急性腦梗死課件

急性腦梗死1急性腦梗死第一節(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。2急性腦梗死第二節(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。3急性腦梗死第三節(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4急性腦梗死第四節(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MRADSA5急性腦梗死6急性腦梗死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。7急性腦梗死

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

8急性腦梗死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(hù)劑脫水問題9急性腦梗死超早期溶栓治療10急性腦梗死抗栓治療TheannualizedratesoftotalMajorbleedingeventsSecondarystrokepreventionofantithromboticsAmJCardiol.2009，15;103(8):1107-12.11急性腦梗死Design13studiesfollow-up：>or=1yeartocompare：aspirin(<or=325mg/day),clopidogrel,anticoagulants(warfarinandothervitaminKantagonists),aspirinplusclopidogrel,andaspirinplusextended-releasedipyridamole(ER-DP)

12急性腦梗死Totalbleedingrate4.8%-aspirin(<or=325mg/day)2.9%-clopidogrel3.6%-aspirinplusER-DP10.1%-aspirinplusclopidogrel16.8%-anticoagulation13急性腦梗死Majorbleedingrate1%-aspirin(<or=325mg/day)0.85%-clopidogrel0.93%-aspirinplusER-DP1.7%-aspirinplusclopidogrel2.5%-anticoagulation

14急性腦梗死ConclusionThecombinationofaspirinandclopidogrelisassociatedwithsignificantlygreaterbleedingthaneitheraspirin(<or=325mg/day)orclopidogrelalone.AspirinplusER-DPhasagreaterbleedingratethanclopidogrelbutalowerratethanaspirin(<or=325mg/day)alone

15急性腦梗死Proton-pumpinhibitors(PPIs)andclopidogrel

13,608patients33%(n=4529)ofpatientswereonaPPIatrandomisationNoassociationexistedbetweenPPIuseandriskoftheprimaryendpointThecurrentfindingsdonotsupporttheneedtoavoidconcomitantuseofPPIs

Lancet.2009Sep19;374(9694):989-97.Epub2009Aug3116急性腦梗死17急性腦梗死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?18急性腦梗死pleiotropiceffectsofstatins

pleiotropiceffectsbeyondtheireffectsoncholesterollevelsvasoprotectivemechanismsimprovedendothelialfunctionincreasedbioavailabilityofnitricoxideimmunomodulationandantiinflammationstabilizationofatheroscleroticplaquesantioxidantstemcell-regulatingcapacities19急性腦梗死Preventstrokeandimproveoutcome

statinsreducetheriskofmyocardialinfarctionandstrokestatinsmayalsoimproveoutcomeafterstrokeandmyocardialinfarctionadministeredaftertheeventabruptdiscontinuationafteracutecerebrovasculareventsmayimpairvascularfunctionandincreasemorbidityandmortality20急性腦梗死EffectsincriticallyillpatientsMajorsurgerySepsisHigh-vascularriskIVformulationofHydrophilicstatins21急性腦梗死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......4.168687/6872164691242226/2604354/385186/16622急性腦梗死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

23急性腦梗死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

24急性腦梗死ControllingBPforstroke>or=2medicationswithdifferentmechanismsofactionwillbenecessaryRAAShaveproventobeexcellenttherapeutictargetsAnumberofantiatheroscleroticeffectshavebeenattributedtoangiotensin-convertingenzymeinhibitorsandangiotensinreceptorblockerscombinationtherapywiththeseagentshasbecomethefocusofrecentclinicaltrialsAmHeartJ.2009Jun;157(6Suppl):S24-3025急性腦梗死Cumulativeproportionsofpatientsprescribednewmedicationnewstatin(adding)clopidogrelnewBPloweringmed.2newBPloweringmed.EXPRESSstudy,Rothwelletal,Lancet2007;370:1432-4226急性腦梗死ACEIsclinicalevidencesuggeststhatACEIsaddedtostandardtherapyreduceCVmortality,MI,andstrokeinabroadpopulationofpatientsathighriskforischemicevents.27急性腦梗死ARBs

andischemicstrokepreventionTheStudyonCognitionandPrognosisintheElderly(SCOPE)assessedtheeffectofcandesartantherapyonCVeventsinelderlypatients.SCOPEtrialassessedtheeffectofcandesartantherapyonCVeventsinelderlypatients.Activetreatmentwasassociatedwithasignificantreductioninnonfatalstroke(28%,P=.04vsplacebo)andtotalstroke(24%,P=.056vsplacebo).28急性腦梗死PRoFESStriallimitationsDiastolicBP(<80mmHg)inthefirstmonthpost-strokemayhavebeentoolowinatleastonethirdofthepopulationBaselinesystolicbloodpressurelessthan130mmHg,becauseahighdoseoftelmisartanwasgivenafteraveryshortpost-strokedelay(median15days)29急性腦梗死CombinationACEI/ARBtherapyCombinationtherapyresultedina2.4/1.4-mmHggreaterdecreaseinBPcomparedwithramiprilaloneAgrowingnumberofstudiesindicatethatARBsandACEIsprovidestrokeprotectionbeyondtheirabilitytoreduce30急性腦梗死Meta-analysis4randomizedclinicaltrialsincluding426patients.94%hadischemicstrokeFluoroquinolonesin2andtetracyclineoracombinationofbeta-lactamantibioticwithbeta-lactamaseinhibitorin1Within24hoursDurationforbetween3and5daysArchNeurol.2009Sep;66(9):1076-81Preventiveantibioticsinpatientswithacutestroke

31急性腦梗死控制高血糖32急性腦梗死ManagementofhyperglycemiaincriticallyillpatientsAbetterlong-termoutcomewasshowninpatientswhosufferedfromMIandwhounderwentmeticulousbloodglucosecontrol1,548surgicalintensivecarepatientshadbeenrandomlyallocatedtoeithertheconventionalapproach(insulininfusionstartedonlywhenbloodglucoselevelsexceeded12mmol/L)orintensiveinsulintherapy(insulininfusedtomaintainbloodglucoseatalevelof4