1、Cerebrovascular Diseases,Xue QunDepartment of NeurologyThe First Affiliated Hospital of Soochow University,第一节,outline（ 概述 ）,key concepts,Cerebrovascular diseases: the focal or diffused function disorders of the brain , on the basic disorder of the cerebral vascular wall or of the blood flowType:Acc
2、ute:TIA (transient ischemic attack)Stroke Chronic:Cerebrovascular dementia,Stroke（apoplexy/cerebrovascular accident）: a syndrome characterized by the acute onset of a neurologic deficit that persists for at least 24 hours, reflects focal involvement of the central nervous system, and is the result o
3、f a disturbance of the cerebral circulation. Types: ischemia : local thrombosis or embolization from a distant site hemorrhage：,Stroke,ischemia : Cerebral ischemic stroke (cerebral infarction) arterothrombotic infarctionCerebral embolismLacunar infarctionhemorrhage： Cerebral hemorrhage Subarachnoid
4、hemorrhage,Territories of the principal cerebral arteries,Anterior circulationInternal carotid arteryOphthalmic arteryposterior communicating arteryAnterior choroidal artery (hippocampus, globus pallidus, lower internal capsule)Anterior cerebral artery(medial frontal 额叶and parietal 顶叶cortex and subj
5、acent white matter,anterior corpus callosum胼胝体)Middle cerebral artery(lateral frontal, parietal , occipital,and temporal 颞叶cortex and subjacent white matter) Lenticulostriate branches (caudate nucleus尾状核, putamen壳核, upper internal capsule),Territories of the principal cerebral arteries,Posterior cir
6、culationVertebral artery Posterior inferior cerebellar (medulla,lower cerebellium)Basilar artery Anterior inferior cerebllar(lower and midpons, mid cerebellium) Superior cerebellar (upper pons,lower mid cerebellum) Posterior cereballar (medial occipital and temporal cortex and subjacent white matter
7、,posterrior corpus callosum胼胝体,upper midbrain)Thalamoperforate branches丘脑穿通动脉(thalamus)Thalamogeniculate branches丘脑膝状体动脉 (thalamus),Pathology, physiology and blood circulation regulation,Weight of brain is 1.5kg , about 23%of body weightCBF 7501000ml/min (CBFCPP/CVR) Cerebral blood flow cerebral per
8、fusion pressure / cerebral vascular resistance CBF=(MAC-ICP)r4/(8*L) MAC(平均动脉压)，ICP（颅内压), r (caliber管径)， （blood viscosity血黏度），L（血管长度）,第二节Epidemiology and prevention(流行病学和预防),Etiologic factors,Vascular disorders Atherosclerosis / inflamatory disorder/cerebral amyloidosis(淀粉样变)/ Vascular malformations
9、 /aneurysmCardiac and hemodynomics disordersMural thrombus / rheumatic heart disease/ arrhythmias / endocarditisHematologic disorders(blood constituent and hemorheology disorders)Hypercoagulable state / leukocytosis / thrombocytosis / polythemia(红细胞增多)others,Risk factors,HypertensionDiabetes mellitu
10、sCardiac disorderHyperhomocysteinemiaTIA or stroke historySmoking or alcohol abuseHyperlipemiaOthers: obesity, age, contraceptive（避孕）, high fibrinogen ,Primary prevention (一级预防),HypertensionCardiac disorderDiabetes mellitusHyperlipemiaSmoking or alcohol abuseWeight controlCarotid artery stenosisHype
11、rhomocysteinemia (16umol/l)high fibrinogenExercise, diet,Secondary prevention (二级预防),Hypertension, Cardiac disorder, Diabetes mellitus, Hyperlipemia,Smoking or alcohol abuse, Weight control, Carotid artery stenosis, Hyperhomocysteinemia (16umol/l), high fibrinogen, Exercise, dietAnti-platelet aggreg
12、ationpost-stroke cognitive handicap intervention post-stroke depression intervention,第三节transient ischemic attack （短暂性脑缺血发作）,transient ischemic attack (TIA),Transient, repeatedly, episode（发作性）,Last a few minutes 1 hour, often completely recover within 30min,never last over 24 hours, leave no symptom
13、 , physical sign or sequela（后遗症）,Etiological factors and pathogenesis,Mini-embolismCerebral vascular spasmBlood constituent and hemodynamic（血液动力学） alterationOthers: vasculitis, cervical syndrome,（颈椎病）,Clinical situation,Middle-age or senium, malefemale,Company with hypertension, diabetes, cardiac di
14、sease, hyperlipemiaAcute onset, usually reach to the peak within 5min, recover within 30min,never last over 24 hours, leave no symptom , physical sign or sequelaRelative fixed symptom,relapse,Clinical situation,Internal carotid artery TIAOphthalmic artery crossing paralysisHorner sign crossing paral
15、ysisAphasia失语( dominant hemisphere)Vertebral-Basilar artery TIADrop attack: reticular formation of brain stem (脑干网状结构)Transient global amnesiaBinocular vision disorder attack（双眼视力障碍）vertigo(眩晕), nausea(恶心),vomiting(呕吐), diplopia(复视),dysequilibrium(平衡失调), dysphagia(吞咽困难),Diagnosis,Case historyPlatele
16、t counting and aggregation rateBlood sugar and blood lipid on an empty stomachProthrombin time and partial thromboplastin timeErythrocyte sedimentation（血沉）EEG,TCDCT,MRA,CTA,DSA,differential diagnosis,Partial epilepsiaMenieres diseaseCardiac disorderRIND(reversible ischemic neurologic deficit)Migrain
17、e headache( 偏头痛)Tumor,treatment,Etiological treatmentProphylactic drugs(预防用药)Anti-platelet aggregation drugsAnticoagulant drugsBrain conservancySurgery prognosis,第四节 cerebral infarction （脑梗死）,cerebral infarction,Prolonged interruption of blood flow leads to irreversible injury and persistent neurolo
18、gic deficitsclinic category RIND(reversible ischemic neurologic deficit):3wProgressive ischemic stroke :6h2wCompleted ischemic stroke:6hPathologic categoryAtherothrombotic cerebral infarction (artery to artery embolism/thromboembolism & cerebral thrombosis)Cerebral embolismLacunar infarctionCerebral
19、 watershed infarction,Part one,Atherothrombotic cerebral infarction,Arterothrombotic cerebral infarction,Thrombus forms in the artery basing on the cerebral atherosclerosis or other disorder of the vascular wall, leads to the prolonged interruption of blood flow , irreversible injury and persistent
20、neurological deficits.etiologic factorCerebral atherosclerosis,PathogenesisEndothelial injuryadherence of monocyto/macrophages/T-lymphocytemigration and subendothelial localization of the cellsformation of platelet thrombusproliferative lesion (fibrous plaque)Energy,excitatory amino acid,calcium ove
21、rload, ischemic cerebral edema,nitric oxide,immediate early genes, neurotrophic factors,heat shock protein, CK, apoptosisIschemic penumbra(缺血半暗带)CBF20 ml/100g.min electric failure thresholdCBF10 ml/100g.min membrane failure thresholdReperfusion damage,hemorrhagic infarctionTTW (therapeutic time wind
22、ow), RTW (reperfusion time window), CTW (cytoprotective time window)Pathology,Clinical findings,elder person with atherosclerosis, hypertension,diabetes,cardiac disorderStepwise incremental neurologic deficitsAssociated symptoms(often without seizures,headache,vomiting,dementia)In quiet status,Inter
23、nal carotid artery,SyndromeTransient monocular blindness(retinal artery ischemia)the severity is highly variableSymptomatic similar to the MCA occlusion or asymptomatic,Middle cereberal artery occlusion,Anatomy: supplies most of the cerebral hemisphere and deep subcortical structuressuperior divisio
24、n: the entire motor and sensory cortical representation of the face,hand, and arm;and the expressive language area of the dominant hemisphere; inferior division: the visual radiations,the region of visual cortex related to macular vision; the receptive language area of the dominant hemispherelenticu
25、lostriate branches:the basal ganglia and the posterior limb of the internal capsule (the motor fibers related to the face,hand, arm, and leg),Middle cereberal artery occlusion,Syndrome:superior division stroke: contralateral hemiparesis that affects the face, hand, and arm but spares the legContrala
26、teral hemisensory deficit in the same distributionNo homonymose hemianopia(偏盲）Brocars aphasia ( the dominant hemisphere is involved), which is characterized by impairment of language expression with intact comprehension,Middle cereberal artery occlusion,Syndrome:Inferior division stroke:Contralatera
27、l homonymose hemianopia ,may be denser inferiorlyImpairment of cortical sensory functionsDisorders of spatial thoughtWernickes aphasia(dominant hemisphere),manifested by impaired comprehension and fluent but often nonsensasiacal speechAcute confusional state(non domonant hemisphere),Middle cereberal
28、 artery occlusion,Syndrome:the bifurcation or trifurcation of MCAContalateral hemiparesis and hemisensory deficit involving the face and arm far more than the legHomonymous hemianopiaGlobal(dominant hemisphere) aphasia,characterized by combined expressive and receptive,Middle cerebral artery occlusi
29、on,Syndrome:the stem of MCAContalateral hemiparesis and hemisensory deficit involving the face ,hand,arm and the legHomonymous hemianopiaGlobal(dominant hemisphere) aphasia,anterior cerebral artery occlusion,Anatomy: supplies the parasagittal 矢状旁cerebral cortexincludes portions of motor and sensory
30、cortex related to the leg and micturition排尿 centerSyndrome: Contralateral paralysis and sensory loss affecting leg ,voluntary control of micturition may be impaired,Basilar Artery system,Anatomy:branches of BA supply the occipital and medial temporal ， medial thalamus, the posterior limb of the inte
31、rnal capsule,and the entire brain stem and cerebellumClinical syndromes:a serious event that is often incompatible with survival, produces bilateral neurologic signs referable to involvement of both vertebral artery (VA) or of a lone unpaired VA Ipsilateral cerebellar ataxia共济失调, vertigo, nausea, vo
32、miting, dysphagia吞咽困难,dysarthria构音障碍coma,constricted pupils, high temperature,locked in syndrome, hemiplegia or quadriplegia四肢瘫,even death,Basilar Artery system,Locked in syndrome:with basilar occlusion,the ventral portion of the pons (basis pontis) is infarcted and the tegmentum is spared,such pati
33、ents remain conscious but quadriplegic.They may open their eyes or move their eyes vertically on command.Weber syndrome: ipsilateral III nerve palsy, contralateral hemiparesisParinaud syndrome:unable to move eyes verticallyBenedikt syndrome: ipsilateral III nerve palsy, involuntary movement不自主运动 on
34、the contralateral,Basilar Artery system,Millard-Gubler syndrome: ipsilateral facial nerve, abducent nerve paralysis, contralateral hemiplagiaFoville syndrome: syntropy gaze paralysis to the focus, ipsilateral facial nerve, abducent nerve paralysis, contralateral hemiplagiaWallenberg syndrome: ipsila
35、teral cerebellar ataxia,Horners syndrome,facial sensory deficit;contrlateral impaired pain and temperature sensation; nystagus(眼震), vertigo，nausea, vomiting, dysphagia, dysarthria, and hiccupTop of the basilar artery syndrome: abnormal eye movement, pupil, consciousness and behavior, lose of remembe
36、rance, contralateral hemiablepsia or cortexablepsia,Posterior artery,Anatomy:supply the occipital cerebral cortex,medial temporal lob,thalamus,and rostral midbrain(中脑脚)Clinical syndrome:homonymous hemianopia affecting contralateral visual field,vertical gaze palsy; oculomotor nerve palsy,internuclea
37、r ophthalmoplegia,vertical skew deviation of the eyes;anomic aphasia,visual agnosia(失认)；cortical blindness,memory impairment,inability to recognize familiar things,exotonic visual and behavioral syndrome.,Investigative studies,Blood testsComplete blood count (to find possible cause of stroke as thro
38、mbocytosis, polycythemia, anemia,and leukocytosis)Erythrocyte sedimentation rate(血沉)（to detect giant cell arteritis or other vasculitides）Serologic assay for syphilis(梅毒)（FTA-ABS /CSF VDRL）Serum glucose (to detect hypoglycemia or hyperosmolar nonketotic hyperglycemia高渗性非酮症性高血糖)Serum cholesterol and
39、lipids,Investigative studies,Electrocardiaogram(to detect unrecognized myocardial infarction or cardiac arythmias, such as fibrillation)CT:low densityMRI:T1-weighted MRI scan shows decreases signal,T2 -weighted MRI scan shows increases signalLumbar puncture(腰穿) Cerebral angiographyUltrasonography /
40、transcranial doppler/ Echocardiography(心超)ElectroencephalogramSPECT，PET,Diagnosis and differential diagnosis,Onset and course: neurologic deficits progress over seconds to hours / occasionally days,happened in quiet status or in sleepDuration of deficits: persist for at least 24 hrRIND (almost compl
41、etely resolve in a few days, 220/120mmHg）Antiedema agents: mannitol, furosemideNeuroprotective agents: barbiturates,the opioid antagonist naloxone, calcium channel antagonists, excitatory amino acid receptor antagonistsSymptomatic treatment 对症治疗：blood pressure, temperature, hyperglycemia, pneumonia,
42、 bedsore, upper gastrointestinal hemorrhage, dysphagia, electrolyte disturbanceSurgeryconvalescent treatmentSecondary prevention,prognosis,Mortality 10%Multilation rate 50%about 40% patients who survived the acute period would recidivism,Part two,Cerebral embolism （脑栓塞）,Cerebral embolism,All kinds o
43、f emboli enter the cerebral vascular,break down blood flow,induce the district brain necrosis,and turn up relevant neurological deficiency.Etiological factors and pathogenesisCardiac genesis (70%)Mural thrombus(附壁血栓) / rheumatic heart disease/ arrhythmias （心律失常）/ endocarditisNon cardiac genesisFract
44、ure, cancer, airRed infarction(hemorrhagic infarction),Clinic finding,Onset : begin abruptly,usually within a few seconds or minutes, neurologic deficits may be maximal at onset, happened in quiet or in active status Age: young as well as oldHistory: TIAs, Mural thrombus/ rheumatic heart disease/ ar
45、rhythmias / endocarditis/ fractureAssociated symptoms:headache, vomiting, seizures, or disorders of consciousness can be found in some patients.Symptoms relate with the emboli original diseases or emboli signs in other tissues,Syndromes:,Internal carotid artery system:Contralateral hemiparesis and h
46、emisensory lossContralateral homonymous hemianopiaaphasia(dominant hemisphere), characterized by combined expressive and receptivevertebral-basilar artery system:Ipsilateral cerebellar ataxia, vertigo, nausea, vomiting, dysphagia, dysarthria coma, constricted pupils, high temperature, locked in syndrom, hemiplegia or qudriplegia(四肢瘫), even death,
