李亞雄讀書報告-基底動脈閉塞.ppt

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

2、近端和中段 顱外血栓栓子基底動脈遠端,BAO,主干閉塞：反復眩暈、惡心、復視、構音障礙等，病情發(fā)展快而出現(xiàn)四肢癱、昏迷、并導致死亡 分支閉塞： 腦橋腹外側綜合癥 閉鎖綜合癥 基底動脈尖綜合癥 等 (構音障礙、瞳孔改變、球部癥狀和意識障礙,Examination,實驗室檢查：凝血酶原時間、部分凝血活酶時間、膽固醇水平、血脂、心肌同工酶、肌鈣蛋白水平 影像學檢查：頭顱CT（24h） MRI和MRA CTA DSA,Diagnosis,危險因素 （高血壓、糖尿?。?局灶性神經功能缺損 可有反復TIA 影像學資料,Therapy,急性期治療： 時間再通預后 一般治療 溶栓治療 靜脈溶栓(IVT) 動脈

3、溶栓(IAT) 在BAO急性期，靜脈溶栓聯(lián)合機械性血栓取出術(EMT)可以明顯提高閉塞血管的再通率，改善預后,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,個體化原則 預防再閉塞： 阿司匹林 所有患者在治療后1-7天內都復查CT或MRI 出院后隨訪3個月 Intravenous abciximab and intraarterial rt-PA (

7、bridging therapy,Results,IVT治療時間窗延長到6h Bridging Therapy時間窗延長到24h 缺點：人數(shù)少，缺少大規(guī)模隨機對照試驗。 聯(lián)合治療前景廣闊 (血管成形術/支架置入術,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,