心源性腦栓塞1.病歷特點中年男性，反復發作漸進性病程；既往高血壓史，夾層動脈瘤及主動脈瓣關閉不全換瓣術后3年，口服抗凝藥不規范。近2年多次腦梗塞史。發病表現為反復發作的神經功能缺損，漸進性的神經功能缺損。查體主要表現為言語表達障礙，構音含混，右面部麻木及右肢輕偏癱，及右側同向偏盲。輔助檢查：凝血象（INR）偏低；

CT：腦內多發梗塞2.定位診斷雙側頸內動脈系統，左側著椎基底動脈系統？

3.定性診斷心源性栓塞主動脈機械瓣膜組織栓子脫落

4.AorticDissectionAnatomy,PhysiologyandPrinciplesofTherapy5.History1555–Vesaliusdiagnosedapulsatingtumornearthevertebraeinapatient’sbackandcalledit“adilatationoftheaorta”18261826–Laennecintroducedthetermdissectinganeurysm1800’s–surgerywasperformedontheentitybyJohnHunter,AstleyCooperandothersevenbeforetheeraofgeneralanesthesiaEarlyoperationsweredesignedtoproducedistalinternalfenestrationtocausedownstreamdecompressionoftheaorta.6.History1951LamandAramintroducedhomograftsforrepairofdescendingthoracicaneurysms1953CooleyandDeBakeyusedartificialgraftsforrepair1953Bahnsonintroducedaneurysmorrhaphy1957cardiopulmonarybypassbecameavailable7.DefinitionTrueaneurysm–localizedenlargementoftheaortacontainedbyallthelayersoftheaorticwallFalseaneurysm–enlargementcontainedbytheaorticadventitiaandperiaorticfibroustissue.8.9.10.DefinitionAorticdissection–SuddencatastrophiceventinwhichatearintheintimaallowsbloodtoescapefromthetruelumenoftheaortarapidlyseparatingtheinnerfromtheouterlayerofthemediaColumnofbloodisdrivenbytheforceoftheleftventricularsystolicpressurewhichstripstheintimafromtheadventitia11.DefinitionAcute–lessthan14daysoldChickenortheegg?–Hemorrhageinthemediacausesruptureoftheintimaordissectinghematomainanintimaltear.12.CausesofAneurysmMedialdegenerationandlocaldilatationAtherosclerosisSyphilis(ascendingonly)Bacterialinfections(mycotic)CongenitalabnormalitiesTraumaAnnuloaorticectasia13.CausesofDissectionInherentweaknessoftheaorticwallHypertension–70-90%PregnancyIatrogenicBicuspidaorticvalveandcoarctationClosedchesttrauma14.PathophysiologyLawofLaplace:Asasphereincreasesinsize,thewalltensionofthesphereincreasesWeakenedwallDilatationExpansionwithpressure-relatedsymptomsRupture15.NaturalHistoryNotwelldocumentedSigns,symptomsandprognosisrelatedtothesizeoftheaneurysmThoracicaneurysmslargerthan6cmaremorepronetorupturethanthesmallerones5yearsurvivalforsymptomaticaneurysmsis27%whereas58%withasymptomaticonessurvivedthesameperiodoftime.Ruptureisthemostcommoncauseofdeath16.NaturalHistoryManypatientswithdissectiondieacutelyduetocardiactamponadeordissectionoftheLAD8%ofascendingrupturessurvivewithouttreatment75%survivedescendingdissection17.ClassificationTypeI-BeginsattheaorticvalveandmayproceedtoandincludetheabdominalaortaTypeII–Beginsdistaltotheleftsubclavianarteryandcanencompasstheentireaortatotheiliacarteries18.19.20.21.AnatomicalConsiderations22.PathoanatomyDissectionoftheascendingaortaariseswithinseveralcentimetersoftheaorticvalve–66%DissectionofthedescendingaortaoccurjustbeyondtheleftsubclavianarteryattheligamentumarteriosumSmallpercentageoccuratthetransversearchordescendingaorta23.PathophysiologyAfterdissectionintothemedia,bloodrushesintothedissectedareaNecrosisoftheaorticwallthendevelopsseveraldaysaftertheevent–observedin62%ofcasesComplicationsincludeaorticrupture,obstructionandocclusionofaorticbranches24.25.ClinicalSignsandSymptoms26.DemographicsMales>females3:1SixthorseventhdecadeoflifePatientswithascendingdissectionareabouttenyearsyoungeratpresentationthanthosewithdescendingdissection27.SymptomsSudden,severechestpain–tearingsensationintheanteriorchestradiatingtothearmsortobetweenthescapulaeMayhavesyncope,neurologicsigns,weakness,hypotension.28.PhysicalFindingsParalysisMuffledhearttonesNewonsetaorticinsufficiencymurmurUnequalbloodpressureandpulsesintheextremitiesJugularvenousdistention–tamponadeAbdominalpain–acuteAcutehypertensionandanuria29.DiagnosisPlainchestradiograph–widenedmediastinum,pleuraleffusionElectrocardiogram–mayresembleacutemyocardialinfarctionparticularlyiftheLADisaffectedCTscan–identifiestheproblembutdoesnotprovidearoadmapAngiography–goldstandardTransesophagealechocardiography30.31.32.33.34.Therapy35.AscendingDissectionSurgicalemergencyCanonlybetreatedbyoperationMayormaynotrequireaorticvalvereplacementand/orcoronarybypasssurgerydependingontheprogressionofthedissectionMortality–about20%dependingonothermedicalproblemsandthepresenceofneurologicalsymptoms36.DescendingDissectionTherapycontroversialIfrupturepresent–operationistheonlyalternativeIntheabsenceofrupture,medicallytreatedpatientsdobetterthanthoseundergoingoperationduetocomorbidities37.GoalofOperativeTherapyObliterationofthesiteoftheintimaltearandthefalselumenReapproximationofthedissectedaortaRepairofaorticvalveorreplacementwithvalveconduitPerformbypassgraftingasneeded38.ConductoftheOperationAppropriatepreoperativeassessmentGeneralanesthesiaCardiopulmonarybypassAscendingdissection–profoundhypothermiawithcirculatory