缺血性脑血管病二级预防

1缺血性脑血管病二级预防2Disclosures3ContentsBrainEmbolism?DonorSourcePathophysiologyofEmbolicparticlesRecipientArteryTreatment﹠PreventionComplications4ContentsBrainEmbolism?DonorSourcePathophysiologyNatureofEmbolicParticlesRecipientArteryTreatment﹠PreventionComplications5DefinitionofanembolusUndissolvedmaterialcarriedbythebloodcurrentandimpactedinsomepartofthevascularsystemsuchasthrombi,tissuefragments,clumpsofbacteria,fatglobules,orairbubblesDictionary6PrevalentConceptsEmbolism=Cardiac-originembolismThehitrateisveryhighTreatmentisbasedonthesource-anticoagulantsforcardiac-originembolismandantiplateletsforarterialsourceembolism7BrainEmbolismClinicalFeatures危险因素--动脉粥样硬化较少--心脏病因素较多（如AF、心肌病、心瓣膜病、心衰等--主动脉弓病变--头颈部大血管病变--静脉血栓形成条件--其他部位栓塞证据8临床提示栓塞的证据TIA或小中风通常单次或发作频率较低，但单次发作持续时间比较长症状在一开始就达高峰，或阶梯式发展有时在活动、咳嗽、打喷嚏时发作梗塞灶可累及不同形态的多个血管区域出血转化多见，也是较为特征性的影像学改变可发现远端血管内栓子梗塞灶常成楔形，位于皮质或皮质下存在心脏、动脉或静脉栓子源的证据910ContentsBrainEmbolism?RecipientArteryDonorSourcePathophysiologyNatureofEmbolicParticlesTreatment﹠PreventionComplications11BrainEmbolismActorsintheDramaRecipientArteryDonorSource--Heart--Aorta--Cervico-CranialArteries--Veins(ParadoxicalEmbolism)Embolicmatter(the“stuff”)121314ClotinBA15常见的栓塞部位1617TherecipientarteriesareresponsiblefortheclinicalpresentationWhatinformationisusedtoclassifyastrokeasembolic18RecipientarteriesFactorsfavoringanembolicstrokemechanismTimingofsymptoms--maxatonsetoronestepwithin24~48hoursSizeofinfarctInfarctlocation--cortical,cortical/subcorticalHemorrhagictransformationAppearanceonvascularimagingofrecepientartery--noimportantunderlyingAS,passageofblockage,shapeofblock,fillingdefect19SizeofInfarctsStrokeDataBankSizeofinfractsonCTscan--Cardiac-originembolism-themedianvolumeofinfractswas2.4xthatfoundinpatientswithintra-arterialembolism早期意识障碍发生率--心源性29.8%--动脉源性6.1%20Recipientarteries(Atnecropsyandimaging）Open-noblockageDistalblockagebeyondtheinfarctAbruptocclusionwithoutnarrowingAbsenceofunderlyingASorotherintrinsicdiseaseNoattachmentofthrombustoartery2122Hemorrhagictransforamtionisanveryimportantcluetoanembolicmechanism2324ContentsBrainEmbolism?RecipientArteryDonorSourcePathophysiologyNatureofEmbolicParticlesTreatment﹠PreventionComplications25DonorSourceHeartAortaCervico-CranialArteriesVeins(ParadoxicalEmbolism)26查找栓子来源-心脏27形成血栓的三个必要条件AregionofcirculatorystasisInjurytoanendothelialsurfaceIncreasedbloodcoagulability28CardiacsourcesArrythmias–AFValveDiseasesMyocardialInfractionMyocardiopathiesCardiacTumorsParadoxicalEmbolism29临床最常见的心源性哈佛大学卒中登记库--Atrialarrhythmias--Congestiveheartfailure--Akineticregions30心律失常-房颤AF发病率约4%，房颤患者中风发病率高出正常5倍95%房颤无症状，发作性AF和持续性AF有着一样的中风风险，不同的检测手段阳性率差异很大，外置检测方法的敏感性为25%/24小时，50%/7d，70%/30d。SubclinicalAF:episodesofatrialrate190beatsperminutefor6minutes,duringthe3-monthwindowSubclinicalAFwasassociatedwitha5.5-foldincreasedriskofclinicalAFanda2.5-foldincreasedriskofischemicstrokeorsystemicembolismAF引起的中风是可防，华法令降低非瓣膜性房颤患者的中风发生率64%，降低全因死亡率约26%31矛盾栓塞-PFO胚胎期的原发隔和继发隔未完全愈合者即为PFO约有30%的成年人存在PFO，卒中患者检出率会更高，尤其是“隐源性卒中”未闭PFO的平均直径约4.9mm检查方法：TTE和/或TEE加静脉注射对比剂；TCD发泡实验有PFO不一定就是脑梗塞的原因32矛盾栓塞-PFOFivecriteriaforparadoxicembolism(1)Situationsthatpromotethrombosisoflegorpelvicveins(2)Increasedcoagulability(3)Suddenonsetofstrokeduringsexualintercourse,strainingatstool,orotheractivitythatincludesaValsalvamaneuverorpromotesright-to-leftshuntingofblood(4)Pulmonaryembolismwithinashorttimebeforeoraftertheneurologicischemicevent(5)Absenceofotherputativecausesofstrokeafterthoroughevaluation33静脉系统血栓形成因素34脑栓塞患者，栓子正通过间隔FromLouisCaplan35卵圆孔区域的巨大粘液瘤36EchoContrastAmarkerofslow/stagnantflowwithintheLA37RegionofCirculatoryStasis38Clots39常用的检查手段EEG、长程EEG、内植式hoterTTETEE包括注入造影剂TCD及发泡实验CT/MRI40尸检的主动脉41TEE42Donorsource-AortaAnimportantsiteofatheromatousdiseaseAnimportantsourceofbrainembolism溃疡性斑块中风发生率4.1%，复杂可移动突出的斑块中风发生率13.7%TEE是标准的检查手段，largeplaquesandfloatingmobilethrombiwithinthelumenoftheaorta，但对溃疡性斑块检出效果较差43ArteriallesionsthoughtunstableandpotentialdonorsourcesofembolismSeverestenosisorocclusionDissectionPlaques:--Hypoecholic--Heterogeneousinechocharacteristics--Irregularborders44头颈部大血管检查方法B超TCDCTA/MRADSA4546Clot47LimitationofpresenttechnologyThequestionisnotwhethertolookattheheartandaortabuthowthoroughlytodoso.Cardiac--Toosmalllessthan1or2mm--ThrombushasflownthenestAortic--BlindareaonTEE--ulcerplaque48ContentsBrainEmbolism?DonorSourceRecipientArteryPathophysiologyNatureofEmbolicParticlesTreatment﹠PreventionComplications49Directanalysesofemboli(Necropsy)Inmostatherothromboticstrokes,fibrinandplateletrichthrombiofvariousthicknessesdevelopattheculpritplaquesofCA,whicharefinallyoccludedwithfibrinandredcellrichthrombiInmostcardioembolicstrokes,redthrombigeneratedintheheartorperpheralveinsaredislodgedtoembolizetobrainarteries50ExamineretrievedclotsAmong50retrievedclots,22(44%)werefibrin-dominant,13(26)BRCdominant,and15(30%)mixedHyperdensevesselsweremoreoftenseenwithRBCdominantandmixedthanfibrin-dominantclots(100%vs67%vs20%)51Embolicmateri