脑小血管病概念与治疗

脑小血管病——概念与治疗2014.11.15脑小血管注射硫酸钡的标本。白质中央血管密度低。Salamon,N.,Neuroimagingofcerebralsmallvesseldisease.BrainPathol,2014.24(5):p.519-24.脑小血管注射硫酸钡的标本。供应胼胝体的小分支。Salamon,N.,Neuroimagingofcerebralsmallvesseldisease.BrainPathol,2014.24(5):p.519-24.脑小血管病的分类急性：卒中慢性：痴呆腔隙综合征腔隙综合征(1)纯运动性轻偏瘫(PMH)最常见。病灶可发生在内囊、脑桥、大脑脚、基底节、大脑皮质、放射冠等处。(2)纯感觉性卒中(PSS)病灶位于丘脑腹后核，通常为大脑后动脉的丘脑穿通支梗死所致。少数病例可由脊髓丘脑束、丘脑皮质束的病灶所致，也可因病灶侵及整个丘脑的外侧及内囊后肢的放射冠而引起。(3)感觉运动性卒中(SMS)病灶位于丘脑腹后外侧核和内囊后肢，通常由大脑后动脉的丘脑穿通支或脉络膜后动脉闭塞所致。(4)共济失调轻偏瘫(HAH)病灶发生在脑桥基底部或内囊，放射冠、小脑等处也可发生。(5)构音不良-手笨拙综合征(DHS)病灶位于脑桥基底部的上1/3和2/3交界处或内囊最上部分的膝部。脑小血管病的分类微出血血管周围间隙扩大白质疏松腔隙MR表现Wardlaw,J.M.,etal.,Neuroimagingstandardsforresearchintosmallvesseldiseaseanditscontributiontoageingandneurodegeneration.TheLancetNeurology,2013.12(8):p.822-838.急性腔梗的1年演变Wardlaw,J.M.,C.Smith,andM.Dichgans,Mechanismsofsporadiccerebralsmallvesseldisease:insightsfromneuroimaging.LancetNeurol,2013.12(5):p.483-97.腔隙常在白质高信号边缘Duering,M.,etal.,Incidentlacunespreferentiallylocalizetotheedgeofwhitematterhyperintensities:insightsintothepathophysiologyofcerebralsmallvesseldisease.Brain,2013.136(Pt9):p.2717-26.一名75岁男性，短暂性神经症状发作后1周出现症状性左侧额叶出血Charidimou,A.,J.C.Baron,andD.J.Werring,Transientfocalneurologicalepisodes,cerebralamyloidangiopathy,andintracerebralhemorrhagerisk:lookingbeyondTIAs.IntJStroke,2013.8(2):p.105-8.SVDscore(range0–4)男性(OR1.58,95%CI1.10–2.29),高血压(OR1.50,95%CI1.02–2.20),吸烟(OR2.81,95%CI1.59–3.63),腔隙性卒中(OR2.45,95%CI1.70–3.54)与SVDScore相关.脑萎缩与SVDScore无关Staals,J.,etal.,Strokesubtype,vascularriskfactors,andtotalMRIbrainsmall-vesseldiseaseburden.Neurology,2014.83(14):p.1228-34.脑小血管病的分类动脉硬化性血管炎遗传性肿瘤性感染性药物相关性一名CADASIL（伴皮质下梗死和脑白质病的常染色体显性遗传性脑动脉病）患者56岁和66岁的影像Salamon,N.,Neuroimagingofcerebralsmallvesseldisease.BrainPathol,2014.24(5):p.519-24.一名66岁的女性CADASIL患者Salamon,N.,Neuroimagingofcerebralsmallvesseldisease.BrainPathol,2014.24(5):p.519-24.COL4A1突变47岁无症状COL4A1突变患者（A,C,E,G,I,J）。57岁CADASIL患者。一名HERNS(伴有视网膜病-肾病-卒中的遗传性内皮细胞病)患者早期曾被误诊为多发性硬化Salamon,N.,Neuroimagingofcerebralsmallvesseldisease.BrainPathol,2014.24(5):p.519-24.一名HERNS患者的影像早期有占位效应和强化。Salamon,N.,Neuroimagingofcerebralsmallvesseldisease.BrainPathol,2014.24(5):p.519-24.19一名Susac综合征（脑病，视网膜小动脉闭塞，听力丧失）患者的胼胝体中部病灶Salamon,N.,Neuroimagingofcerebralsmallvesseldisease.BrainPathol,2014.24(5):p.519-24.7T75岁，男性。动脉，静脉vanVeluw,S.J.,etal.,Highresolutionimagingofcerebralsmallvesseldiseasewith7TMRI.ActaNeurochirSuppl,2014.119:p.125-30.7Ta.58岁，男，一过性黑矇，栓塞，基底动脉高信号。b.49岁，男，反复TIA，动脉粥样硬化，颈内动脉末端高信号。c.66岁，女，血管周围间隙。d.19岁，男，非扩大的血管周围间隙。vanVeluw,S.J.,etal.,Highresolutionimagingofcerebralsmallvesseldiseasewith7TMRI.ActaNeurochirSuppl,2014.119:p.125-30.7TA.89岁，男性，7T。B.同一人，3T。C.42岁，男性，微出血。D.57岁，女性，房颤，突发失语、左侧轻瘫，心源性栓塞。vanVeluw,S.J.,etal.,Highresolutionimagingofcerebralsmallvesseldiseasewith7TMRI.ActaNeurochirSuppl,2014.119:p.125-30.深部梗死，大脑中动脉栓塞Moran,C.,T.G.Phan,andV.K.Srikanth,Cerebralsmallvesseldisease:areviewofclinical,radiological,andhistopathologicalphenotypes.IntJStroke,2012.7(1):p.36-46.孤立病灶Kim,J.T.,etal.,Lesionpatternsofsmalldeepinfarctshavedifferentclinicalandimagingcharacteristics.EurNeurol,2010.63(6):p.343-9.线性病灶Kim,J.T.,etal.,Lesionpatternsofsmalldeepinfarctshavedifferentclinicalandimagingcharacteristics.EurNeurol,2010.63(6):p.343-9.治疗腔隙性卒中A.纹状体内囊卒中B.丘脑卒中：丘脑结节动脉膝状体动脉脉络膜后动脉旁正中动脉C.脉络膜前动脉D.髓质穿支JNeurol(2014)261:405–411小血管病A-C.75岁，男性，共济失调轻偏瘫，4分。未溶栓。核磁显示内囊后肢病灶。出院时遗留左下肢轻瘫，1分。D-E.55岁，男性，感觉运动性轻偏瘫，5分。溶栓。复查CT显示内囊后肢病灶。出院时遗留右下肢轻瘫，1分。Pantoni,L.,F.Fierini,andA.Poggesi,Thrombolysisinacutestrokepatientswithcerebralsmallvesseldisease.CerebrovascDis,2014.37(1):p.5-13.3个月结局JNeurol(2014)261:405–411SPS3随机析因设计抗血小板治疗阿司匹林＋安慰剂阿司匹林＋氯吡格雷降低血压治疗常规（收缩压130－149mmHg)强化（收缩压130mmHg)SPS3设计要点主要终点所有卒中复发次要终点认知下降大血管事件／死亡终点事件样本量•8个国家81家医疗中心•3020例•平均随访3.7年•失访率3％SPS3结论谢谢大家！