脑血管病-1.ppt

脑脑 血血 管管 疾疾 病病 cerebrovascular diseases中南大学湘雅医院神经内科中南大学湘雅医院神经内科中南大学湘雅医院神经内科中南大学湘雅医院神经内科 谷文萍谷文萍谷文萍谷文萍Wenping Gu,MD.PhD.Neurology Wenping Gu,MD.PhD.Neurology Department,Xiangya Hospital,central Department,Xiangya Hospital,central south Universitysouth University第一页，共七十页。脑血管疾病脑血管疾病(jbng)(jbng)Cerebrovascular Diseases，CVDCVDn n在脑血管病变基础在脑血管病变基础(jch(jch)上发生的局限性或弥漫性脑功能上发生的局限性或弥漫性脑功能障碍障碍 the cerebral diseases that are resulted from the cerebral diseases that are resulted from various cerebrovascular diseasesvarious cerebrovascular diseases第二页，共七十页。第三页，共七十页。第四页，共七十页。急性急性(jxng)(jxng)脑血管疾病分类脑血管疾病分类classification of acute cerebrovascular diseasesclassification of acute cerebrovascular diseasesn n短暂性脑缺血发作短暂性脑缺血发作（transient ischemic attacktransient ischemic attack，TIATIA）n n颈动脉系统颈动脉系统(xt(xt ng)ng)internal carotid artery systeminternal carotid artery system TIATIAn n椎基底动脉系统椎基底动脉系统basilar-vertebral artery system TIAbasilar-vertebral artery system TIAn n脑卒中脑卒中（stroke,apoplexy,cerebrovascular accidentstroke,apoplexy,cerebrovascular accident）n n蛛网膜下腔出血（蛛网膜下腔出血（subarachnoid hemorrhagesubarachnoid hemorrhage）n n脑出血（脑出血（intracerebral hemorrhage,ICHintracerebral hemorrhage,ICH）n n脑梗死脑梗死 (cerebral infarction)(cerebral infarction)n n动脉粥样硬化性血栓性脑梗死动脉粥样硬化性血栓性脑梗死 (arterothrombotic cerebral infarction)(arterothrombotic cerebral infarction)n n脑栓塞脑栓塞(cerebral embolism)(cerebral embolism)n n腔隙性脑梗死腔隙性脑梗死(lacunar infarction),(lacunar infarction),等等第五页，共七十页。其他其他(qt)(qt)分类脑血管疾病分类脑血管疾病 other classification of cerebrovascular diseasesn n椎基底动脉供血不足（椎基底动脉供血不足（Vertebrobasilar arterial insufficiencyVertebrobasilar arterial insufficiency）n n脑血管性痴呆脑血管性痴呆(chdi)(chdi)（cerebral vascular dementia）n n高血压脑病（高血压脑病（hypertensive encephalopathyhypertensive encephalopathy）n n颅内动脉瘤（颅内动脉瘤（intracranial aneurysm）n n颅内血管畸形（颅内血管畸形（intracranial vascular malformation）n n脑动脉炎（脑动脉炎（cerebral arteritis）n n颅内静脉、静脉窦血栓形成（颅内静脉、静脉窦血栓形成（thrombosis of venous sinus）n n颅外段动、静脉疾病颅外段动、静脉疾病n n其他动脉疾病其他动脉疾病(other arterial diseases)(other arterial diseases)第六页，共七十页。脑的血液循环脑的血液循环(xu y xn hun)(xu y xn hun)blood circulation of cerebullar颈内动脉颈内动脉(dngmi)系统系统(internal carotid artery system)椎基底椎基底(j d)动动系统系统(basilar-vertebral artery脑组织脑组织(brain tissue)静脉系统静脉系统(vein system)静脉窦静脉窦(vein sinuses)颈内静脉(internal carotid vein)第七页，共七十页。颈内动脉颈内动脉(dngmi)(dngmi)系统系统internal carotid artery systeminternal carotid artery systemn n眼动脉眼动脉(dngmi)(dngmi)(ophthalmic(ophthalmic arteryarteryn n后交通动脉后交通动脉(posterior(posterior communicating artery)communicating artery)n n脉络前动脉脉络前动脉(anterior(anterior choroidal artery)choroidal artery)n n大脑前动脉大脑前动脉(anterior(anterior cerebral artery)cerebral artery)n n大脑中动脉(middle cerebral artery)第八页，共七十页。椎椎-基底基底(j d(j d)动脉系统动脉系统vertebrobasilar circulationvertebrobasilar circulationn n椎动脉vertebral arteryn n基底动脉基底动脉(dngmi)(dngmi)basilar arteryn n大脑后动脉大脑后动脉posterior cerebral artery第九页，共七十页。脑的供血区域脑的供血区域(qy)(qy)n n颈内动脉系统颈内动脉系统(internal carotid(internal carotid artery)artery)n n又称前循环又称前循环,供应额、颞、顶叶供应额、颞、顶叶和基底核等大脑半球前和基底核等大脑半球前3/53/5血血流流n nprovide the blood of frontal provide the blood of frontal lobe,temporal lobe and parietal lobe,et lobe,temporal lobe and parietal lobe,et al aln n椎椎-基底动脉系统（基底动脉系统（basilar-basilar-vetebral artery)vetebral artery)n n又称后循环，供应小脑、脑干、丘又称后循环，供应小脑、脑干、丘脑脑(qin(qin o)o)和枕、颞叶等大脑半球和枕、颞叶等大脑半球后后2/52/5血液血液 n nprovide the blood of cerebellum,brain provide the blood of cerebellum,brain stem,cerebral ganglion,occipital lobe,stem,cerebral ganglion,occipital lobe,第十页，共七十页。脑动脉细小脑动脉细小(xxi(xxi o)o)分支分支n n穿通支穿通支（perforating branch）间脑间脑(diencephalon)(diencephalon)、纹状体、纹状体(corpus(corpus striatum)striatum)、内囊、内囊(internal capsule)(internal capsule)、脑干基底部中线脑干基底部中线(zhngxin)(zhngxin)旁结构旁结构n n皮质支皮质支（cortical branch）大脑半球皮质及皮质下白质与脑干的背外侧脑底动脉脑底动脉脑底动脉脑底动脉(dngmi)(dngmi)环环环环大脑中动脉近端大脑中动脉近端大脑中动脉近端大脑中动脉近端基底动脉基底动脉基底动脉基底动脉 第十一页，共七十页。第十二页，共七十页。第十三页，共七十页。脑动脉脑动脉(dngmi)(dngmi)侧支循环侧支循环compensatory circulationcompensatory circulationn nWillisWillis环环n n双侧颈内动脉双侧颈内动脉(dngmi)(dngmi)internal carotic arteyinternal carotic arteyn n双侧大脑前动脉双侧大脑前动脉 anterior cerebral arteyanterior cerebral arteyn n双侧大脑后动脉双侧大脑后动脉 posterior cerebral arteryposterior cerebral arteryn n前交通动脉前交通动脉 anterior communicating arteryanterior communicating arteryn n双侧后交通动脉双侧后交通动脉 posterior communicating arteryposterior communicating artery第十四页，共七十页。其他其他(qt)(qt)侧支循环侧支循环(other other compensatory circulation)compensatory circulation)n n大脑前、中、后动脉皮质支在大脑表面彼此(b(b c c)交通n n颈内、外动脉围绕眼耳、鼻、的深浅分支互相吻合n n大脑动脉皮质支与来自颈外动脉的脑膜动脉分支也存在丰富的侧支吻合n n分水岭脑梗死cerebral watershed infarctioncerebral watershed infarction第十五页，共七十页。脑的静脉脑的静脉(jngmi)(jngmi)(cerebral veins)大脑大脑(dno)上静脉上静脉大脑中静脉大脑中静脉大脑下静脉大脑下静脉superior,middle,inferior cerebral veins上矢状窦上矢状窦Superior sagittal sinus海绵海绵(himin)窦窦sinus横窦横窦Transverse sinus大脑大大脑大静脉静脉Great cerebral vein直窦直窦Straight sinus颈内静脉颈内静脉Internal carotidvein已状窦已状窦Sigmoid sinus下矢状窦下矢状窦Inferior sagittal sinus大脑镰静脉大脑镰静脉Falx cerebral vein第十六页，共七十页。脑血流及其调节脑血流及其调节(tioji)(tioji)blood circulation regulation 脑血供丰富。在正常情况下，脑血流量（CBF）具有自动调节作用：CBF=（MAP-ICP）r4/（8L）。在缺血或缺氧的病理状态下，脑血管的自动调节机制紊乱，血管扩张或反应异常，脑水肿和颅内压升高(shn o)，就会出现缺血区的充血和过度灌注或脑内盗血现象In the normal conditions,cerebral blood flow can autoregulate.CBF can increase while cerebral perfusion pressure rises and cerebrovascular resistance is decreased.In the ischemic and hypoxic pathologic behavior,the autoregulation mechanisms disorder,blood vessels ectasia or response abnormality,cerebral edema and intracranial pressure will rise,so it appears hyperemia and superperfusion or cerebral steal phenomenon in the ischemic region第十七页，共七十页。脑卒中脑卒中(Stroke)n n发病率、死亡率、致残率均高n n与心脏病、恶性肿瘤构成人类三大致死病因n n不但危害中老年人健康，而且发病有年轻化趋势n n给社会和家庭带来沉重(chnzhng)(chnzhng)的负担n nmorbidity,mortality and mutilation rate of stroke are high第十八页，共七十页。流行病学流行病学(li xn(li xn bn bn xu)xu)epidemiologyn n我国城市脑血管病的年发病率、死亡率和时点(sh(sh di di n)n)患病率分别为219/10 万、116/10 万和719/10 万n n农村地区分别为185/10 万、142/10 万和394/10 万第十九页，共七十页。n n在对脑卒中进行有效治疗的同时积极开展针对脑血管疾病危险因素的预防预防更加(gnji)(gnji)重要n nthe preservation of the risk factors is more important than the treatment of stroke第二十页，共七十页。分类分类(fn li)(fn li)classification n n一级预防：防发生n nfirst-level prevention:prevent occurrencen n二级预防：防复发n nsecond-level prevention:prevent recidivationn n三级预防：发病(f bng)(f bng)后治疗n nthird-level prevention:the therapy after morbility第二十一页，共七十页。一级预防一级预防(primary prevention)n n指发病(f bng)(f bng)前的预防，即通过早期改变不健康的生活方式，积极主动地控制各种危险因素，从而达到脑卒中不发生或推迟发病年龄的目的第二十二页，共七十页。脑卒中危险脑卒中危险(wixi(wixi n)n)因素因素risk factors n n可干预性可干预性may intervene：高血压：高血压(hypertension)hypertension)、心脏、心脏病病(heart dieases)heart dieases)、糖尿病、糖尿病(diabetes)diabetes)、血脂异常(hyperlipemia)hyperlipemia)、高同型半胱氨酸血症、短暂性脑缺血发、高同型半胱氨酸血症、短暂性脑缺血发作作(historic stroke)、吸烟、吸烟(smoking)smoking)、酗酒(heavy heavy alcohol consumption)alcohol consumption)、肥胖、无症状性劲动脉狭窄、口服避孕药物、肺炎衣原体感染(g(g nrnr n)n)、情绪应激、抗凝治疗等n n不可干预性non-interventionnon-intervention ：年龄、性别、种族、遗传：年龄、性别、种族、遗传因素等因素等第二十三页，共七十页。二级预防二级预防(yfng)(yfng)(secondary prevention)n n是针对发生过一次或多次脑卒中的患者，通过寻找卒中事件发生的原因，纠正(jizhng)(jizhng)所有可干预的危险因素，达到降低卒中复发危险性的目的n n二级预防主要是防止中风复发第二十四页，共七十页。脑卒中主要症状和体征脑卒中主要症状和体征sings and symptomsn n起病突然(onste suddenly)n n全脑症状(whole brain symptom)n n局灶性症状和体征(focal sings and symptoms)n n颈内动脉系统颈内动脉系统(xt(xtng)ng)表现表现(internal carotid artery)(internal carotid artery)n n椎-基底动脉系统表现基底动脉系统表现 (basilar-vetebral artery)(basilar-vetebral artery)n n脑膜刺激征脑膜刺激征 (meningeal irritation sign)meningeal irritation sign)第二十五页，共七十页。短暂性脑缺血发作(fzu)(fzu)transient ischemic attack第二十六页，共七十页。短暂性脑缺血发作短暂性脑缺血发作(fzu)transient ischemic attack,TIAn n脑动脉一过性供血不足脑动脉一过性供血不足(bz)(bz)transient insufficiency of blood in cerebral arteriesn n短暂发作短暂发作 transient attack transient attackn n局灶性脑功能障碍局灶性脑功能障碍 focal brain disordern n24小时内完全恢复 complete recovery in 24 hoursn n可反复发作可反复发作 recurrent attacks第二十七页，共七十页。病因病因(bngyn)和发病机制和发病机制etiopathogenisis and pathogenesyn n微栓塞 microembolism microembolismn n脑血管痉挛、狭窄或受压 cerebrovascular spasm cerebrovascular spasmn n血流动力学改变hemodynamics disordershemodynamics disordersn n血压血压(xuy)(xuy)、血液成分改变、血液成分改变blood compotents disordersn n其他 others 第二十八页，共七十页。临床表现临床表现clinical clinical situationsituationn n5050岁岁 patients older than 50,patients older than 50,n n常伴有动脉硬化、高血压、糖尿病、冠心病等常伴有动脉硬化、高血压、糖尿病、冠心病等 accomply with accomply with angiosclerosis,hypertension,diabetes,coronary artery diseasen n发病突然，迅速出现局限性神经功能障碍发病突然，迅速出现局限性神经功能障碍 acute onset of a neurologic deficitacute onset of a neurologic deficitn n持续时间短持续时间短 ，2424小时小时(xi(xi osh)osh)neurologic deficit persists for less 24 hoursneurologic deficit persists for less 24 hoursn n不留后遗症不留后遗症 no residualno residualn n可反复发作可反复发作 recurrent attacks第二十九页，共七十页。颈内动脉颈内动脉(dngmi)(dngmi)系统系统TIA TIA of internal carotid arteryTIA of internal carotid arteryn n短暂性偏侧或单肢无力短暂性偏侧或单肢无力 transient hemiparesis transient hemiparesisn n面部面部(min b)(min b)、单肢或偏身麻木、单肢或偏身麻木 hemisensory disturbancesn n同向偏盲或单眼一过性失明同向偏盲或单眼一过性失明 homonymous hemianopia or transient homonymous hemianopia or transient ocellanae acroisan n失语失语 aphasia第三十页，共七十页。椎椎基底动脉基底动脉(dngmi)(dngmi)系统系统TIATIA of vertebrobasilar circulationn n眩晕（vertigo）、复视(f sh)(f sh)（diplopia）、吞咽困难（acataposis）、共济失调（ataxia）n n交叉性瘫痪（crossed paralysis）n n跌倒发作（drop attack）、短暂全面性遗忘症（transient global amnesia TGA）、双眼视力障碍发作（the onset of binocular vision disorders）第三十一页，共七十页。诊断诊断(zhndun)(zhndun)approach to diagnosisapproach to diagnosisn n中老年患者 senior seniorn n突然(trn)(trn)出现局限性神经功能障碍 acute onset of a neurologic deficitn n2424小时完全恢复 complete recovery in 24 hoursn nCTCT、MRIMRI（）n nTCDTCD监测监测第三十二页，共七十页。鉴别鉴别(jinbi)(jinbi)诊断诊断differential diagnosisdifferential diagnosisn n部分(b fen)(b fen)性癫痫（part epilepsy）n n梅尼埃病（Meniere disease）n n颅内占位性病变（intracranial spaceoccupying lesion）第三十三页，共七十页。治疗治疗(zhlio)(zhlio)treatmenttreatmentn药物治疗(drug treatment)n抗血小板聚集(jj)(antiplatelet therapy)nAsprin 50150mg，po，Qdn噻氯匹定（ticlopidine)n氯吡格雷(clopidogrel)n双嘧达莫(dipyridamole,DPA)n奥扎格雷(ozagrel)80mg，ivgtt，bidn抗凝(anticoagulation)n肝素(heparin)100mg+5%葡萄糖500ml，ivgtt，1020滴/minn低分子肝素(low molecular weight heparin)4000IU，腹壁皮下注射，bidnWarfarin n钙拮抗剂：尼莫地平、盐酸氟桂嗪（nimodipine、flunarizine）n其他（others）n中药治疗（tranditional medicine treatment）n扩血管治疗：罂粟碱、倍他司丁、烟酸（papaverine、betahistine、nicotinic acid）第三十四页，共七十页。治疗治疗(zhlio)(zhlio)treatmenttreatmentn n病因治疗病因治疗(etilogical treatment)n n手术治疗(surgery)(surgery)n n管腔狭窄管腔狭窄70%70%，伴反复，伴反复TIATIA，可考虑，可考虑(k(k ol ol)介入治疗或颈动介入治疗或颈动脉内膜剥除术脉内膜剥除术第三十五页，共七十页。预后预后(yhu)(yhu)prognosisn n脑梗死 cerebral infarctionn n反复发作(fzu)(fzu)recurrent attacksn n自行缓解 release without treatment第三十六页，共七十页。缺血性脑卒中缺血性脑卒中cerebral ischemic stroke第三十七页，共七十页。缺血性脑卒中缺血性脑卒中cerebral ischemic stroke,CIScerebral ischemic stroke,CISn n由于脑部血液供应障碍由于脑部血液供应障碍(zhng i)(zhng i)，缺血、缺氧引起的局限，缺血、缺氧引起的局限性脑组织的缺血性坏死或脑软化性脑组织的缺血性坏死或脑软化n n又称脑梗死（又称脑梗死（cerebral infarction,CI),临床常见类型有动脉粥样硬化性血栓性脑梗死、脑栓塞和腔隙性梗死等。脑梗死约占全部脑卒中的8080n nCerebral ischemic stroke is again called cerebral infarction,Cerebral ischemic stroke is again called cerebral infarction,which is caused by insufficient inflow of blood ,then ischemia which is caused by insufficient inflow of blood ,then ischemia and hypoxia cause local cerebral tissueand hypoxia cause local cerebral tissue s ischemic necrosis or s ischemic necrosis or encephalomalaciaencephalomalacia 第三十八页，共七十页。动脉动脉(dngmi)(dngmi)粥样硬化性血栓性脑梗死粥样硬化性血栓性脑梗死arterothrombotic cerebral infarctionarterothrombotic cerebral infarctionn n通常是指脑动脉的主干或其皮层支因动脉粥样硬化等血管病变通常是指脑动脉的主干或其皮层支因动脉粥样硬化等血管病变(bngbin)(bngbin)，导致的官腔狭窄或闭塞并进而发生学栓形成，造成脑局部，导致的官腔狭窄或闭塞并进而发生学栓形成，造成脑局部供血区血流中断，发生脑组织缺血、缺氧、软化坏死，出现相应的神供血区血流中断，发生脑组织缺血、缺氧、软化坏死，出现相应的神经系统症状和体征经系统症状和体征n nthe vessel diseases are caused by cerebral arterial stemsthe vessel diseases are caused by cerebral arterial stems or its cortex or its cortex branchesbranches atherosclerosis and various arteritis,which cause vessel atherosclerosis and various arteritis,which cause vessel constriction or emphraxis and then form thrombosis and local constriction or emphraxis and then form thrombosis and local blood flow breaks.So cerebral tissue ischemia,hypoxia,softening blood flow breaks.So cerebral tissue ischemia,hypoxia,softening and necrosis,which cause corresponding nervous system symptoms and necrosis,which cause corresponding nervous system symptoms and signs.and signs.第三十九页，共七十页。病因病因(bngyn)(bngyn)etiopathogenisisn n脑动脉粥样硬化脑动脉粥样硬化c cerebral atherosclerosisn n高血压高血压 hypertensionn n糖尿病糖尿病 diabetes n n血脂异常血脂异常hyperlipemiahyperlipemian n脑动脉炎脑动脉炎cerebral arteritis n n结缔组织疾病结缔组织疾病connective tissue diseasesn n先天性血管畸形先天性血管畸形congenital vascular malformationcongenital vascular malformationn n真性红细胞增多真性红细胞增多(zn(zn du)du)症症polycythemia rubra verapolycythemia rubra veran n血高凝状态血高凝状态hypercoagulabale state hypercoagulabale state n n血小板增多症血小板增多症thrombocythemia thrombocythemia 第四十页，共七十页。发病发病(f bng)(f bng)机制机制nosogenesisnosogenesisn n脑梗死脑梗死(cerebral infarction)灶形成机制灶形成机制n n脑血流障碍脑血流障碍(cerebral blood flow disorder)(cerebral blood flow disorder)n n神经细胞缺血性损害神经细胞缺血性损害(nerve cell ischemia damage)(nerve cell ischemia damage)n n能量代谢障碍能量代谢障碍(energy metabolism disorder)(energy metabolism disorder)和酸中毒和酸中毒(acidosis)(acidosis)n n兴奋性氨基酸（兴奋性氨基酸（excitatory amino acid)excitatory amino acid)毒性和钙超载毒性和钙超载(calcium overload)(calcium overload)n n磷脂降解磷脂降解(phospholipid degradation)(phospholipid degradation)和脂类介导的毒性作用和脂类介导的毒性作用n n自由基自由基(free radical)(free radical)损伤损伤n n缺血性脑水肿缺血性脑水肿(ischemic brain edema)(ischemic brain edema)n n一氧化碳一氧化碳(nitric oxide)(nitric oxide)毒性毒性n n即早基因即早基因(jyn)(jyn)(immediate early genes)(immediate early genes)、神经营养因子、神经营养因子(neurotrophic(neurotrophic factors)factors)和热休克蛋白和热休克蛋白(heat shock protein)(heat shock protein)等基因表达改变等基因表达改变n n细胞因子细胞因子第四十一页，共七十页。再灌注再灌注(gunzh)(gunzh)时间窗时间窗reperfusion time windowreperfusion time windown n超早期治疗的关键是抢救缺血半暗带，采取脑保护措施减超早期治疗的关键是抢救缺血半暗带，采取脑保护措施减轻再灌注轻再灌注(gunzh)(gunzh)损伤，目前普遍把脑缺血的超早期治疗时损伤，目前普遍把脑缺血的超早期治疗时间窗定为间窗定为6小时之内小时之内n nThe key to therapy is to salvage ischemic penumbra in the The key to therapy is to salvage ischemic penumbra in the ultra-earlier period and take actions to reduce reperfusion ultra-earlier period and take actions to reduce reperfusion damadge.At present,cerebral ischemic therapy time window damadge.At present,cerebral ischemic therapy time window in the ultra-earlier period is settled within 6 hoursin the ultra-earlier period is settled within 6 hours第四十二页，共七十页。临床表现临床表现clinical manifestationclinical manifestationn n老年人(senior)n n有动脉粥样硬化、高血压、糖尿病或冠心病史(with angiosclerosis,hypertension,diabetes,coronary artery disease)n n常在安静或睡眠(shumin)(shumin)中起病(onset at quiet or sleep)n n一般无头痛、呕吐、昏迷等全脑症状(no headache、vomit、coma）第四十三页，共七十页。颈内动脉颈内动脉(dngmi)(dngmi)系统脑梗死临床表现系统脑梗死临床表现(clinical manifestation)(clinical manifestation)n n颈内动脉血栓形成颈内动脉血栓形成(xngchng)(xngchng)（internal carotid artery internal carotid artery thrombosisthrombosis）n n大脑中动脉血栓形成大脑中动脉血栓形成(middle cerebral artery thrombosis)n n大脑前动脉血栓形成大脑前动脉血栓形成(anterior cerebral artery thrombosis)第四十四页，共七十页。第四十五页，共七十页。第四十六页，共七十页。椎椎-基底基底(j d(j d)动脉系统脑梗死动脉系统脑梗死(basilar-vetebral artery system infarction)n n大脑后动脉血栓形成(posterior cerebral artery thrombosis)n n椎动脉血栓形成(vetebral artery thrombosis)n n延髓背外侧延髓背外侧(wi c)(wi c)综合征综合征(Wallenberg syndrome)(Wallenberg syndrome)n n基底动脉血栓形成(basilar artery thrombosis)n n脑桥腹外侧综合征脑桥腹