1、脑卒中基本知识 cerebrovascular diseases,脑血管疾病Cerebrovascular Diseases， CVD,在脑血管病变或血流障碍基础上发生的局限性或弥漫性脑功能障碍 the cerebral diseases that are resulted from various cerebrovascular diseases,病因etiopathogenisis,高血压性脑动脉硬化(cerebral arteriosclerosis)脑动脉粥样硬化(cerebral atherosclerosis)心脏病(cardiac disease)先天性脑动脉病变(inborm
2、arteriosis)脑动脉炎(cerebral arteritis)肿瘤(ambury)外伤(surgical trauma)血液病(hematologic disease),急性脑血管疾病分类classification of acute cerebrovascular diseases,短暂性脑缺血发作（transient ischemic attack TIA）颈动脉系统(internal carotid artery system) TIA椎基底动脉系统(basilar-vertebral artery system)TIA脑卒中（stroke, apoplexy, cerebrov
3、ascular accident）蛛网膜下腔出血（subarachnoid hemorrhage）脑出血（intracerebral hemorrhage, ICH）脑梗死 (cerebral infarction) 动脉血栓性脑梗死 (arterothrombotic cerebral infarction)脑栓塞(cerebral embolism)腔隙性脑梗死(lacunar infarction), 等,其他分类的脑血管疾病,椎基底动脉供血不足（Vertebrobasilar arterial insufficiency）脑血管性痴呆（cerebral vascular dementi
4、a）高血压脑病（hypertensive encephalopathy）颅内动脉瘤（intracranial aneurysm）颅内血管畸形（intracranial vascular malformation）脑动脉炎（cerebral arteritis）颅内静脉、静脉窦血栓形成（thrombosis of venous sinus）颅外段动、静脉疾病其他动脉疾病,颈内动脉系统internal carotid artery system,眼动脉(ophthalmic artery后交通动脉(posterior communicating artery)脉络前动脉(anterior chor
5、oidal artery)大脑前动脉(anterior cerebral artery)大脑中动脉(middle cerebral artery),椎-基底动脉系统vertebrobasilar circulation,椎动脉vertebral artery基底动脉basilar artery大脑后动脉posterior cerebral artery,脑的供血区域及临床表现,颈内动脉系统(internal carotid artery)又称前循环,供应额、颞、顶叶和基底核等大脑半球前3/5血流椎-基底动脉系统（basilar-vetebral artery)又称后循环，供应小脑、脑干、丘脑和
6、枕、颞叶等大脑半球后2/5血液,脑动脉的细小分支,穿通支（perforating branch）间脑、纹状体、内囊、脑干基底部中线旁结构皮质支（cortical branch） 大脑半球皮质及皮质下白质与脑干的背外侧,脑底动脉环大脑中动脉近端基底动脉,脑动脉的侧支循环compensatory circulation,Willis环的构成双侧颈内动脉 internal carotic artey双侧大脑前动脉 anterior cerebral artey双侧大脑后动脉 posterior cerebral artery前交通动脉 anterior communicating artery双侧后
7、交通动脉 posterior communicating artery,其他侧支循环,大脑前、中、后动脉皮质支在大脑表面彼此交通颈内、外动脉围绕眼耳、鼻、的深浅分支互相吻合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分水岭脑梗死cerebral watershed infarction,脑的静脉(cerebral veins),大脑上静脉大脑中静脉大脑下静脉superior,middle,inferior cerebral veins,上矢状窦Superior sagittal sinus海绵窦sinus横窦Transverse sinus,大脑大静脉Great cerebr
8、al vein,直窦Straight sinus,颈内静脉Internal carotidvein,已状窦Sigmoid sinus,下矢状窦Inferior sagittal sinus,大脑镰静脉Falx cerebral vein,脑静脉的结构特点construction features of vena encephali,管腔大，管壁薄，缺乏弹力纤维无静脉瓣大多不与动脉伴行静脉窦由坚韧的硬脑膜围成，内衬一层内皮细胞,脑血流及其调节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/（8
9、L）。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，就会出现缺血区的充血和过度灌注或脑内盗血现象。,脑血管病的危险因素risk factor,高血压(hypertension)糖尿病(diabetes)心脏病(heart dieases)高脂血症(hyperlipemia)TIA 或脑卒中史(historic stroke)吸烟(smoking)和酗酒(heavy alcohol consumption)等不可干预的因素,基本病因etiopathogenisis,血管壁病变(dissepiment disorders)高血压性脑细小动脉硬化(hyp
10、ertensive atherosclerosis)脑动脉粥样硬化(atherosclerosis)血管先天性发育异常和遗传性疾病各种感染和非感染性动、静脉炎中毒、代谢及全身疾病导致的血管壁病变心脏病(cardiac diseases)其他病因,促发因素onset factor,血流动力学因素（hemodynamics）血压过高或过低血容量改变心脏病血液成分异常（blood constituent abnormality）血粘稠度改变血小板数量或功能异常凝血或纤溶系统功能障碍,主要的症状和体征sings and symptoms,起病突然全脑症状局灶性症状和体征(focal sings and
11、 symptoms)颈内动脉系统表现 (internal carotid artery)椎-基底动脉系统表现 (basilar-vetebral artery)脑膜刺激征,短暂性脑缺血发作,transient ischemic attack,短暂性脑缺血发作transient ischemic attack , TIA,脑动脉一过性供血不足 transient insufficiency of blood in cerebral arteries短暂发作 transient attack局灶性脑功能障碍 focal brain disorder24小时内完全恢复 complete recove
12、ry in 24 hours可反复发作 recurrent attacks,病因和发病机制etiopathogenisis and pathogenesy,微栓塞 microembolism脑血管痉挛 cerebrovascular spasm血流动力学改变 hemodynamics disorders血液成分改变 blood compotents disorders,临床表现clinical situation,50岁 patients older than 50, 常伴有动脉硬化、高血压、糖尿病、冠心病等 accomply with angiosclerosis, hypertension
13、, diabetes, coronary artery disease发病突然，迅速出现局限性神经功能障碍 acute onset of a neurologic deficit持续时间短 ，24小时 neurologic deficit persists for less 24 hours不留后遗症 no residual可反复发作 recurrent attacks,颈内动脉系统TIA TIA of internal carotid artery,短暂性偏侧或单肢无力 transient hemiparesis面部、单肢或偏身麻木 hemisensory disturbances同向偏盲或
14、单眼一过性失明 homonymous hemianopia or transient ocellanae acroisa失语 aphasia,椎基底动脉系统TIA的表现TIA of vertebrobasilar circulation,眩晕（vertigo）、复视（diplopia）、吞咽困难（acataposis）、共济失调（ataxia）交叉性瘫痪（crossed paralysis）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 disorde
15、rs）,诊断approach to diagnosis,中老年患者 senior突然出现局限性神经功能障碍 acute onset of a neurologic deficit24小时完全恢复 complete recovery in 24 hoursCT、MRI（）TCD监测,鉴别诊断differential diagnosis,部分性癫痫（part epilepsy）梅尼埃病（Meniere disease）颅内占位性病变（intracranial spaceoccupying lesion）,治疗treatment,药物治疗(drug treatment)抗凝 (anticoagula
16、tion)肝素(heparin)100mg+5%葡萄糖500ml，ivgtt，1020滴/min低分子肝素(low molecular weight heparin)4000IU，腹壁皮下注射，bid抗血小板聚集 (antiplatelet therapy)Asprin 50300mg，po， Qd奥扎格雷(ozagrel) 80mg，ivgtt，bid扩血管治疗罂粟碱、倍他司丁、烟酸（papaverine、betahistine、nicotinic acid）其他（others）尼莫地平、盐酸氟桂嗪（nimodipine、flunarizine）中药治疗（tranditional medic
17、ine treatment）,治疗treatment,手术治疗(surgery)管腔狭窄75%，伴反复TIA，可考虑介入治疗或颈动脉内膜剥除术病因治疗(etilogical treatment),预后prognosis,脑梗死 cerebral infarction反复发作 recurrent attacks自行缓解 release without treatment,缺血性脑卒中,cerebral ischemic stroke,缺血性脑卒中cerebral ischemic stroke , CIS,由于脑部血液供应障碍，缺血、缺氧引起的局限性脑组织的缺血性坏死或脑软化。又称脑梗死（cer
18、ebral infarction,CI),临床常见类型有动脉血栓性脑梗死、脑栓塞和腔隙性梗死等。脑梗死约占全部脑卒中的80。,动脉血栓性脑梗死arterothrombotic cerebral infarction,通常是指脑动脉的主干或其皮层支因动脉粥样硬化及各种动脉炎等血管病变，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，出现相应的神经系统症状和体征。动脉血栓性脑梗死包括动脉-动脉栓塞和脑血栓形成。,病因etiopathogenisis,脑动脉粥样硬化(cerebral atherosclerosis)高血压、糖尿病、高脂血症可加速脑动
19、脉粥样硬化脑动脉炎结缔组织疾病先天性血管畸形真性红细胞增多症血高凝状态血小板增多症,发病机制nosogenesis,血栓形成机制 血管内皮损伤 血小板粘附 释放TXA2、2-HT、PAF等 更多的血小板粘附聚集 形成白色血栓+启动的凝血瀑布 血栓 红色血栓,发病机制nosogenesis,脑梗死灶形成机制脑血流障碍神经细胞缺血性损害能量代谢障碍和酸中毒兴奋性氨基酸（excitatory amino acid)毒性和钙超载(calcium overload)磷脂降解和脂类介导的毒性作用自由基(free radical)损伤缺血性脑水肿一氧化碳(nitric oxide)毒性即早基因(immedi
20、ate early genes)、神经营养因子(neurotrophic factors)和热休克蛋白(heat shock protein)等基因表达改变细胞因子,再灌注时间窗reperfusion time window,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损伤，目前普遍把脑缺血的超早期治疗时间窗定为6小时之内,临床表现clinical manifestation,老年人(senior)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)常在
21、安静或睡眠中起病(onset at quiet or sleep)一般无头痛、呕吐、昏迷等全脑症状(no headache、vomit、coma）,颈内动脉系统脑梗死临床表现(clinical manifestation),颈内动脉血栓形成（internal carotid artery thrombosis）大脑中动脉血栓形成(middle cerebral artery thrombosis)大脑前动脉血栓形成(anterior cerebral artery thrombosis),24, Middle cerebral artery,25, Posterior cerebral art
22、ery,26,椎-基底动脉系统脑梗死(basilar-vetebral artery system infarction),椎-基底动脉血栓形成(basilar-vetebral artery thrombosis)椎动脉闭塞(vetebral artery occlusion)基底动脉主干闭塞椎-基底动脉不同部位的旁中央支和长螺旋支闭塞大脑后动脉血栓形成(posterior cerebral artery thrombosis)小脑梗死(cerebella infarction),辅助检查auxiliary examination,血常规和生化检查头颅CT头颅MRI+DWI血管造影B超多普勒
23、断层扫描和TCD检查腰穿脑脊液检查,诊断和鉴别诊断(diagnosis and differential diagnosis),急性期一般治疗general treatment in acute stage,维持呼吸功能调整血压控制血糖控制体温预防并发症营养支持,急性期溶栓治疗thrombolysis treatment,溶栓时间窗（time window)起病3小时内，36小时可慎重选择病例，6小时后疗效不佳，并有较大出血危险适应征年龄小于75岁瘫痪肢体肌力3级以下无明显意识障碍用药时血压低于180/110mmHg禁忌征有出血倾向、大面积脑梗死、严重心、肝、肾疾病者常用药物组织型纤维蛋白溶解
24、酶原激活剂(tPA)尿激酶(UK)链激酶(SK)溶栓治疗有颅内或身体其他部位出血的危险，有的可导致死亡,急性期其他治疗(other treatment),降纤治疗（defibrase）抗凝、抗血小板聚集治疗血液稀释疗法扩血管治疗脱水降颅压脑保护治疗高压氧治疗中医中药治疗外科治疗,康复期治疗treatment in convalescence stage,康复治疗药物治疗,脑栓塞,cerebral embolism,脑栓塞cerebral embolism,是指各种栓子随血流进人颅内动脉系统使血管腔急性闭塞引起相应供血区脑组织缺血坏死及脑功能障碍。Cerebral embolismcerebra
25、l tissue ischemia , necrosis and cerebral function disorders that are caused by various emboli entering cranium artery system following blood flow and making blood vessel acutely emphraxis,病因etiopathogenisis,心源性脑栓塞心脏瓣膜病和心内膜病心率失常心脏手术先天性心脏病心脏肿瘤非心源性脑栓塞原因不明,临床表现clinical manifestation,任何年龄均可发病，以青壮年多见。活动中
26、突然起病，数秒或数分达高峰，是发病最急的脑卒中，且多为完全性卒中。Cerebral embolism can be found at any age, but most of them is at young prime of ones life.The onset suddenly starts at activities, achieves peaks after a few second or minutes. It is the acutest stroke among all strokes,and most of them are completed strokes.局限性神经缺失
27、症状与栓塞动脉供血区的功能相对应。Limited nerve deletion symptoms are corresponded with embolism artery sufficient blood regions.大多数病人有栓子来源的原发病Most of patients trouble proepisode that emboli come from,诊断及鉴别诊断diagnosis and differential diagnosis,根据病史和临床表现，诊断不难。应注意与脑血栓形成、脑出血的鉴别,治疗treatment,脑栓塞治疗与动脉血栓性脑梗死的治疗基本相同原发疾病治疗控
28、制心律失常手术治疗先天性心脏病和风湿性心瓣膜病控制感染性心内膜炎,腔隙性梗死,lacunar infarct,腔隙性梗死lacunar infarct,是指发生在大脑半球深部白质及脑干的缺血性微梗死，因脑组织缺血、坏死、液化并由吞噬细胞移走而形成腔隙。Lacunar infarctischemic microinfarctions that occur at cerebral hemisphere deep white matter and brainstem .Phagocytes shift the ischemic ,necrotic and liquefied cerebral tis
29、sues and form lacunas,病因及病理etiopathogenisis and pathology,高血压所致的脑内细小动脉病变是腔隙性梗死的主要原因腔隙性梗死灶呈不规则的圆形、卵圆形、狭长形，直径多为34mm,病灶主要分布于基底节区、放射冠区、丘脑和脑干,临床表现clinical situation,老年患者，65岁(senior, 65)有高血压病史(with hypertetion)多在安静时急性或逐渐起病(onset at quiet)无头痛、意识障碍等全脑症状(no headache、coma)可表现为多种不同的腔隙综合征,临床常见的腔隙综合征compartmenta
30、l syndrome,纯运动性轻偏瘫(pure motor hemiparesis PMH）纯感觉性卒中(pure sensory stroke,PSS)感觉运动性卒中(sensorimotor stroke, SMS)共济失调性轻偏瘫(ataxic-hemiparesis,AH)构音障碍-手笨拙综合征(dysarthric-clumsy hand syndrome ,DCHS),诊断及鉴别诊断diagnosis and differential diagnosis,临床诊断多年的高血压病史(hypertesion histery)突然出现局灶性神经定位体征(acute onset of a neurologic deficit)影象学检查在相应部位有腔隙灶需与其他类型的脑卒中鉴别,治疗treatment,与动脉血栓性脑梗死治疗基本相同,
