脑血管疾病 Cerebrovascular Disease (CVD)

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1 脑血管疾病 Cerebrovascular Disease (CVD)
Department of Neurology 2nd hospital of Kunming Medical University

2 Section 1 Introduction Definition
CVD: The term of CVD designates any abnormality of the brain resulting from various pathological process of the blood vessels 脑血管病是各种脑血管病变引起脑部疾病的总称。

3 Definition Stroke: The stroke is a syndrome characterized by the acute onset of a neurologic deficit that reflects focal/diffused involvement of the CNS and is the result of a disturbance of the cerebral circulation. 脑卒中是指急性起病 、迅速出现局限性或弥漫性脑功能缺失征象的脑血管性事件。

4 Epidemiology: CVD is the third most common cause of death after heart disease and cancer. Incidence: 100~300/100,000 morbidity: 100~740/100,000 mortality: 50~100/100,000 About 50%~70% of survivors shows disability in different degree.

5 Classification of CVD According to the lasting time of neurologic deficit: TIA (<24h) stroke (>24h). According to the severity of neurologic deficit: minor stroke major stroke silent stroke According to the pathological features: ischemic stroke hemorrhagic stroke (see table 8-1)

6 脑部的血液供应-Blood supply in brain
颈内动脉系统 - internal carotid artery (ICA) S. 眼动脉-ophthalmic artery 后交通动脉-post communicating artery 脉络膜前动脉-anterior choroidal artery 大脑前动脉-anterior cerebral artery (ACA) 大脑中动脉-middle cerebral artery (MCA) 供应眼部及大脑半球前3/5部分即额叶、颞叶、顶叶及基地节的血液 见图the circle of Willis环 见图脑基底部动脉

7 椎-基底动脉系统-vertebral-basilar artery S.
椎动脉(VA): Which is divided into anterior spinal artery (脊髓前动脉) posterior spinal artery (脊髓后动脉) medullary artery (延髓动脉) posterior inferior cerebellar artery (小脑后下动脉)

8 基底动脉(BA): Which has branches of
anterior inferior cerebellar artery（小脑前下动脉） branches of pons（脑桥支） internal auditory artery（内听动脉） superior cerebellar artery （小脑上动脉）

9 大脑后动脉 (posterior cerebral artery, PCA) , which is the terminal division of BA
椎基底动脉系统供应脑干,小脑及大脑 半球后2/5部分即枕叶及颞叶的基底面，枕叶的内侧及丘脑等。

10 Etiology of CVD Vascular disorder Atherosclerosis
Inflammatory disorders (TB,syphilitic arteritis, SLE, etc.) Congenital vascular malformation (aneurysm, AVM ) Lesions of any cause

11 Etiology of CVD Heart diseases and blood kinetics changes
Hypertention or hypotension Atrial fibrillation, Rheumatic heart disease, arrhythmias etc.

12 Changes in blood constituent and hemodynamics
Increase in blood viscosity Abnormality in blood coagulation mechanism Others Such as emboli of air , fat, cancer cells. Blood vessel spasm, trauma, etc.

13 Risk factors Several factors are known to increase the liability to stroke. The most important of these are: Hypertention Heart diseases Diabetes TIA or stroke history

14 Risk factors Smoking and alcohol Hyperlipidmia
Others: food, symptomless ICA bruit, overweight, drug abuse, contraceptive，age, sex, family history, race, etc.

15 Section 2 Transient Ischemic Attack, TIA (短暂性脑缺血发作)
Concept Etiology and mechanism Clinical findings Investigative studies Diagnosis and differentiation Treatment and prevention

16 TIA-Concept TIA is brief, repeated, reversible episodes of focal ischemic neurologic disturbance. The duration of which should be less than 24h (usually lasting about several min to 1h). Repeated TIAs of uniform type are more often a warning sign of ischemic stroke.

17

18 TIA-Clinical findings
Age of onset, 50~70, male > female Basic features: Transient episode (<24h) Reversible resolve completely repeated and uniform type

19

20 Clinical features of carotid artery TIA
Common symptom/sign: weakness of opposite limbs. (对侧单肢无力或轻偏瘫)。 Characteristic symptom/sign: ophthalmic artery crossing paralysis （眼动脉交叉瘫) Horner’s crossing paralysis （Horner 氏交叉瘫) Aphasia (dominant hemisphere is involved)

21 Clinical features of carotid artery TIA
Possible symptoms: contralateral single limb- or hemi-sensory deficit contralateral homonymous hemianopia

22 TIA of Vertebra-basilar artery
Common symptom/sign: vertigo, dysequilibrium, usually no tinnitus (眩晕，平衡失调，多不伴有耳鸣 ) Characteristic symptom/sign: drop attack （跌倒发作） transient global amnesia（ TGA,短暂性全面性遗忘） bioccular vision disorder (双眼视力障碍)

23 TIA of Vertebral-basilar artery
Possible symptom/sign: swallowing disorder, dysarthria/dysphagia (吞咽障碍、构音不清) incoordination (共济失调) disturbence of consciousness with /without small pupils (意识障碍伴或不伴瞳孔缩小)

24 TIA of Vertebral-basilar artery
Possible symptom/sign: unilateral/bilateral facial/perioral numbness or crossing sensory deficit (一侧或双侧面部/口周麻木或交叉性感觉障碍) extraocular palsy or diplopia (眼外肌麻痹或复视) crossed paralysis (交叉性瘫痪)

25 TIA Symptoms Related to Cerebral Circulation

26 TIA-Diagnosis and differentiation
mainly depend upon history. But the causes of TIA are very important. differentiation: partial seizure (局限性癫痫) Méniere Disease (美尼耳氏病) Heart diseases: Adams-stokes syndrome, severe arrhythmia, etc.

27 Management Diagnosis of Carotid Stenosis

28 Investigative study Blood Test: Blood count, ESR, blood glucose, etc.
EEG, CT or MIR ECG, Cardiac Ultralsound Carotid Duplex Ultrasound Others

29

30

31 TIA-treatment and prevention
Treatment in terms of etiology Drugs for prevention Antiplatelet agents: Aspirin (ASA), Ticlopidine, Dipyridamole, Clopidogre Anticoagulation therapy: 肝素 (heparin)， 低分子肝素 (lower molecule heparin)，华法林 (warfarin)

32 TIA-treatment and prevention
Drugs for prevention Others: Chinese traditional medicines, vasodilatation agents, blood volume enlargement doses and surgical treatment（carotid endoarterectomy, intralumenal stents） Cerebral protective agents

33 Prognosis 1/3 will develop into cerebral Infarction afterward 1/3 recurrence 1/3 resolved

34 Summary the most important parts need to be emphasized are:
clinical findings, diagnosis menagement

35 Case Example A 55 year old male presents to the emergency department with acute onset of Left arm weakness: Unable to lift left arm off of lap Symptoms improved on the way to the hospital

36 Case Example PMHx: Hypertension Takes enalapril Social Hx:
Smokes 1 ppd

37 Case Example Physical Exam Overweight 160/90, 80, 14, 37.5C
Right carotid bruit Heart with regular rate and rhythm; No murmur

38 Case Example Neuro exam 30 min after the onset of symptoms
Motor 4/5 strength in left upper extremity. Sensory subjective decrease in pinprick in left upper extremity compared to the right Reflexes were 2+ except for the left biceps, which was 3+, Gait steady

39 Case Example Neuro exam
After an immediate CT scan, The patient’s symptoms had completely resolved and he had a normal neurologic exam

40 Questions What is the possible diagnosis of the patient?
Which artery territory is involved? What is the probable cause? How should you menage the problem?

41 Section 3 脑梗塞-cerebral infarction
Concept: Cerebral infarction (CI) is necrosis and malacia of brain tissues due to ischemia and anoxia of the brain , which is in turn caused by deprived or insufficient blood supply in brain 是指脑部血液供应障碍，缺血、缺氧引起脑组织坏死软化。

42 cerebral infarction Common types: 脑血栓形成 (cerebral thrombosis, CT)
脑栓塞 (cerebral embolism) 脑分水岭梗塞 (cerebral watershed infarction, CWSI) 腔隙性梗塞 (lacunar infarct)

43 脑血栓形成-cerebralthrombosis(CT)
Etiology Pathology Clinical Features Diagnosis and differentiation treatment Prognosis and prevention

44 Etiology Stenosis of artery thrombosis
Atherosclerosis-the most common cause of CT Arteritis Others: vascular malformation, blood dyscrasia (高凝状态-hypercoagulable state、真性红细胞增多症-polycythemia vera, 血小板增多-thrombocytosis、DIC等)

45 Etiology vascular spasm: SAH, migraine, eclampsia (子痫), trauma, etc.
Indeterminate

46 Pathology 好发部位 : 大脑中动脉 颈动脉虹吸部及起始部 椎动脉及基底动脉中下段
4/5 located in region of ICA territory, 1/5 located in region of V-B A

47 Pathology 超早期（1~6h):脑组织改变不明显。 急性期（6~24h):脑组织苍白、轻度肿胀，NC、胶质细胞及血管内皮细胞缺血

48 Pathology 软化期（3d~4w）：脑组织开始液化变软 恢复期（3~4w）：胶质细胞、胶质纤维及毛细血管增生，形成胶质瘢痕和中风囊

49 Pathophysiology Blood flow blockage >30 seconds--metabolic change, >1 min -- cease of neuron activity, >5min -- cerebral infarct. Ischemic penumbra (缺血半暗带） time window (6h)

50 Pathophysiology Reperfusion damage: possible mechanisms:
自由基 (free radical)形成及其瀑布式反应 神经细胞内钙超载(calcium overload) EAA毒性作用(toxic effect of excitatory amino acid) 酸中毒(acidosis)

51 Types 大面积脑梗死（a large area CI）
分水岭脑梗死 (cerebral watershed infarction, CWSI) 出血性脑梗死 (hemorrhagic infarct, HI) 多发性脑梗死 (multiple infarct, MI)

52 Clinical features Clinical types
Complete stroke: reaches peak within several hours (<6h) progressive stroke: reaches peak within 48h reversible ischemic neurological deficit (RIND): Lasting >24h and recovering within 3ws

53 Clinical features General features:
Middle-aged or elderly people (caused by Atherosclerosis), youth or middle-aged people (caused by arteritis). Stroke onset at quiet state and reaches the peak within several hours to 1~2 days.

54 Clinical features General features:
Usually, the patients are awake and alert except for those with a large area of CI or infarction in brainstem.

55 Clinical syndromes of CI
Occlusion syndrome of carotid artery Carotid artery occlusion may be asymptomatic. Symptomatic occlusion results in syndromes follow: Transient monocular blindness caused by ipsilateral retinal artery ischemia. Horner’s sign.

56 Clinical syndromes of CI
Occlusion syndrome of carotid artery Carotid artery or ophthalmic artery bruit and a weakened pulse in carotid artery. Contralateral hemiplegia, hemisensory deficit, and homonymous hemianopia. Aphasia, if dominant hemisphere involvement.

57 Clinical syndromes of CI
Oclusion syndrome of MCA 主干闭塞 (Occlusion in stem): is a severe stroke syndrome which combines the features of superior and inferior division stroke. 三偏症状 (contralateral hemiparesis, hemisensory deficit, and homonymous hemianopia).

58 Clinical syndromes of CI
Oclusion syndrome of MCA 失语症、体象障碍 (globle aphasia, if dominant hemisphere is involved, and body image disturbence ) 意识障碍、颅内压增高、脑疝可导致死亡 (disturbence of consciousness, increased ICP, and herniation)

59 Clinical syndromes of CI
Oclusion syndrome of MCA 皮层支闭塞(occlusion in superior division) 中枢性面舌瘫和偏瘫，偏瘫上肢重于下肢 (contralateral hemiparesis that affects the face, hand, and arm but less severe in the leg).

60 Clinical syndromes of CI
Oclusion syndrome of MCA 皮层支闭塞(occlusion in superior division) 伴感觉障碍，主要是皮质感觉障碍 (contralateral hemisensory deficit,mainly shows cortical sensory deficit) 失语、体象障碍 (aphasia and body image disturbence)

61 Clinical syndromes of CI
Oclusion syndrome of MCA 深穿支闭塞(occlusion in inferior division) 对侧偏瘫(contralateral hemiparesis, upper and lower limbs evenly affected) 对侧偏身感觉障碍及偏盲(contralateral hemisensory deficit and homonymous hemianopia) 可有失语(dominant hemisphere involved)

62 Clinical syndromes of CI
Occlusion syndrome of ACA 主干闭塞(occlusion in stem) 中枢性面舌瘫、偏瘫下肢重于上肢(挑扁担样瘫) (Shoulde-pole-carry-like), 伴轻度感觉障碍 尿便障碍或尿急(旁中央小叶损), (incontinence , paracentral lobule is affected)

63 Clinical syndromes of CI
Occlusion syndrome of ACA 主干闭塞 (occlusion in stem) 精神症状 (psychiatric symptom) (颞极与胼胝体受累，temporal pole andcorpus callosum are affected)，常可见强握、吸吮反射 (额叶病变) (grasp reflex, suck reflex are common signs, lision in frontal lobe).

64 Clinical syndromes of CI
Occlusion syndrome of ACA 皮层支闭塞(occlusion in superior division) 对侧偏瘫，下肢重于上肢 (sensorimotor deficit of the opposite leg and foot and , to less degree, of the shoulder and arm )

65 Clinical syndromes of CI
Occlusion syndrome of ACA 深穿支闭塞 (occlusion in inferior division) 面、舌、肩瘫 (contralateral paresis includes face, lingua, shoulder)

66 Clinical syndromes of CI
Occlusion syndrome of PCA 主干闭塞 (occlusion in stem )： 对侧偏盲、偏瘫及偏身感觉障碍(较轻) 丘脑综合症 (thalamic syndrome) 主侧半球病变可有失读症(alexia).

67 Clinical syndromes of CI
Occlusion syndrome of PCA 皮层支闭塞（ occlusion in superior division ） 对侧同向性偏盲(contralateral homonymous hemianopia)、象限盲(quadrant hemianopia)、皮质盲(cortical blidness, bilateral involvment)

68 Clinical syndromes of CI
Occlusion syndrome of PCA 皮层支闭塞（ occlusion in superior division ） 主侧颞下动脉闭塞时可见视觉性失认症 (visual agnosia)和颜色失认(achromatopsia) 主侧半球顶枕动脉闭塞可有对侧偏盲，失语。

69 Clinical syndromes of CI
PCA occlusion syndrome 深穿支闭塞 (occlusion in inferior division) 丘脑穿通动脉闭塞：红核综合征（Claude syndrome) 丘脑综合征(thalamic syndrome): snesory loss, spontaneous pain and dysesthesias, choreoathetosis, intention tremor, spasm of hand, mild hemiparesis.

70 Clinical syndromes of CI
PCA occlusion syndrome 深穿支闭塞 (occlusion in inferior division) 中脑分支闭塞：Weber syndrome: third nerve palsy ad contralateral hemiplegia.

71 Clinical syndromes of CI
Syndrome of vertebral- basilar artery occlusion 主干闭塞：广泛脑干梗死。Shows symptoms of cranial nerves, pyramidal tract, and cerebellum.

72 Clinical syndromes of CI
Syndrome of vertebral- basilar artery occlusion 基底动脉尖综合征（Top of the basilar Syndrome）: Abnormality in eye movement and pupils disturbance of consciousness (loss of consciousness) homonymous hemianopia or cortical blindness severe memory disorder

73 Clincal syndromes of CI
Syndrome of vertebral- basilar artery occlusion 脑干分支闭塞 Weber syndrome Millard-Gubler syndrome Foville syndrome

74 Clincal syndromes of CI
Syndrome of vertebral- basilar artery occlusion 小脑后下动脉闭塞-延髓背外侧综合症(Wallenberg syndrome) 眼球震颤 (nystagmus) 交叉性感觉障碍 (crossed sensory deficit) 球麻痹 (bulbar paralysis) 病灶侧Horner征 (ipslateral Hornor sign) 病灶侧小脑性共济失调 (ipslateral cerebellar ataxia)

75 Clincal syndromes of CI
Syndrome of vertebral- basilar artery occlusion 闭锁综合征(Locked -in syndrome): 基底动脉分支双侧闭塞 Cerebellar infarction 由小脑上动脉(superior cerebellar artery)、小脑后下动脉(posterior inferior cerebellar artery)、小脑前下动脉闭塞 (anterior inferior cerebellar artery)所致。

76 Laboratory findings CT scan：normal at the day of onset of the stroke, shows the low density of the infarct after 24~48h. CT is preferred for initial diagnosis since it can make the critical distinction between ischemia and hemorrhage (见图 )

77 Laboratory findings MRI：may be superior to CT scan for demonstrating early ischemic infarcts, showing ischemic stroke in brainstem or cerebellum and detecting thrombosis occlusion of venous sinuses.

78 Laboratory findings Cerebral angiography：MRA, DSA
Blood tests and ECG: Serum glucose, cholesterol and lipid ,hemorheology. TCD and CSF

79 Diagnosis and differentiation
diagnosis can be made depending on the clinical features (Patients presenting with focal central nervous system dysfunction of sudden onset, Lasting more than 24h) CT and MRI changes

80 Diagnosis and differentiation
Differential diagnosis: Cerebral hemorrhage cerebral embolism Other structural brain lesions: tumor,abscess, etc.

81 脑出血和脑梗塞的鉴别要点. 脑出血. 脑梗塞. 1. 发病年龄 60岁以下. 多60岁以上 2. TIA史 多无 常有. 3
脑出血和脑梗塞的鉴别要点 脑出血 脑梗塞 1.发病年龄 岁以下 多60岁以上 2.TIA史 多无 常有 3.起病状态 活动中 安静状态或睡眠中 4.起病速度 急(分、时) 较缓(时、日) 5.血压 明显增高 正常或增高 6.全脑症状 明显 多无 7.意识障碍 较重 较轻或无 8.颈强直 可有 无 9.头颅CT 高密度病灶 低密度病灶 10.脑脊液 血性,洗肉水样 无色透明 其中最重要的是2、3.两条。

82 Treatment 急性期治疗（Treatment in acute stage） 治疗原则： 超早期治疗--力争溶栓； 综合保护治疗；
个体化治疗； 整体化治疗； 对危险因素及时予以预防性干预措施。

83 Treatment 超早期溶栓治疗 目的：溶解血栓；迅速恢复梗死区血流灌注；减轻神经元损伤。（6h）
complications: Hemorrhage, reperfusion damage and brain edema, reocclusion.

84 Treatment 超早期溶栓治疗 Thrombolytic agents :Urokinase (UK), Straptokinase (SK), recombinant tissue plasminogen activator (rt-PA)

85 Treatment 超早期溶栓治疗 Indications: Age < 75
no disturbance of consciousness within 6h(or 12h for progressive stroke) of onset Bp < 200/120mmHg no hemorrhage shown on CT scanning exclusion of TIA no other hemorrhagic diseases

86 Treatment Antiplatelet agents
The regime is as described in the section of TIA. Anticoagulation agents: to prevent the progression of thrombosis. The agents used are the same as mentioned in the section of TIA. Fibrinogen degradation therapy: 降纤酶 (Defibrase), 巴曲酶 (Batroxobin), 安洛克酶(Ancrod)和引激酶。

87 Treatment Neuroprotective agents: 抗自由基：V-E V-C 甘露醇 激素等
抑制脑代谢—急性期时应降低脑代谢，减少脑细胞耗氧量使缺血区血流量增加 钙离子拮抗剂：西比灵 尼莫地平等 亚低温 胰岛素维持血糖正常低限水平

88 Treatment Other forms of medical treatment: such as therapies aimed at improving blood flow: hemodilution, metabolic improving agents-ATP, Co-A, 脑活素等。

89 Treatment Surgical treatment General treatment
ICU: monitoring ECG, Bp, R, P, etc. Antiedema agents Preventing infection Physical therapy and rehabilitation Preventive measures

90 腔隙性脑梗塞-Lacunar Infarction
Concept： Small penetrating arteries located deep in the brain may become occluded as a result of changes in the vessel wall induced by chronic hypertension and atherosclerosis. 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，占脑梗死的。多见于基底节区、放射冠、丘脑、脑干等部位。

91 腔隙性脑梗塞-Lacunar Infarction
Common types: 纯运动性卒中(Pure motor hemiparesis, PMH) 纯感觉性卒(Pure sensory stroke, PSS) 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) 感觉运动性卒中(Sensorimotor stroke, SMS) 腔隙状态(Lacunar state)

92 脑栓塞-Cerebral embolism
Concept Etiology and mechanism Clinical findings Investigative studies Diagnosis and differentiation Treatment and prognosis

93 脑栓塞-Cerebral embolism
Concept： embolism produces stroke when cerebral arteries occluded by the distal passage of thrombus from the heart,aortic arch, or large cerebral arteries. 脑栓塞指各种栓子随血流进入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。

94 脑栓塞-Cerebral embolism
Etiology 心源性 (Cardiogenic) 非心源性 (non-cardiogenic) 来源不明 (source unknown) Pathology 多见于颈内动脉系统，尤其是左侧大脑中动脉，病理上与脑血栓形成基本相同。但栓子常为多发切易破碎。

95 Clinical findings 发病急骤，症状在数秒或数分钟内达高峰，是血管病中最快的 多属完全性中风，栓塞部位继发血栓时病情可逐渐进展
可有头痛、局灶性癫痫和不同程度的意识障碍 神经系统定位体征 原发病的症状和体征 易发生梗塞后出血

96 Laboratory Findings CT, MRI: indicate ischemic Infarct or hemorrhagic infarct MRA shows the stenosis of large cerebral arteries. CSF examination: Can be normal, or with increased ICP. Red blood cells can be seen grossly or under microscope.

97 Laboratory Findings ECG: 心律失常 (arrhythmia)、心肌梗塞(myocardical infarction, MI) 等 Ultrasonography Echocardiography Cerebral angiography

98 Diagnosis and differentiation
诊断：急骤起病，有定位体征，有栓子来源 鉴别诊断： 与脑出血、脑血栓鉴别 有局限性癫痫者应与其它引起癫痫的疾病鉴别.

99 Treatment and prognosis
Antiedema and increased ICP Recurrence prevention treatment: emboli originated disease treatment. Vasodilation agents

100 Treatment and prevention
others prognosis: mortality - 5%~15%. Die from severe cerebral edema, herniation, respiratory system infection, and heart failure. Majority of Survivors will have severe disability

101 本课重点 TIA的临床特点，颈内动脉和椎-基底动脉TIA的最常见的表现及特有症状 脑血栓形成的常见病因，好发部位，临床特点及治疗重点
腔隙性脑梗死的常见临床类型几表现 脑栓塞的常见病因、临床特点及鉴别诊断

102 谢 谢