1、Cerebrovascular Diseases,Xue Qun Department of Neurology The 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 flow Type
2、: Accute: 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
3、result of a disturbance of the cerebral circulation. Types: ischemia : local thrombosis orembolization from a distant site hemorrhage：,Stroke,ischemia : Cerebral ischemic stroke (cerebral infarction) arterothrombotic infarction Cerebral embolism Lacunar infarctionhemorrhage：Cerebral hemorrhageSubara
4、chnoid hemorrhage,Territories of the principal cerebral arteries,Anterior circulation Internal carotid artery Ophthalmic artery posterior communicating artery Anterior choroidal artery (hippocampus, globus pallidus, lower internal capsule) Anterior cerebral artery(medial frontal 额叶and parietal 顶叶cor
5、tex and subjacent 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,P
6、osterior circulation Vertebral artery Posterior inferior cerebellar (medulla,lower cerebellium) Basilar arteryAnterior inferior cerebllar(lower and midpons, mid cerebellium)Superior cerebellar (upper pons,lower mid cerebellum)Posterior cereballar (medial occipital and temporal cortex and subjacent w
7、hite matter,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
8、cerebral perfusion pressure / cerebral vascular resistanceCBF=(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 disordersAtherosclerosis / inflamatory disorder/cerebral amyloidosis(淀粉样变)/ Vascular mal
9、formations /aneurysmCardiac and hemodynomics disorders Mural 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,Hypertension Di
10、abetes mellitus Cardiac disorder Hyperhomocysteinemia TIA or stroke history Smoking or alcohol abuse Hyperlipemia Others: obesity, age, contraceptive（避孕）, high fibrinogen ,Primary prevention (一级预防),Hypertension Cardiac disorder Diabetes mellitus Hyperlipemia Smoking or alcohol abuse Weight control C
11、arotid artery stenosis Hyperhomocysteinemia (16umol/l) high fibrinogen Exercise, 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, Exerc
12、ise, diet Anti-platelet aggregation post-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
13、 over 24 hours, leave no symptom , physical sign or sequela（后遗症）,Etiological factors and pathogenesis,Mini-embolism Cerebral vascular spasm Blood constituent and hemodynamic（血液动力学） alteration Others: vasculitis, cervical syndrome,（颈椎病）,Clinical situation,Middle-age or senium, malefemale, Company wit
14、h hypertension, diabetes, cardiac disease, hyperlipemia Acute onset, usually reach to the peak within 5min, recover within 30min,never last over 24 hours, leave no symptom , physical sign or sequela Relative fixed symptom,relapse,Clinical situation,Internal carotid artery TIA Ophthalmic artery cross
15、ing paralysis Horner sign crossing paralysis Aphasia失语( dominant hemisphere) Vertebral-Basilar artery TIA Drop attack: reticular formation of brain stem (脑干网状结构) Transient global amnesia Binocular 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),
16、 dysphagia(吞咽困难),Diagnosis,Case history Platelet counting and aggregation rate Blood sugar and blood lipid on an empty stomach Prothrombin time and partial thromboplastin time Erythrocyte sedimentation（血沉） EEG,TCD CT,MRA,CTA,DSA,differential diagnosis,Partial epilepsia Menieres disease Cardiac disor
17、der RIND(reversible ischemic neurologic deficit) Migraine headache( 偏头痛) Tumor,treatment,Etiological treatment Prophylactic drugs(预防用药) Anti-platelet aggregation drugs Anticoagulant drugs Brain conservancy Surgeryprognosis,第四节 cerebral infarction （脑梗死）,cerebral infarction,Prolonged interruption of b
18、lood flow leads to irreversible injury and persistent neurologic deficits clinic categoryRIND(reversible ischemic neurologic deficit):3w Progressive ischemic stroke :6h2w Completed ischemic stroke:6h Pathologic category Atherothrombotic cerebral infarction (artery to artery embolism/thromboembolism
19、& cerebral thrombosis) Cerebral embolism Lacunar infarction Cerebral 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 prolon
20、ged interruption of blood flow , irreversible injury and persistent neurological deficits.etiologic factor Cerebral atherosclerosis,Pathogenesis Endothelial injury adherence of monocyto/macrophages/T-lymphocyte migration and subendothelial localization of the cells formation of platelet thrombus pro
21、liferative lesion (fibrous plaque) Energy,excitatory amino acid,calcium overload, ischemic cerebral edema,nitric oxide,immediate early genes, neurotrophic factors,heat shock protein, CK, apoptosis Ischemic penumbra(缺血半暗带) CBF20 ml/100g.min electric failure threshold CBF10 ml/100g.min membrane failur
22、e threshold Reperfusion damage,hemorrhagic infarction TTW (therapeutic time window), RTW (reperfusion time window), CTW (cytoprotective time window) Pathology,Clinical findings,elder person with atherosclerosis, hypertension,diabetes,cardiac disorder Stepwise incremental neurologic deficits Associat
23、ed symptoms(often without seizures,headache,vomiting,dementia) In quiet status,Internal carotid artery,Syndrome Transient monocular blindness(retinal artery ischemia) the severity is highly variable Symptomatic similar to the MCA occlusion or asymptomatic,Middle cereberal artery occlusion,Anatomy: s
24、upplies most of the cerebral hemisphere and deep subcortical structuressuperior division: 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 r
25、elated to macular vision; the receptive language area of the dominant hemisphere lenticulostriate 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:
26、contralateral hemiparesis that affects the face, hand, and arm but spares the leg Contralateral hemisensory deficit in the same distribution No homonymose hemianopia(偏盲） Brocars aphasia ( the dominant hemisphere is involved), which is characterized by impairment of language expression with intact co
27、mprehension,Middle cereberal artery occlusion,Syndrome: Inferior division stroke: Contralateral homonymose hemianopia ,may be denser inferiorly Impairment of cortical sensory functions Disorders of spatial thought Wernickes aphasia(dominant hemisphere),manifested by impaired comprehension and fluent
28、 but often nonsensasiacal speech Acute confusional state(non domonant hemisphere),Middle cereberal artery occlusion,Syndrome: the bifurcation or trifurcation of MCA Contalateral hemiparesis and hemisensory deficit involving the face and arm far more than the leg Homonymous hemianopia Global(dominant
29、 hemisphere) aphasia,characterized by combined expressive and receptive,Middle cerebral artery occlusion,Syndrome: the stem of MCA Contalateral hemiparesis and hemisensory deficit involving the face ,hand,arm and the leg Homonymous hemianopia Global(dominant hemisphere) aphasia,anterior cerebral art
30、ery occlusion,Anatomy: supplies the parasagittal 矢状旁cerebral cortexincludes portions of motor and sensory cortex related to the leg and micturition排尿 center Syndrome: Contralateral paralysis and sensory loss affecting leg ,voluntary control of micturition may be impaired,Basilar Artery system,Anatom
31、y:branches of BA supply the occipital and medial temporal ， medial thalamus, the posterior limb of the internal 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
32、 both vertebral artery (VA) or of a lone unpaired VA Ipsilateral cerebellar ataxia共济失调, vertigo, nausea, vomiting, 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
33、occlusion,the ventral portion of the pons (basis pontis) is infarcted and the tegmentum is spared,such patients remain conscious but quadriplegic.They may open their eyes or move their eyes vertically on command. Weber syndrome: ipsilateral III nerve palsy, contralateral hemiparesis Parinaud syndrom
34、e:unable to move eyes vertically Benedikt syndrome: ipsilateral III nerve palsy, involuntary movement不自主运动 on the contralateral,Basilar Artery system,Millard-Gubler syndrome: ipsilateral facial nerve, abducent nerve paralysis, contralateral hemiplagiaFoville syndrome: syntropy gaze paralysis to the
35、focus, ipsilateral facial nerve, abducent nerve paralysis, contralateral hemiplagiaWallenberg syndrome: ipsilateral cerebellar ataxia,Horners syndrome,facial sensory deficit;contrlateral impaired pain and temperature sensation; nystagus(眼震), vertigo，nausea, vomiting, dysphagia, dysarthria, and hiccu
36、pTop of the basilar artery syndrome: abnormal eye movement, pupil, consciousness and behavior, lose of rememberance, contralateral hemiablepsia or cortexablepsia,Posterior artery,Anatomy:supply the occipital cerebral cortex,medial temporal lob,thalamus,and rostral midbrain(中脑脚)Clinical syndrome:homo
37、nymous hemianopia affecting contralateral visual field,vertical gaze palsy; oculomotor nerve palsy,internuclear 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 behavi
38、oral syndrome.,Investigative studies,Blood tests Complete blood count (to find possible cause of stroke as thrombocytosis, 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 VDR
39、L） Serum glucose (to detect hypoglycemia or hyperosmolar nonketotic hyperglycemia高渗性非酮症性高血糖) Serum cholesterol and lipids,Investigative studies,Electrocardiaogram(to detect unrecognized myocardial infarction or cardiac arythmias, such as fibrillation) CT:low density MRI:T1-weighted MRI scan shows de
40、creases signal,T2 -weighted MRI scan shows increases signal Lumbar puncture(腰穿) Cerebral angiography Ultrasonography / transcranial doppler/ Echocardiography(心超) Electroencephalogram SPECT，PET,Diagnosis and differential diagnosis,Onset and course: neurologic deficits progress over seconds to hours /
41、 occasionally days,happened in quiet status or in sleep Duration of deficits: persist for at least 24 hr RIND (almost completely resolve in a few days, 3weeks) History: artherosclerosis, hypertension, diabetes mellitus,coronary artery disease, TIAs, Associated symptoms:without headache, vomiting, se
42、izures, or coma. CT scan and MRI: T1 short, T2 long,Treatment,Thrombolytic therapy: tissue plasminogen activator(tPA) 0.9mg/kg within 3hr,urokinase,major complication is hemorrhage affecting brain or other tissues。 Contraindication:time has over 3h,CT scan has shown evidence of a large ischemic stro
43、ke or of hemorrhage,coagulation function has been compromised by the administration of warfarin or heparin or by throbocytopenia (platelet 180/110mmHg, elder than 75y Within the first 24h after t-PA,anticoagulant and antiplateletagents should not be given.,Treatment,Acute period Antiplatelet agents:
44、 Asprin, ticlopidine, clopidogrel Blood dilute Expand blood vessel Defibrase: batoxobin, ancrod Anticoagulation: heparin, warfarin Antihypertensive agents（Bp220/120mmHg） Antiedema agents: mannitol, furosemide Neuroprotective agents: barbiturates,the opioid antagonist naloxone, calcium channel antago
45、nists, excitatory amino acid receptor antagonists Symptomatic treatment 对症治疗：blood pressure, temperature, hyperglycemia, pneumonia, bedsore, upper gastrointestinal hemorrhage, dysphagia, electrolyte disturbance Surgery convalescent treatment Secondary prevention,prognosis,Mortality 10%Multilation ra
46、te 50%about 40% patients who survived the acute period would recidivism,Part two,Cerebral embolism （脑栓塞）,Cerebral embolism,All kinds of emboli enter the cerebral vascular,break down blood flow,induce the district brain necrosis,and turn up relevant neurological deficiency.Etiological factors and pat
47、hogenesis Cardiac genesis (70%) Mural thrombus(附壁血栓) / rheumatic heart disease/ arrhythmias （心律失常）/ endocarditis Non cardiac genesis Fracture, cancer, air Red infarction(hemorrhagic infarction),Clinic finding,Onset : begin abruptly,usually within a few seconds or minutes, neurologic deficits may be
48、maximal at onset, happened in quiet or in active status Age: young as well as oldHistory: TIAs, Mural thrombus/ rheumatic heart disease/ arrhythmias / endocarditis/ fractureAssociated symptoms:headache, vomiting, seizures, or disorders of consciousness can be found in some patients.Symptoms relate w
49、ith the emboli original diseases or emboli signs in other tissues,Syndromes:,Internal carotid artery system: Contralateral hemiparesis and hemisensory loss Contralateral homonymous hemianopia aphasia(dominant hemisphere), characterized by combined expressive and receptive vertebral-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,Investigative studies,
