李亞雄讀書報(bào)告-基底動(dòng)脈閉塞.ppt

1、Basilar Artery Occlusion,08級(jí)腦外科研究生 李亞雄,Introduction,約20%的缺血性卒中是椎基底動(dòng)脈閉塞所致?；讋?dòng)脈閉塞(basilar artery occlusionBAO)有臨床表現(xiàn)復(fù)雜、發(fā)病兇險(xiǎn)、病情重、預(yù)后差(90%)等特點(diǎn)，即使采用抗凝和降纖等治療，患者死亡率仍然接近50,Anatomy,Etiopathogenisis,動(dòng)脈粥樣硬化合并狹窄 血栓栓塞 其它：頸部外傷 動(dòng)脈炎 基底動(dòng)脈瘤 高凝狀態(tài) 藥物濫用等,Clinical manifestation,臨床表現(xiàn)取決于動(dòng)脈閉塞的部位、支配的范圍和側(cè)支循環(huán)狀況。 動(dòng)脈粥樣硬化椎基底動(dòng)脈 基底動(dòng)脈

2、近端和中段 顱外血栓栓子基底動(dòng)脈遠(yuǎn)端,BAO,主干閉塞：反復(fù)眩暈、惡心、復(fù)視、構(gòu)音障礙等，病情發(fā)展快而出現(xiàn)四肢癱、昏迷、并導(dǎo)致死亡 分支閉塞： 腦橋腹外側(cè)綜合癥 閉鎖綜合癥 基底動(dòng)脈尖綜合癥 等 (構(gòu)音障礙、瞳孔改變、球部癥狀和意識(shí)障礙,Examination,實(shí)驗(yàn)室檢查：凝血酶原時(shí)間、部分凝血活酶時(shí)間、膽固醇水平、血脂、心肌同工酶、肌鈣蛋白水平 影像學(xué)檢查：頭顱CT（24h） MRI和MRA CTA DSA,Diagnosis,危險(xiǎn)因素 （高血壓、糖尿病） 局灶性神經(jīng)功能缺損 可有反復(fù)TIA 影像學(xué)資料,Therapy,急性期治療： 時(shí)間再通預(yù)后 一般治療 溶栓治療 靜脈溶栓(IVT) 動(dòng)脈

3、溶栓(IAT) 在BAO急性期，靜脈溶栓聯(lián)合機(jī)械性血栓取出術(shù)(EMT)可以明顯提高閉塞血管的再通率，改善預(yù)后,Inclusion criteria,有明確的BAO的癥狀 CT除外腦出血 CTA證據(jù) 6h 無IVT禁忌癥,Methods,Clinical signs (all three required) suggesting acute basilar artery occlusion (BAO): reduced consciousness (GCS 14) oculomotor dysfunction and/or bulbar signs hemi- or tetraparesis a

4、nd/or ataxia,Exclusion of cerebral hemorrhage on CT Evidence of BAO on CTA Treatment within six hours after symptom onset IVT (0,9 mg/kg rt-PA,Transfer to our Stroke Center(24h) (if patient was initially admitted to Community Hospital) CT and CTA Persisting BAO EMT,Intensive Care Unit 或者 CT and CTA

5、Patent Basilar Artery Intensive Care Unit,A total of 106 patients with the clinical syndrome of BAO (symptoms_24 hours) and subsequent confirmation by CT or MRA presented to our institution. Department of Neurology,University of Heidelberg,criteria of the Trial in Myocardial Infarction (TIMI) : TIMI

6、 0, complete occlusion of the BA; TIMI 1, partial recanalization but remnant occlusion; TIMI 2, incomplete recanalization with continuous BA patency but remnant thrombus; TIMI 3, complete recanalization,個(gè)體化原則 預(yù)防再閉塞： 阿司匹林 所有患者在治療后1-7天內(nèi)都復(fù)查CT或MRI 出院后隨訪3個(gè)月 Intravenous abciximab and intraarterial rt-PA (

7、bridging therapy,Results,IVT治療時(shí)間窗延長(zhǎng)到6h Bridging Therapy時(shí)間窗延長(zhǎng)到24h 缺點(diǎn)：人數(shù)少，缺少大規(guī)模隨機(jī)對(duì)照試驗(yàn)。 聯(lián)合治療前景廣闊 (血管成形術(shù)/支架置入術(shù),2009 AHA Scientific Statement,Mechanical Clot Extraction, Angioplasty and Stenting,ESO-Guidelines for Management of Ischaemic Stroke 2008,ESO-Guidelines for Management of Ischaemic Stroke 2008

8、(BAO,References,Staged Escalation Therapy in Acute Basilar Artery Occlusion: Intravenous Thrombolysis and On-Demand Consecutive Endovascular Mechanical Thrombectomy: Preliminary Experience in 16 Patients stroke. 2008;39:1496-1500,References,Therapy of Acute Basilar Artery Occlusion Intraarterial Thrombolysis Alone vs Bridging Therapy stroke. 2009;40:140-146,References,