Harrisons Principles of Internal Medicine哈里森内科学原理.docVIP

PAGE PAGE 1 Harrisons Principles of Internal Medicine - 16th Ed. (2005) 349. CEREBROVASCULAR DISEASES - Wade S. Smith, S. Claiborne Johnston, J. Donald Easton INTRODUCTION Cerebrovascular diseases include some of the most common and devastating disorders: ischemic stroke, hemorrhagic stroke, and cerebrovascular anomalies such as intracranial aneurysms and arteriovenous malformations (AVMs). They cause ~200,000 deaths each year in the United States and are a major cause of disability. The incidence of cerebrovascular diseases increases with age, and the number of strokes is projected to increase as the elderly population grows, with a doubling in stroke deaths in the United States by 2030. Most cerebrovascular diseases are manifest by the abrupt onset of a focal neurologic deficit, as if the patient was struck by the hand of God. A stroke, or cerebrovascular accident, is defined by this abrupt onset of a neurologic deficit that is attributable to a focal vascular cause. Thus, the definition of stroke is clinical, and laboratory studies including brain imaging are used to support the diagnosis. The clinical manifestations of stroke are highly variable because of the complex anatomy of the brain and its vasculature. Cerebral ischemia is caused by a reduction in blood flow that lasts longer than several seconds. Neurologic symptoms are manifest within seconds because neurons lack glycogen, so energy failure is rapid. When blood flow is quickly restored, brain tissue can recover fully and the patients symptoms are only transient: this is called a transient ischemic attack (TIA). Typically the neurologic signs and symptoms of a TIA last for 5 to 15 min but, by definition, must last ?24 h. If the cessation of flow lasts for more than a few minutes, infarction or death of brain tissue results. Stroke has occurred if the neurologic signs and symptoms last for ?24 h. A generalized reduction in cerebral blood flow due to systemic hypotension (e.g., cardiac arrhythmia,