脑小血管病概念与治疗_精品文档.pptx

1、脑小血管病脑小血管病概念与治疗概念与治疗杜万良北京天坛医院神经内科2014.11.15脑小血管注射硫酸钡的标本。白质中央血管密度低。Salamon,N.,Neuroimaging of cerebral small vessel disease.Brain Pathol,2014.24(5):p.519-24.脑小血管注射硫酸钡的标本。供应胼胝体的小分支。Salamon,N.,Neuroimaging of cerebral small vessel disease.Brain Pathol,2014.24(5):p.519-24.脑小血管病的分类急性：卒中慢性：痴呆腔隙综合征 腔隙综合征(1

2、)纯运动性轻偏瘫(PMH)最常见。病灶可发生在内囊、脑桥、大脑脚、基底节、大脑皮质、放射冠等处。(2)纯感觉性卒中(PSS)病灶位于丘脑腹后核，通常为大脑后动脉的丘脑穿通支梗死所致。少数病例可由脊髓丘脑束、丘脑皮质束的病灶所致，也可因病灶侵及整个丘脑的外侧及内囊后肢的放射冠而引起。(3)感觉运动性卒中(SMS)病灶位于丘脑腹后外侧核和内囊后肢，通常由大脑后动脉的丘脑穿通支或脉络膜后动脉闭塞所致。(4)共济失调轻偏瘫(HAH)病灶发生在脑桥基底部或内囊，放射冠、小脑等处也可发生。(5)构音不良-手笨拙综合征(DHS)病灶位于脑桥基底部的上1/3 和2/3 交界处或内囊最上部分的膝部。脑小血管病的

3、分类微出血血管周围间隙扩大白质疏松腔隙MR表现Wardlaw,J.M.,et al.,Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration.The Lancet Neurology,2013.12(8):p.822-838.急性腔梗的急性腔梗的1年演变年演变Wardlaw,J.M.,C.Smith,and M.Dichgans,Mechanisms of sporadic cerebral small vessel di

4、sease:insights from neuroimaging.Lancet Neurol,2013.12(5):p.483-97.腔隙常在腔隙常在 白质高信号边白质高信号边缘缘Duering,M.,et al.,Incident lacunes preferentially localize to the edge of white matter hyperintensities:insights into the pathophysiology of cerebral small vessel disease.Brain,2013.136(Pt 9):p.2717-26.一名75岁男性，

5、短暂性神经症状发作后1周出现症状性左侧额叶出血Charidimou,A.,J.C.Baron,and D.J.Werring,Transient focal neurological episodes,cerebral amyloid angiopathy,and intracerebral hemorrhage risk:looking beyond TIAs.Int J Stroke,2013.8(2):p.105-8.SVD score(range 04)男性(OR 1.58,95%CI 1.102.29),高血压(OR 1.50,95%CI 1.022.20),吸烟(OR 2.81,9

6、5%CI 1.593.63),腔隙性卒中(OR 2.45,95%CI 1.703.54)与SVDScore相关.脑萎缩与SVDScore无关Staals,J.,et al.,Stroke subtype,vascular risk factors,and total MRI brain small-vessel disease burden.Neurology,2014.83(14):p.1228-34.脑小血管病的分类动脉硬化性血管炎遗传性肿瘤性感染性药物相关性一名CADASIL（伴皮质下梗死和脑白质病的常染色体显性遗传性脑动脉病）患者56岁和66岁的影像Salamon,N.,Neuroim

7、aging of cerebral small vessel disease.Brain Pathol,2014.24(5):p.519-24.一名66岁的女性CADASIL患者Salamon,N.,Neuroimaging of cerebral small vessel disease.Brain Pathol,2014.24(5):p.519-24.COL4A1突变突变47岁无症状COL4A1突变患者（A,C,E,G,I,J）。57岁CADASIL患者。一名HERNS(伴有视网膜病-肾病-卒中的遗传性内皮细胞病)患者早期曾被误诊为多发性硬化Salamon,N.,Neuroimaging

8、of cerebral small vessel disease.Brain Pathol,2014.24(5):p.519-24.一名一名HERNS患者的影像早期有占位效应和强化。Salamon,N.,Neuroimaging of cerebral small vessel disease.Brain Pathol,2014.24(5):p.519-24.一名Susac综合征（脑病，视网膜小动脉闭塞，听力丧失）患者的胼胝体中部病灶Salamon,N.,Neuroimaging of cerebral small vessel disease.Brain Pathol,2014.24(5):

9、p.519-24.7T75岁，男性。动脉，静脉van Veluw,S.J.,et al.,High resolution imaging of cerebral small vessel disease with 7 T MRI.Acta Neurochir Suppl,2014.119:p.125-30.7Ta.58岁，男，一过性黑矇，栓塞，基底动脉高信号。b.49岁，男，反复TIA，动脉粥样硬化，颈内动脉末端高信号。c.66岁，女，血管周围间隙。d.19岁，男，非扩大的血管周围间隙。van Veluw,S.J.,et al.,High resolution imaging of cereb

10、ral small vessel disease with 7 T MRI.Acta Neurochir Suppl,2014.119:p.125-30.7TA.89岁，男性，7T。B.同一人，3T。C.42岁，男性，微出血。D.57岁，女性，房颤，突发失语、左侧轻瘫，心源性栓塞。van Veluw,S.J.,et al.,High resolution imaging of cerebral small vessel disease with 7 T MRI.Acta Neurochir Suppl,2014.119:p.125-30.深部梗死，大脑中动脉栓塞Moran,C.,T.G.Pha

11、n,and V.K.Srikanth,Cerebral small vessel disease:a review of clinical,radiological,and histopathological phenotypes.Int J Stroke,2012.7(1):p.36-46.孤立病灶Kim,J.T.,et al.,Lesion patterns of small deep infarcts have different clinical and imaging characteristics.Eur Neurol,2010.63(6):p.343-9.线性病灶Kim,J.T.

12、,et al.,Lesion patterns of small deep infarcts have different clinical and imaging characteristics.Eur Neurol,2010.63(6):p.343-9.治治疗腔隙性卒中A.纹状体内囊卒中B.丘脑卒中：丘脑结节动脉膝状体动脉脉络膜后动脉旁正中动脉C.脉络膜前动脉D.髓质穿支J Neurol(2014)261:405411小血管病A-C.75岁，男性，共济失调轻偏瘫，4分。未溶栓。核磁显示内囊后肢病灶。出院时遗留左下肢轻瘫，1分。D-E.55岁，男性，感觉运动性轻偏瘫，5分。溶栓。复查CT显示

13、内囊后肢病灶。出院时遗留右下肢轻瘫，1分。Pantoni,L.,F.Fierini,and A.Poggesi,Thrombolysis in acute stroke patients with cerebral small vessel disease.Cerebrovasc Dis,2014.37(1):p.5-13.3个月结局J Neurol(2014)261:405411SPS3随机析因设计抗血小板治疗阿司匹林安慰剂阿司匹林氯吡格雷降低血压治疗常规（收缩压130149mmHg)强化（收缩压130mmHg)SPS3 设计要点主要终点所有卒中复发次要次要终点点认知下降知下降大血管事大血管事件死亡件死亡终点事件终点事件样本量样本量8个国家81家医疗中心 3020例平均随访3.7年失访率3SPS3 结论降低收降低收缩压安全、可耐受安全、可耐受收收缩压小于小于130mmHg可以减少卒中大可以减少卒中大约20（p=0.08)降低血降低血压降低降低脑出血出血23本本结果与之前降低血果与之前降低血压的的结果一致果一致谢谢大家！