王学峰《神经病学精品教学》4.2CVD.pptVIP

Examples of CT and MRI (MCA occlusion) a Magnetic resonance angiography, b diffusion-weighted imaging and c perfusion-weighted imaging performed in a patient 2.5 hours after onset of aphasia and right hemiparesis. Occlusion of the left middle cerebral artery trunk (arrow) is seen, with a small diffusion abnormality and a large perfusion abnormality indicative of a large ischemic penumbra (tissue potentially salvageable with thrombolysis). Diagnosis Middle to old age Risk factors including previous TIAs Symptoms peak within min to several days Neurologic deficits correspond to occluded brain areas Positive image findings Differential diagnosis Thrombotic vs. embolic Age, heart disease, TIAs, onset Ischemic vs. hemorrhagic Age, TIAs, background activity, symptom onset, sings of intracranial hypertension, imaging study Subdural/epidural hematoma History of head injury, sings of intracranial hypertension, CT finding Space occupying lesions Broken tumor or abscess Principles of treatment General management: very important Management of brain edema Targeting on thrombosis Thrombolysis, fibrinolytics, anticoagulants, antipltelets (Avoid combined use of these drugs) Neuroprotection Surgery Rehabilitation General management Airway Hypertension(200/110mmHg) Blood sugar Hyperthemia Upper gastrointestinal bleeding Fluid and electrolyte imbalance Heart disease Epilepsy Brain edema Elevation of the head end of the bed to a 20–30 degree angle to improve venous drainage. Hypoxia, hypercapnia, hyperthermia, hyperglycemia, and antihypertensive drugs, particularly those that can cause cerebral vasodilatation, should be avoided. Osmotherapy (manitol, glycerol fructose, corticosteroids). Surgical: decompressive surgery, ventricular drainage. Thrombolysis Indications Time window: 4.5 hrs for rt-PA, 6hrs for urokinase(UK) No known intracranial hemorrhage Contraindications Bleeding tendency (history of bleeding, anticoagulants, low plasma platelets), recent (3months) cerebra