急性腦梗死[醫(yī)術(shù)材料]

1、11 12 是由于局部腦血流中斷引起,時(shí)間超過 2小時(shí)，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。 13 腦動(dòng)脈粥樣硬化腦動(dòng)脈粥樣硬化：高血壓、高血脂、 吸煙 小血管玻璃樣變小血管玻璃樣變：高血壓、糖尿病 低灌注性腦梗死低灌注性腦梗死：動(dòng)脈狹窄 心源性腦栓塞心源性腦栓塞：冠心病、風(fēng)心病 血管炎血管炎：SLE、 結(jié)核、螺旋體動(dòng)脈炎 其它：其它：避孕藥。 14 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(dòng)脈硬化，S-小血管，C-心源 性，O-其它 15 血脂、糖代謝、HCY 心臟、血管彩超 頭顱C

2、T及CT A 頭顱MRI及MRA DSA 16 17 OCSP 完全前循環(huán)：完全前循環(huán)：意識(shí)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)部分前循環(huán)：皮層枝或深穿支 完全后循環(huán)完全后循環(huán)：四肢癱瘓、眩暈、意識(shí)障礙 腔隙性腦梗死腔隙性腦梗死：21型，常見有5型。 18 19 腦梗死的急性期治療腦梗死的急性期治療 超早期溶栓治療超早期溶栓治療 抗栓治療抗栓治療 他汀類藥物他汀類藥物 抗高血壓藥物抗高血壓藥物 控制高血糖控制高血糖 抗炎抗炎 神經(jīng)保護(hù)劑神經(jīng)保護(hù)劑 脫水問題脫水問題 110 超早期溶栓治療超早期溶栓治療 111 抗栓治療抗栓治療 The annualized rates

3、 of total Major bleeding events Secondary stroke prevention of antithrombotics Am J Cardiol. 2009，15;103(8):1107-12. 112 Design 13 studies follow-up： or =1 year to compare：aspirin ( or =325 mg/day), clopidogrel, anticoagulants (warfarin and other vitamin K antagonists), aspirin plus clopidogrel, and

4、 aspirin plus extended-release dipyridamole (ER-DP) 113 Total bleeding rate 4.8%-aspirin ( or =325 mg/day) 2.9% - clopidogrel 3.6%- aspirin plus ER-DP 10.1% - aspirin plus clopidogrel 16.8%- anticoagulation 114 Major bleeding rate 1% - aspirin ( or =325 mg/day) 0.85%-clopidogrel 0.93%-aspirin plus E

5、R-DP 1.7%-aspirin plus clopidogrel 2.5%-anticoagulation 115 Conclusion The combination of aspirin and clopidogrel is associated with significantly greater bleeding than either aspirin ( or =325 mg/day) or clopidogrel alone. Aspirin plus ER-DP has a greater bleeding rate than clopidogrel but a lower

6、rate than aspirin ( or =2 medications with different mechanisms of action will be necessary RAAS have proven to be excellent therapeutic targets A number of antiatherosclerotic effects have been attributed to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers combination ther

7、apy with these agents has become the focus of recent clinical trials Am Heart J. 2009 Jun;157(6 Suppl):S24-30 126 Cumulative proportions of patients prescribed new medication new statin (adding) clopidogrel new BP lowering med. 2 new BP lowering med. EXPRESS study, Rothwell et al, Lancet 2007;370:14

8、32-42 127 ACEIs clinical evidence suggests that ACEIs added to standard therapy reduce CV mortality, MI, and stroke in a broad population of patients at high risk for ischemic events. 128 ARBs and ischemic stroke prevention The Study on Cognition and Prognosis in the Elderly (SCOPE) assessed the eff

9、ect of candesartan therapy on CV events in elderly patients. SCOPE trial assessed the effect of candesartan therapy on CV events in elderly patients. Active treatment was associated with a significant reduction in nonfatal stroke (28%, P = .04 vs placebo) and total stroke (24%, P = .056 vs placebo).

10、 129 PRoFESS trial limitations Diastolic BP (80 mmHg) in the first month post- stroke may have been too low in at least one third of the population Baseline systolic blood pressure less than 130 mmHg, because a high dose of telmisartan was given after a very short post-stroke delay (median 15 days)

11、130 Combination ACEI/ARB therapy Combination therapy resulted in a 2.4/1.4- mm Hg greater decrease in BP compared with ramipril alone A growing number of studies indicate that ARBs and ACEIs provide stroke protection beyond their ability to reduce 131 Meta-analysis 4 randomized clinical trials inclu

12、ding 426 patients.94% had ischemic stroke Fluoroquinolones in 2 and tetracycline or a combination of beta-lactam antibiotic with beta- lactamase inhibitor in 1 Within 24 hours Duration for between 3 and 5 days Arch Neurol. 2009 Sep;66(9):1076-81 Preventive antibiotics in patients with acute stroke 1

13、32 控制高血糖控制高血糖 133 Management of hyperglycemia in critically ill patients A better long-term outcome was shown in patients who suffered from MI and who underwent meticulous blood glucose control 1,548 surgical intensive care patients had been randomly allocated to either the conventional approach (in

14、sulin infusion started only when blood glucose levels exceeded 12 mmol/L) or intensive insulin therapy (insulin infused to maintain blood glucose at a level of 4.5-6.1 mmol/L 80 110 mg/dL) Intensive insulin therapy reduced intensive care mortality by more than 40% Mesotten D, Van den Berghe G. Clini

15、cal potential of insulin therapy in critically ill patients. Drugs 2003;63:625-636 134 Intravenous insulin is feasible and achieves euglycemia in stroke Gray et al. Stroke 2004;35:122 Bruno et al.Neurology 2004;62:1441 135 Glucose-Potassium-Insulin infusion in the management of post stroke hyperglycemia: the UK Glucose Insulin in Stroke Trial (GIST-UK). Lancet N