急性腦梗死演示文稿

急性腦梗死演示文稿1*現(xiàn)在是1頁\一共有40頁\編輯于星期五優(yōu)選急性腦梗死2*現(xiàn)在是2頁\一共有40頁\編輯于星期五第一節(jié)急性腦梗死的概述是由于局部腦血流中斷引起,時間超過2小時，DWI上有表現(xiàn)。占腦卒中的85%。85%預(yù)后是好的，15%的缺血腦卒中預(yù)后差，死亡率高。3*現(xiàn)在是3頁\一共有40頁\編輯于星期五第二節(jié)急性腦梗死的病因腦動脈粥樣硬化：高血壓、高血脂、吸煙小血管玻璃樣變：高血壓、糖尿病低灌注性腦梗死：動脈狹窄心源性腦栓塞：冠心病、風(fēng)心病血管炎：SLE、結(jié)核、螺旋體動脈炎其它：避孕藥。4*現(xiàn)在是4頁\一共有40頁\編輯于星期五第三節(jié)急性腦梗死的分類OCSP：按臨床癥狀分：完全前循環(huán)、部分前循環(huán)、完全后循環(huán)、腔隙性腦梗死ASCO：A-動脈硬化，S-小血管，C-心源性，O-其它5*現(xiàn)在是5頁\一共有40頁\編輯于星期五第四節(jié)急性腦梗死的診斷血脂、糖代謝、HCY心臟、血管彩超頭顱CT及CTA頭顱MRI及MRADSA6*現(xiàn)在是6頁\一共有40頁\編輯于星期五7*現(xiàn)在是7頁\一共有40頁\編輯于星期五OCSP完全前循環(huán)：意識障礙、眼球凝視、語言障礙加偏癱（皮層枝加深穿支）部分前循環(huán)：皮層枝或深穿支完全后循環(huán)：四肢癱瘓、眩暈、意識障礙腔隙性腦梗死：21型，常見有5型。8*現(xiàn)在是8頁\一共有40頁\編輯于星期五

急性腦梗死的治療陸正齊中山大學(xué)附屬第三醫(yī)院神經(jīng)病學(xué)科

9*現(xiàn)在是9頁\一共有40頁\編輯于星期五腦梗死的急性期治療超早期溶栓治療抗栓治療他汀類藥物抗高血壓藥物控制高血糖抗炎神經(jīng)保護劑脫水問題10*現(xiàn)在是10頁\一共有40頁\編輯于星期五超早期溶栓治療11*現(xiàn)在是11頁\一共有40頁\編輯于星期五抗栓治療TheannualizedratesoftotalMajorbleedingeventsSecondarystrokepreventionofantithromboticsAmJCardiol.2009，15;103(8):1107-12.12*現(xiàn)在是12頁\一共有40頁\編輯于星期五

Design13studiesfollow-up：>or=1yeartocompare：aspirin(<or=325mg/day),clopidogrel,anticoagulants(warfarinandothervitaminKantagonists),aspirinplusclopidogrel,andaspirinplusextended-releasedipyridamole(ER-DP)

13*現(xiàn)在是13頁\一共有40頁\編輯于星期五Totalbleedingrate4.8%-aspirin(<or=325mg/day)2.9%-clopidogrel3.6%-aspirinplusER-DP10.1%-aspirinplusclopidogrel16.8%-anticoagulation14*現(xiàn)在是14頁\一共有40頁\編輯于星期五Majorbleedingrate1%-aspirin(<or=325mg/day)0.85%-clopidogrel0.93%-aspirinplusER-DP1.7%-aspirinplusclopidogrel2.5%-anticoagulation

15*現(xiàn)在是15頁\一共有40頁\編輯于星期五ConclusionThecombinationofaspirinandclopidogrelisassociatedwithsignificantlygreaterbleedingthaneitheraspirin(<or=325mg/day)orclopidogrelalone.AspirinplusER-DPhasagreaterbleedingratethanclopidogrelbutalowerratethanaspirin(<or=325mg/day)alone

16*現(xiàn)在是16頁\一共有40頁\編輯于星期五Proton-pumpinhibitors(PPIs)andclopidogrel

13,608patients33%(n=4529)ofpatientswereonaPPIatrandomisationNoassociationexistedbetweenPPIuseandriskoftheprimaryendpointThecurrentfindingsdonotsupporttheneedtoavoidconcomitantuseofPPIs

Lancet.2009Sep19;374(9694):989-97.Epub2009Aug3117*現(xiàn)在是17頁\一共有40頁\編輯于星期五18*現(xiàn)在是18頁\一共有40頁\編輯于星期五

StatinsforstrokePleiotropiceffectsPreventORtreatment?criticallyillpatients?腎病血透病人及腎移植病人?出血性卒中?大劑量與標(biāo)準(zhǔn)劑量?19*現(xiàn)在是19頁\一共有40頁\編輯于星期五pleiotropiceffectsofstatins

pleiotropiceffectsbeyondtheireffectsoncholesterollevelsvasoprotectivemechanismsimprovedendothelialfunctionincreasedbioavailabilityofnitricoxideimmunomodulationandantiinflammationstabilizationofatheroscleroticplaquesantioxidantstemcell-regulatingcapacities20*現(xiàn)在是20頁\一共有40頁\編輯于星期五Preventstrokeandimproveoutcome

statinsreducetheriskofmyocardialinfarctionandstrokestatinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheeventabruptdiscontinuationafteracutecerebrovasculareventsmayimpairvascularfunctionandincreasemorbidityandmortality21*現(xiàn)在是21頁\一共有40頁\編輯于星期五EffectsincriticallyillpatientsMajorsurgerySepsisHigh-vascularriskIVformulationofHydrophilicstatins22*現(xiàn)在是22頁\一共有40頁\編輯于星期五研究名稱出版時間處理因素mg對照因素mg平均隨訪時間（年）病例數(shù)(I/C)平均年齡(歲)男性比例（%）基礎(chǔ)LDHMg/dl卒中病例數(shù)(I/C)致死卒中(I/C)腦出血A(I/C)ALLHAT-ALL2002pravastatin40空白4.85170/51856650146209/23153/56..PROSPER2002pravastatin40安慰劑3.22891/29137548147135/13122/14..GREACE2002atorvastatin10-80空白3800/80059791809/170/11/1HPS2002simvastatin40安慰劑510269/102676575131444/58596/11951/53ASCOT-ALL2003atorvastatin10安慰劑3.35168/5137638113389/121....ALERT2003fluvastatin40安慰劑5.11050/1052506615974/6317/14..CARDS2004atorvastatin10安慰劑3.91428/1410626811721/391/70/0PROVEIT2004atorvastatin80pravastatin4022099/2063587810621/19....AtoZ2004simvastatin80安慰劑22265/2232617611228/35....ALLIANCE2004simvastatin81空白4.31217/1225618314735/39....TNT2005simvastatin82atorvastatin104.94995/5006618198117/155..16/19DDDD2005simvastatin83安慰劑4619/636665412660/4527/133/5IDEAL2005simvastatin84simvastatin204.84439/44496281121151/174....SPARCL2006simvastatin85安慰劑4.92365/23666360133265/31124/4155/33ASPEN2006simvastatin86安慰劑41211/1199616611334/38....MEGA2006simvastatin87飲食5.33866/3966583115650/62..14/16CORONA2007simvastatin88安慰劑2.72514/24977376137103/11514/1115/9JUPITER2008simvastatin89安慰劑1.98901/8901666210833/643/66/9AURORA2009simvastatin90安慰劑3.21389/1384646210093/8140/3625/21SEARCH2009simvastatin91simvastatin206.76031/6033648397255/27957/67..合計......4.168687/6872164691242226/2604354/385186/16623*現(xiàn)在是23頁\一共有40頁\編輯于星期五他汀與安慰劑或空白對照比較對所有卒中預(yù)防的meta分析

24*現(xiàn)在是24頁\一共有40頁\編輯于星期五4個研究大劑量與標(biāo)準(zhǔn)劑量他汀對所有卒中預(yù)防的meta分析

25*現(xiàn)在是25頁\一共有40頁\編輯于星期五ControllingBPforstroke>or=2medicationswithdifferentmechanismsofactionwillbenecessaryRAAShaveproventobeexcellenttherapeutictargetsAnumberofantiatheroscleroticeffectshavebeenattributedtoangiotensin-convertingenzymeinhibitorsandangiotensinreceptorblockerscombinationtherapywiththeseagentshasbecomethefocusofrecentclinicaltrialsAmHeartJ.2009Jun;157(6Suppl):S24-3026*現(xiàn)在是26頁\一共有40頁\編輯于星期五Cumulativeproportionsofpatientsprescribednewmedicationnewstatin(adding)clopidogrelnewBPloweringmed.2newBPloweringmed.EXPRESSstudy,Rothwelletal,Lancet2007;370:1432-4227*現(xiàn)在是27頁\一共有40頁\編輯于星期五

ACEIsclinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.28*現(xiàn)在是28頁\一共有40頁\編輯于星期五ARBs

andischemicstrokepreventionTheStudyonCognitionandPrognosisintheElderly(SCOPE)assessedtheeffectofcandesartantherapyonCVeventsinelderlypatients.SCOPEtrialassessedtheeffectofcandesartantherapyonCVeventsinelderlypatients.Activetreatmentwasassociatedwithasignificantreductioninnonfatalstroke(28%,P=.04vsplacebo)andtotalstroke(24%,P=.056vsplacebo).29*現(xiàn)在是29頁\一共有40頁\編輯于星期五PRoFESStriallimitationsDiastolicBP(<80mmHg)inthefirstmonthpost-strokemayhavebeentoolowinatleastonethirdofthepopulationBaselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)30*現(xiàn)在是30頁\一共有40頁\編輯于星期五CombinationACEI/ARBtherapyCombinationtherapyresultedina2.4/1.4-mmHggreaterdecreaseinBPcomparedwithramiprilaloneAgrowingnumberofstudiesindicatethatARBsandACEIsprovidestrokeprotectionbeyondtheirabilitytoreduce31*現(xiàn)在是31頁\一共有40頁\編輯于星期五Meta-analysis4randomizedclinicaltrialsincluding426patients.94%hadischemicstrokeFluoroquinolonesin2andtetracyclineoracombinationofbeta-lactamantibioticwithbeta-lactamaseinhibitorin1Within24hoursDurationforbetween3and5daysArchNeurol.2009Sep;66(9):1076-81Preventiveantibioticsinpatientswithacutestroke

32*現(xiàn)在是32頁\一共有40頁\編輯于星期五控制高血糖33*現(xiàn)在是33頁\一共有40頁\編輯于星期五ManagementofhyperglycemiaincriticallyillpatientsAbetterlong-termoutcomewasshowninpatientswhosufferedfromMIandwhounderwentmeticulousbloodglucosecontrol1,548surgicalintensivecarepatientshadbeenrandomlyallocatedtoeithertheconventionalapproach(insulininfusionstartedonlywhenbloodglucoselevelsexceeded12mmol/L)orintensiveinsulintherapy(insulininfusedtomaintainblood