnosismenagementCaseExample

A55yearoldmalepresentstotheemergencydepartmentwithacuteonsetofLeftarmweakness:UnabletoliftleftarmoffoflapSymptomsimprovedonthewaytothehospitalCaseExamplePMHx:HypertensionTakesenalaprilSocialHx:Smokes1ppdCaseExamplePhysicalExamOverweight160/90,80,14,37.5CRightcarotidbruitHeartwithregularrateandrhythm;NomurmurCaseExampleNeuroexam30minaftertheonsetofsymptomsMotor4/5strengthinleftupperextremity.SensorysubjectivedecreaseinpinprickinleftupperextremitycomparedtotherightReflexeswere2+exceptfortheleftbiceps,whichwas3+,GaitsteadyCaseExampleNeuroexamAfteranimmediateCTscan,Thepatient’ssymptomshadcompletelyresolvedandhehadanormalneurologicexamQuestionsWhatisthepossiblediagnosisofthepatient?Whicharteryterritoryisinvolved?Whatistheprobablecause?Howshouldyoumenagetheproblem?Section3腦梗塞-cerebralinfarctionConcept:Cerebralinfarction(CI)isnecrosisandmalaciaofbraintissuesduetoischemiaandanoxiaofthebrain,whichisinturncausedbydeprivedorinsufficientbloodsupplyinbrain.是指腦部血液供給障礙，缺血、缺氧引起腦組織壞死軟化。cerebralinfarctionCommontypes:腦血栓形成(cerebralthrombosis,CT)腦栓塞(cerebralembolism)

腦分水嶺梗塞(cerebralwatershedinfarction,CWSI)

腔隙性梗塞(lacunarinfarct)腦血栓形成-cerebralthrombosis(CT)EtiologyPathologyClinicalFeaturesDiagnosisanddifferentiationtreatmentPrognosisandpreventionEtiology

Stenosisofarterythrombosis

Atherosclerosis-themostcommoncauseofCTArteritisOthers:vascularmalformation,blooddyscrasia(高凝狀態-hypercoagulablestate、真性紅細胞增多癥-polycythemiavera,血小板增多-thrombocytosis、DIC等)

Etiologyvascularspasm:SAH,migraine,eclampsia(子癇),trauma,etc.Indeterminate

Pathology好發部位:大腦中動脈頸動脈虹吸部及起始部椎動脈及基底動脈中下段4/5

locatedinregionofICAterritory,1/5locatedinregionofV-BAPathology超早期（1~6h):腦組織變化不明顯。急性期（6~24h):腦組織蒼白、輕度腫脹，NC、膠質細胞及血管內皮細胞缺血壞死期（24~48h）：組織構造不清神經細胞消失及膠質細胞壞變，炎細胞浸潤，腦組織明顯腫脹Pathology軟化期（3d~4w）：腦組織開始液化變軟恢復期（3~4w）：膠質細胞、膠質纖維及毛細血管增生，形成膠質瘢痕和中風囊PathophysiologyBloodflowblockage>30seconds--metabolicchange,>1min--ceaseofneuronactivity,>5min--cerebralinfarct.Ischemicpenumbra(缺血半暗帶）timewindow(6h)PathophysiologyReperfusiondamage:possiblemechanisms:自由基(freeradical)形成及其瀑布式反應神經細胞內鈣超載(calciumoverload)EAA毒性作用(toxiceffectofexcitatoryaminoacid)酸中毒(acidosis)Types大面積腦梗死（alargeareaCI）分水嶺腦梗死(cerebralwatershedinfarction,CWSI)出血性腦梗死(hemorrhagicinfarct,HI)多發性腦梗死(multipleinfarct,MI)Clinicalfeatures

ClinicaltypesCompletestroke:reachespeakwithinseveralhours(<6h)progressivestroke:reachespeakwithin48hreversibleischemicneurologicaldeficit(RIND):Lasting>24handrecoveringwithin3wsClinicalfeaturesGeneralfeatures:Middle-agedorelderlypeople(causedbyAtherosclerosis),youthormiddle-agedpeople(causedbyarteritis).Strokeonsetatquietstateandreachesthepeakwithinseveralhoursto1~2days.ClinicalfeaturesGeneralfeatures:Usually,thepatientsareawakeandalertexceptforthosewithalargeareaofCIorinfarctioninbrainstem.ClinicalsyndromesofCIOcclusionsyndromeofcarotidarteryCarotidarteryocclusionmaybeasymptomatic.Symptomaticocclusionresultsinsyndromesfollow:Transientmonocularblindnesscausedbyipsilateralretinalarteryischemia.Horner’ssign.ClinicalsyndromesofCIOcclusionsyndromeofcarotidarteryCarotidarteryorophthalmicarterybruitandaweakenedpulseincarotidartery.

Contralateralhemiplegia,hemisensorydeficit,andhomonymoushemianopia.Aphasia,ifdominanthemisphereinvolvement.ClinicalsyndromesofCIOclusionsyndromeofMCA主干閉塞(Occlusioninstem):isaseverestrokesyndromewhichcombinesthefeaturesofsuperiorandinferiordivisionstroke.三偏癥狀

(contralateralhemiparesis,hemisensorydeficit,andhomonymoushemianopia).ClinicalsyndromesofCIOclusionsyndromeofMCA失語癥、體象障礙(globleaphasia,ifdominanthemisphereisinvolved,andbodyimagedisturbence)意識障礙、顱內壓增高、腦疝可造成死亡

(disturbenceofconsciousness,increasedICP,andherniation)ClinicalsyndromesofCIOclusionsyndrome

ofMCA皮層支閉塞(occlusioninsuperiordivision)中樞性面舌癱和偏癱，偏癱上肢重于下肢(contralateralhemiparesisthataffectstheface,hand,andarmbutlesssevereintheleg).ClinicalsyndromesofCIOclusionsyndrome

of

MCA皮層支閉塞(occlusioninsuperiordivision)伴感覺障礙，主要是皮質感覺障礙(contralateralhemisensorydeficit,mainlyshowscorticalsensorydeficit)失語、體象障礙(aphasiaandbodyimagedisturbence)

ClinicalsyndromesofCIOclusionsyndrome

ofMCA深穿支閉塞(occlusionininferiordivision)對側偏癱(contralateralhemiparesis,upperandlowerlimbsevenlyaffected)對側偏身感覺障礙及偏盲(contralateralhemisensorydeficitandhomonymoushemianopia)可有失語(dominanthemisphereinvolved)

ClinicalsyndromesofCIOcclusionsyndromeofACA

主干閉塞(occlusioninstem)中樞性面舌癱、偏癱下肢重于上肢(挑扁擔樣癱)(Shoulde-pole-carry-like),

伴輕度感覺障礙尿便障礙或尿急(旁中央小葉損),(incontinence,paracentrallobuleisaffected)ClinicalsyndromesofCIOcclusionsyndromeofACA

主干閉塞(occlusioninstem)精神癥狀(psychiatricsymptom)(顳極與胼胝體受累，temporalpoleandcorpuscallosumareaffected)，?？梢姀娢?、吸吮反射(額葉病變)(graspreflex,suckreflexarecommonsigns,lisioninfrontallobe).ClinicalsyndromesofCIOcclusionsyndromeofACA皮層支閉塞(occlusioninsuperiordivision)對側偏癱，下肢重于上肢(sensorimotordeficitoftheoppositelegandfootand,tolessdegree,oftheshoulderandarm)ClinicalsyndromesofCIOcclusionsyndromeofACA深穿支閉塞(occlusionininferiordivision)面、舌、肩癱(contralateralparesisincludesface,lingua,shoulder)ClinicalsyndromesofCIOcclusion

syndromeofPCA主干閉塞(occlusioninstem)：對側偏盲、偏癱及偏身感覺障礙(較輕)丘腦綜合癥(thalamicsyndrome)主側半球病變可有失讀癥(alexia).

ClinicalsyndromesofCIOcclusion

syndromeofPCA皮層支閉塞（occlusioninsuperiordivision）對側同向性偏盲(contralateralhomonymoushemianopia)、象限盲(quadranthemianopia)、皮質盲(corticalblidness,bilateralinvolvment)ClinicalsyndromesofCIOcclusion

syndromeofPCA皮層支閉塞（occlusioninsuperiordivision）主側顳下動脈閉塞時可見視覺性失認癥(visualagnosia)和顏色失認(achromatopsia)主側半球頂枕動脈閉塞可有對側偏盲，失語。

ClinicalsyndromesofCIPCAocclusion

syndrome深穿支閉塞(occlusionin

inferiordivision)

丘腦穿通動脈閉塞：紅核綜合征（Claudesyndrome)丘腦綜合征(thalamicsyndrome):snesoryloss,spontaneouspainanddysesthesias,choreoathetosis,intentiontremor,spasmofhand,mildhemiparesis.ClinicalsyndromesofCIPCAocclusion

syndrome深穿支閉塞(occlusionin

inferiordivision)

中腦分支閉塞：Webersyndrome:thirdnervepalsyadcontralateralhemiplegia.

ClinicalsyndromesofCISyndromeofvertebral-basilararteryocclusion主干閉塞：廣泛腦干梗死。Showssymptomsofcranialnerves,pyramidaltract,andcerebellum.ClinicalsyndromesofCISyndromeofvertebral-basilararteryocclusion基底動脈尖綜合征（TopofthebasilarSyndrome）:Abnormalityineyemovementandpupilsdisturbanceofconsciousness(lossofconsciousness)homonymoushemianopiaorcorticalblindnessseverememorydisorderClincalsyndromesofCISyndromeofvertebral-basilararteryocclusion腦干分支閉塞WebersyndromeMillard-GublersyndromeFovillesyndromeClincalsyndromesofCISyndromeofvertebral-basilararteryocclusion小腦后下動脈閉塞-延髓背外側綜合癥(Wallenbergsyndrome)眼球震顫(nystagmus)交叉性感覺障礙(crossedsensorydeficit)球麻痹(bulbarparalysis)

病灶側Horner征(ipslateralHornorsign)病灶側小腦性共濟失調(ipslateralcerebellarataxia)

ClincalsyndromesofCISyndromeofvertebral-basilararteryocclusion閉鎖綜合征(Locked-insyndrome):基底動脈分支雙側閉塞Cerebellarinfarction由小腦上動脈(superiorcerebellarartery)、小腦后下動脈(posteriorinferiorcerebellarartery)、小腦前下動脈閉塞(anteriorinferiorcerebellarartery)所致。LaboratoryfindingsCTscan：normalatthedayofonsetofthestroke,showsthelowdensityoftheinfarctafter24~48h.CTispreferredforinitialdiagnosissinceitcanmakethecriticaldistinctionbetweenischemiaandhemorrhage(見圖)LaboratoryfindingsMRI：maybesuperiortoCTscanfordemonstratingearlyischemicinfarcts,showingischemicstrokeinbrainstemorcerebellumanddetectingthrombosisocclusionofvenoussinuses.LaboratoryfindingsCerebralangiography：MRA,DSABloodtestsandECG:Serumglucose,cholesterolandlipid,hemorheology.TCDandCSFDiagnosisanddifferentiationDiagnosisdiagnosiscanbemade

dependingontheclinicalfeatures(Patientspresentingwithfocalcentralnervoussystemdysfunctionofsuddenonset,Lastingmorethan24h)CTandMRIchangesDiagnosisanddifferentiationDifferentialdiagnosis:

CerebralhemorrhagecerebralembolismOtherstructuralbrainlesions:tumor,abscess,etc.

腦出血和腦梗塞旳鑒別要點

腦出血 腦梗塞

1.發病年齡60歲下列 多60歲以上

2.TIA史多無常有

3.起病狀態活動中 平靜狀態或睡眠中

4.起病速度急(分、時)較緩(時、日)

5.血壓 明顯增高 正常或增高

6.全腦癥狀 明顯多無

7.意識障礙 較重較輕或無

8.頸強直可有無

9.頭顱CT 高密度病灶低密度病灶

10.腦脊液 血性,洗肉水樣無色透明

其中最主要旳是2、3.兩條。

Treatment急性期治療（Treatmentinacutestage）

治療原則：超早期治療--力求溶栓；綜合保護治療；個體化治療；整體化治療；對危險原因及時予以預防性干預措施。Treatment超早期溶栓治療目旳：溶解血栓；迅速恢復梗死區血流灌注；減輕神經元損傷。（6h）complications:Hemorrhage,reperfusiondamageandbrainedema,reocclusion.Treatment超早期溶栓治療Thrombolyticagents:Urokinase(UK),Straptokinase(SK),recombinanttissueplasminogenactivator(rt-PA)Treatment超早期溶栓治療Indications:Age<75nodisturbanceofconsciousnesswithin6h(or12hforprogressivestroke)ofonsetBp<200/120mmHgnohemorrhageshownonCTscanningexclusionofTIAnootherhemorrhagicdiseases

TreatmentAntiplateletagentsTheregimeisasdescribedinthesectionofTIA.Anticoagulationagents:

topreventtheprogressionofthrombosis.TheagentsusedarethesameasmentionedinthesectionofTIA.Fibrinogendegradationtherapy:降纖酶(Defibrase),巴曲酶(Batroxobin),安洛克酶(Ancrod)和引激酶。TreatmentNeuroprotectiveagents:抗自由基：V-EV-C甘露醇激素等克制腦代謝—急性期時應降低腦代謝，降低腦細胞耗氧量使缺血區血流量增長鈣離子拮抗劑：西比靈尼莫地平等亞低溫胰島素維持血糖正常低限水平

TreatmentOtherformsofmedicaltreatment:suchastherapiesaimedatimprovingbloodflow:hemodilution,metabolicimprovingagents-ATP,Co-A,腦活素等。TreatmentSurgicaltreatmentGeneraltreatmentICU:monitoringECG,Bp,R,P,etc.AntiedemaagentsPreventinginfectionPhysicaltherapyandrehabilitationPreventivemeasures腔隙性腦梗塞-LacunarInfarctionConcept：

Smallpenetratingarterieslocateddeep

inthebrainmaybecomeoccludedasaresultofchangesinthevesselwallinducedbychronichypertensionandatherosclerosis.是指發生在大腦半球深部白質及腦干旳缺血性微梗死因腦組織缺血、壞死、液化并由吞噬細胞移走而形成腔隙，占腦梗死旳。多見于基底節區、放射冠、丘腦、腦干等部位。