1、急性脑梗死11第一节第一节 急性脑梗死的概述急性脑梗死的概述是由于局部脑血流中断引起,时间超过2小时，DWI上有表现。占脑卒中的85%。85%预后是好的，15%的缺血脑卒中预后差，死亡率高。21第二节第二节 急性脑梗死的病因急性脑梗死的病因脑动脉粥样硬化脑动脉粥样硬化：高血压、高血脂、吸烟小血管玻璃样变小血管玻璃样变：高血压、糖尿病低灌注性脑梗死低灌注性脑梗死：动脉狭窄心源性脑栓塞心源性脑栓塞：冠心病、风心病血管炎血管炎：SLE、结核、螺旋体动脉炎其它：其它：避孕药。31第三节第三节 急性脑梗死的分类急性脑梗死的分类OCSP：按临床症状分：完全前循环、部分前循环、完全后循环、腔隙性脑梗死 AS
2、CO：A-动脉硬化，S-小血管，C-心源性，O-其它41第四节第四节 急性脑梗死的诊断急性脑梗死的诊断血脂、糖代谢、HCY心脏、血管彩超头颅CT及CT A头颅MRI及MRADSA5161OCSP完全前循环：完全前循环：意识障碍、眼球凝视、语言障碍加偏瘫（皮层枝加深穿支）部分前循环部分前循环：皮层枝或深穿支完全后循环完全后循环：四肢瘫痪、眩晕、意识障碍腔隙性脑梗死腔隙性脑梗死：21型，常见有5型。71急性脑梗死的治疗陆正齐陆正齐 中山大学附属第三医院神经病学科中山大学附属第三医院神经病学科 81脑梗死的急性期治疗脑梗死的急性期治疗超早期溶栓治疗超早期溶栓治疗抗栓治疗抗栓治疗他汀类药物他汀类药物抗
3、高血压药物抗高血压药物控制高血糖控制高血糖抗炎抗炎神经保护剂神经保护剂脱水问题脱水问题91 超早期溶栓治疗超早期溶栓治疗101 抗栓治疗抗栓治疗The annualized rates of total Major bleeding events Secondary stroke prevention of antithromboticsAm J Cardiol.2009，15;103(8):1107-12.111 Design13 studies follow-up：or=1 year to compare：aspirin(or=325 mg/day),clopidogrel,anticoa
4、gulants(warfarin and other vitamin K antagonists),aspirin plus clopidogrel,and aspirin plus extended-release dipyridamole(ER-DP)121Total bleeding rate4.8%-aspirin(or=325 mg/day)2.9%-clopidogrel3.6%-aspirin plus ER-DP10.1%-aspirin plus clopidogrel16.8%-anticoagulation131Major bleeding rate1%-aspirin(
5、or=325 mg/day)0.85%-clopidogrel0.93%-aspirin plus ER-DP1.7%-aspirin plus clopidogrel2.5%-anticoagulation 141ConclusionThe 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 b
6、leeding rate than clopidogrel but a lower rate than aspirin(or=2 medications with different mechanisms of action will be necessaryRAAS have proven to be excellent therapeutic targetsA number of antiatherosclerotic effects have been attributed to angiotensin-converting enzyme inhibitors and angiotens
7、in receptor blockers combination therapy with these agents has become the focus of recent clinical trials Am Heart J.2009 Jun;157(6 Suppl):S24-30 251Cumulative proportions of patients prescribed new medicationnew statin(adding)clopidogrelnew BP lowering med.2 new BP lowering med.EXPRESS study,Rothwe
8、ll et al,Lancet 2007;370:1432-42261 ACEIsclinical 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.271ARBsand ischemic stroke preventionThe Study on Cognition and Prognosis inthe Elderly(SCOPE)
9、assessed the effect of candesartan therapy on CV events in elderly patients.SCOPE trial assessed the effect of candesartantherapy 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 place
10、bo).281PRoFESS trial limitationsDiastolic 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)291Co
11、mbination ACEI/ARB therapyCombination therapy resulted in a 2.4/1.4-mm Hg greater decrease in BP compared with ramipril aloneA growing number of studies indicate that ARBs and ACEIs provide stroke protection beyond their ability to reduce 301Meta-analysis4 randomized clinical trials including 426 pa
12、tients.94%had ischemic stroke Fluoroquinolones in 2 and tetracycline or a combination of beta-lactam antibiotic with beta-lactamase inhibitor in 1Within 24 hours Duration for between 3 and 5 days Arch Neurol.2009 Sep;66(9):1076-81 Preventive antibiotics in patients with acute stroke 311 控制高血糖控制高血糖32
13、1Management of hyperglycemia in critically ill patientsA better long-term outcome was shown in patients who suffered from MI and who underwent meticulous blood glucose control1,548 surgical intensive care patients had been randomly allocated to either the conventional approach(insulin infusion start
14、ed 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.Clinical potential of insulin t
15、herapy in critically ill patients.Drugs 2003;63:625-636 331Intravenous insulin is feasible and achieves euglycemia in strokeGray et al.Stroke 2004;35:122Bruno et al.Neurology 2004;62:1441341Glucose-Potassium-Insulin infusion in the management of post stroke hyperglycemia:the UK Glucose Insulin in Stroke Trial(GIST-UK).Lancet Neurol.2007 May;6(5):397-406.351 神经保护剂神经保护剂古老的神经保护剂神经保护剂新型新型神经保护剂神经保护剂361 古老的神经保护剂神经保护剂胞二磷胆碱胞二磷胆碱依达拉奉依达拉奉371 新型新型神经保护剂神经保护剂激肽系统Rho proteinsEPO、CEPOG-csf381 脱水问题脱水问题一般不脱。391脑卒中后继发进展的原因脑卒中后继发进展的原因分枝动脉病分枝动脉病大动脉的狭窄大动脉的狭窄降血压降血压高血糖高血糖感染感染401分枝动脉病分枝动脉病（BAD）411
