心源性腦栓塞

心源性腦栓塞1.病歷特點(diǎn)中年男性，反復(fù)發(fā)作漸進(jìn)性病程；既往高血壓史，夾層動脈瘤及主動脈瓣關(guān)閉不全換瓣術(shù)后3年，口服抗凝藥不規(guī)范。近2年多次腦梗塞史。發(fā)病表現(xiàn)為反復(fù)發(fā)作的神經(jīng)功能缺損，漸進(jìn)性的神經(jīng)功能缺損。查體主要表現(xiàn)為言語表達(dá)障礙，構(gòu)音含混，右面部麻木及右肢輕偏癱，及右側(cè)同向偏盲。輔助檢查：凝血象（INR）偏低；

CT：腦內(nèi)多發(fā)梗塞2.定位診斷雙側(cè)頸內(nèi)動脈系統(tǒng)，左側(cè)著椎基底動脈系統(tǒng)？

3.定性診斷心源性栓塞主動脈機(jī)械瓣膜組織栓子脫落

4.AorticDissectionAnatomy,PhysiologyandPrinciplesofTherapy5.History1555–Vesaliusdiagnosedapulsatingtumornearthevertebraeinapatient’sbackandcalledit“adilatationoftheaorta”18261826–Laennecintroducedthetermdissectinganeurysm1800’s–surgerywasperformedontheentitybyJohnHunter,AstleyCooperandothersevenbeforetheeraofgeneralanesthesiaEarlyoperationsweredesignedtoproducedistalinternalfenestrationtocausedownstreamdecompressionoftheaorta.6.History1951LamandAramintroducedhomograftsforrepairofdescendingthoracicaneurysms1953CooleyandDeBakeyusedartificialgraftsforrepair1953Bahnsonintroducedaneurysmorrhaphy1957cardiopulmonarybypassbecameavailable7.DefinitionTrueaneurysm–localizedenlargementoftheaortacontainedbyallthelayersoftheaorticwallFalseaneurysm–enlargementcontainedbytheaorticadventitiaandperiaorticfibroustissue.8.9.10.DefinitionAorticdissection–SuddencatastrophiceventinwhichatearintheintimaallowsbloodtoescapefromthetruelumenoftheaortarapidlyseparatingtheinnerfromtheouterlayerofthemediaColumnofbloodisdrivenbytheforceoftheleftventricularsystolicpressurewhichstripstheintimafromtheadventitia11.DefinitionAcute–lessthan14daysoldChickenortheegg?–Hemorrhageinthemediacausesruptureoftheintimaordissectinghematomainanintimaltear.12.CausesofAneurysmMedialdegenerationandlocaldilatationAtherosclerosisSyphilis(ascendingonly)Bacterialinfections(mycotic)CongenitalabnormalitiesTraumaAnnuloaorticectasia13.CausesofDissectionInherentweaknessoftheaorticwallHypertension–70-90%PregnancyIatrogenicBicuspidaorticvalveandcoarctationClosedchesttrauma14.PathophysiologyLawofLaplace:Asasphereincreasesinsize,thewalltensionofthesphereincreasesWeakenedwallDilatationExpansionwithpressure-relatedsymptomsRupture15.NaturalHistoryNotwelldocumentedSigns,symptomsandprognosisrelatedtothesizeoftheaneurysmThoracicaneurysmslargerthan6cmaremorepronetorupturethanthesmallerones5yearsurvivalforsymptomaticaneurysmsis27%whereas58%withasymptomaticonessurvivedthesameperiodoftime.Ruptureisthemostcommoncauseofdeath16.NaturalHistoryManypatientswithdissectiondieacutelyduetocardiactamponadeordissectionoftheLAD8%ofascendingrupturessurvivewithouttreatment75%survivedescendingdissection17.ClassificationTypeI-BeginsattheaorticvalveandmayproceedtoandincludetheabdominalaortaTypeII–Beginsdistaltotheleftsubclavianarteryandcanencompasstheentireaortatotheiliacarteries18.19.20.21.AnatomicalConsiderations22.PathoanatomyDissectionoftheascendingaortaariseswithinseveralcentimetersoftheaorticvalve–66%DissectionofthedescendingaortaoccurjustbeyondtheleftsubclavianarteryattheligamentumarteriosumSmallpercentageoccuratthetransversearchordescendingaorta23.PathophysiologyAfterdissectionintothemedia,bloodrushesintothedissectedareaNecrosisoftheaorticwallthendevelopsseveraldaysaftertheevent–observedin62%ofcasesComplicationsincludeaorticrupture,obstructionandocclusionofaorticbranches24.25.ClinicalSignsandSymptoms26.DemographicsMales>females3:1SixthorseventhdecadeoflifePatientswithascendingdissectionareabouttenyearsyoungeratpresentationthanthosewithdescendingdissection27.SymptomsSudden,severechestpain–tearingsensationintheanteriorchestradiatingtothearmsortobetweenthescapulaeMayhavesyncope,neurologicsigns,weakness,hypotension.28.PhysicalFindingsParalysisMuffledhearttonesNewonsetaorticinsufficiencymurmurUnequalbloodpressureandpulsesintheextremitiesJugularvenousdistention–tamponadeAbdominalpain–acuteAcutehypertensionandanuria29.DiagnosisPlainchestradiograph–widenedmediastinum,pleuraleffusionElectrocardiogram–mayresembleacutemyocardialinfarctionparticularlyiftheLADisaffectedCTscan–identifiestheproblembutdoesnotprovidearoadmapAngiography–goldstandardTransesophagealechocardiography30.31.32.33.34.Therapy35.AscendingDissectionSurgicalemergencyCanonlybetreatedbyoperationMayormaynotrequireaorticvalvereplacementand/orcoronarybypasssurgerydependingontheprogressionofthedissectionMortality–about20%dependingonothermedicalproblemsandthepresenceofneurologicalsymptoms36.DescendingDissectionTherapycontroversialIfrupturepresent–operationistheonlyalternativeIntheabsenceofrupture,medicallytreatedpatientsdobetterthanthoseundergoingoperationduetocomorbidities37.GoalofOperativeTherapyObliterationofthesiteoftheintimaltearandthefalselumenReapproximationofthedissectedaortaRepairofaorticvalveorreplacementwithvalveconduitPerformbypassgraftingasneeded38.ConductoftheOperationAppropriatepreoperativeassessmentGeneralanesthesiaCardiopulmonarybypassAscendingdissection–profoundhypothermiawithcirculatory