Yin MeiYin Mei Department of NeDepartment of Ne

urologyurologyThe No.2 Hospital The No.2 Hospital Affiliated Kunming Affiliated Kunming

Medical CollegeMedical College

脑 血 管 疾 病脑 血 管 疾 病Cerebralvascular Disease CVCerebralvascular Disease CV

DD

OutlineOutline• DefinitionDefinition

• EpidemiologyEpidemiology

• EtiologyEtiology

• Risk FactorsRisk Factors

• Blood Supply to the BrainBlood Supply to the Brain

• Anatomy and pathologyAnatomy and pathology

• ClassificationClassification

• Transient Ischemic Attacks (TIA)Transient Ischemic Attacks (TIA)

Definition of CVDDefinition of CVD

Cerebrovascular disease(CVD)Cerebrovascular disease(CVD) is designated is designated any any abnormality of thabnormality of th

e brain resulting from various pathe brain resulting from various pathologic process of ologic process of the blood vesselsthe blood vessels. . Loss of neurologicalLoss of neurological function is the function is the hallmark of hallmark of CVDCVD. . 脑血管疾病指由于脑部血管病变所导致的脑血管疾病指由于脑部血管病变所导致的

各种各种脑功能异常。脑功能异常。

Definition of StrokeDefinition of Stroke

Stroke - a neurological deficit wStroke - a neurological deficit with ith sudden onsetsudden onset due to vascula due to vascular disease. It is r disease. It is a clinical diagnoa clinical diagnosis sis (not pathological).(not pathological).脑卒中是由于血管病变导致的脑卒中是由于血管病变导致的

急性急性神经功能缺损神经功能缺损

Epidemiology of CVDEpidemiology of CVD流行病学流行病学

– The first most common The first most common cause of death in city cause of death in city (the second in country)(the second in country)

–The most common The most common disabling neurological disabling neurological disorderdisorder

Epidemiology of CVDEpidemiology of CVD– High incidenceHigh incidence:: 高发病率高发病率 2,000,000 new patients per year2,000,000 new patients per year– High morbidityHigh morbidity: : 高患病率高患病率 7,500,000-10,000,000 patients in China7,500,000-10,000,000 patients in China– High mortalityHigh mortality: : 高死亡率高死亡率 1,500,000 patients died of CVD per year1,500,000 patients died of CVD per year– High disabilityHigh disability 高致残率高致残率 50%-70% of survivors show disability in deferent d50%-70% of survivors show disability in deferent d

egreeegree– High costs High costs 高额负担高额负担 40 billion RMB per year40 billion RMB per year

Etiology of CVDEtiology of CVD病因学病因学

•Vascular disorder Vascular disorder 血管疾病血管疾病 Atherosclerosis Atherosclerosis 动脉粥样硬化动脉粥样硬化 Inflammatory disorder (TB, syphilitic artInflammatory disorder (TB, syphilitic art

eritis, SLE, etc.)eritis, SLE, etc.) 炎性疾病炎性疾病 Congenital vascular malformation Congenital vascular malformation

(aneurysm (aneurysm 动脉瘤动脉瘤 , AVM, AVM 动静脉畸形动静脉畸形 )) Lesions of any causeLesions of any cause

Image courtesy of the Internet StrImage courtesy of the Internet Stroke Center at Washington Univeroke Center at Washington University - www.strokecenter.orgsity - www.strokecenter.org

Image courtesy of the Internet StrImage courtesy of the Internet Stroke Center at Washington Univeroke Center at Washington University - www.strokecenter.orgsity - www.strokecenter.org

Cerebral Aneurysms

Etiology of CVD Etiology of CVD 病因学病因学

•Heart disease and blood kinetics cHeart disease and blood kinetics changes hanges 心脏病及血流动力学改变心脏病及血流动力学改变

Hypertension or hypotensionHypertension or hypotension Atrial fibrillation , Rheumatic heart dAtrial fibrillation , Rheumatic heart d

isease , Arrhythmias etc.isease , Arrhythmias etc.

Etiology of CVDEtiology of CVD

• Changes in blood constituent Changes in blood constituent 血液成分改变血液成分改变 Increase in blood viscosityIncrease in blood viscosity 血粘度增加血粘度增加 Abnormality in blood coagulationAbnormality in blood coagulation mechanism mechanism 凝血机制异常凝血机制异常• OthersOthers Emboli of air, fat, cancer cells etc.Emboli of air, fat, cancer cells etc. 栓子栓子

Non-Modifiable Non-Modifiable Risk FactorsRisk Factors不可干预危险因素不可干预危险因素

•Age Age 年龄年龄•GenderGender 性别性别•RaceRace 种族种族•Family historyFamily history 家族史家族史•Low birth weight (<2500g)Low birth weight (<2500g)

ModifiableModifiable Risk FactorsRisk Factors可干预危险因素可干预危险因素

• Cardiovascular diseaseCardiovascular disease 心血管疾病心血管疾病• HypertensionHypertension 高血压高血压

– Lifestyle modificationsLifestyle modifications– Drugs if still >140/90 Drugs if still >140/90 – Isolated systolic hypertensionIsolated systolic hypertension

• Smoke exposureSmoke exposure

ModifiableModifiable Risk FactorsRisk Factors可干预危险因素可干预危险因素

• DiabetesDiabetes 糖尿病糖尿病– Tight control of blood pressure (goal <130Tight control of blood pressure (goal <130

/80)/80)– Tight control of blood sugar?Tight control of blood sugar?– Statin therapyStatin therapy

• Dyslipidosis Dyslipidosis 脂代谢紊乱脂代谢紊乱– Lifestyle modificationsLifestyle modifications– Statin therapyStatin therapy

ModifiableModifiable Risk FactorsRisk Factors可干预危险因素可干预危险因素

•Heavy alcohol consumptionHeavy alcohol consumption• Diet, Activity, ObesityDiet, Activity, Obesity•High homocysteineHigh homocysteine 高同型半胱氨酸高同型半胱氨酸•Oral contraceptive useOral contraceptive use

Blood Supply to the BrainBlood Supply to the BrainAnterior CirculationAnterior Circulation

• Int. CarotidInt. Carotid– arises from arises from

common carotid common carotid – BranchesBranches: anterior : anterior

cerebral, anterior cerebral, anterior communicating, communicating, middle cerebral, middle cerebral, posterior posterior communicatingcommunicating

Blood Supply to the Brain Blood Supply to the Brain Int. CarotidInt. Carotid• Anterior Cerebral (bluAnterior Cerebral (blu

e)e)– Basal ganglia, corpus cBasal ganglia, corpus c

allosum, medial surfacallosum, medial surface of cerebral hemisphee of cerebral hemispheres; superior surface frres; superior surface frontal and parietal lobeontal and parietal lobes s

• Middle Cerebral (red)Middle Cerebral (red)– Frontal lobe, parietal lFrontal lobe, parietal l

obe, cortical surface of obe, cortical surface of the temporal lobe the temporal lobe

Internal Carotid ArteryInternal Carotid Artery颈内动脉系统颈内动脉系统

•主要供应眼部主要供应眼部及大脑半球前及大脑半球前3/53/5 部分即额部分即额叶、颞叶、顶叶、颞叶、顶叶及基底节的叶及基底节的血液血液

Blood Supply to the BrainBlood Supply to the BrainPosterior CirculationPosterior Circulation

•Vertebral-basilarVertebral-basilar– arises from subclavian arises from subclavian

and joins at lower bordand joins at lower border of pons to form basiler of pons to form basilar ar

– BranchesBranches: posterior cer: posterior cerebral, superior cerebellebral, superior cerebella, posterior inferior cera, posterior inferior cerebella, anterior spinal ebella, anterior spinal

Vertebral-basilar ArteryVertebral-basilar Artery椎基底动脉系统椎基底动脉系统

• 主要供应脑干、小脑及大脑半球后主要供应脑干、小脑及大脑半球后 2/52/5 部分即枕部分即枕叶及颞叶的基底面，枕叶的内侧及丘脑等叶及颞叶的基底面，枕叶的内侧及丘脑等

Blood Supply to the Blood Supply to the BrainBrain•Circle of WillisCircle of Willis

WillisWillis 循环循环– Anastomosis of arteries at bAnastomosis of arteries at b

ase of brainase of brain– Permits collateral circulatioPermits collateral circulatio

nn– Formed by 6 vesselsFormed by 6 vessels

• internal carotid internal carotid • anterior and posterior ceanterior and posterior ce

rebralrebral• anterior communicatinganterior communicating• two posterior communictwo posterior communic

ating ating

Anatomy and pathologyAnatomy and pathology病理机制病理机制

• Occlusion leads to sudden severe Occlusion leads to sudden severe ischemiaischemia in the area of brain in the area of brain tissue supplied by the occluded tissue supplied by the occluded artery, and recovery depends artery, and recovery depends upon rapid lyses or upon rapid lyses or fragmentation of the occluding fragmentation of the occluding materialmaterial

PATHOPHYSIOLOGYPATHOPHYSIOLOGYComplete interruption of cerebral blood flComplete interruption of cerebral blood fl

owow• Suppression of Suppression of electrical activityelectrical activity within within

12– 15 sec12– 15 sec• Inhibition of Inhibition of transsynaptic excitationtranssynaptic excitation aft aft

er 2- 4 miner 2- 4 min• Inhibition of Inhibition of electrical excitabilityelectrical excitability after after

4- 6 min4- 6 min• Breakdown of Breakdown of metabolism metabolism shortly thereshortly there

afterafter

Effects of Reduced CBFEffects of Reduced CBF

Normal ml/100g/min

50 – 55 25 20 15 8

Ischemia

脑缺血

Edema Loss of Na/K+ pump

↑lactate electrical failure; ↓ ATP

activity

Penumbra 　半暗带

Infarction　脑梗死

Cell Death

PATHOPHYSIOLOGIC MECHANISMSPATHOPHYSIOLOGIC MECHANISMS

Penumbra 缺血半暗带(blood supply 20 – 50 mL/100 g/min)

Core 中心坏死区(blood supply 0 – 12 mL/100 g/min)

Core: central area where ischemia is severe & infarction develops rapidly

Penumbra: marginally perfused area surrounding the core which has the capacity to recover should perfusion be restored promptly

FACTORS INFLUENCING THE FACTORS INFLUENCING THE SIZE OF ISCHEMIC INFARCTIONSIZE OF ISCHEMIC INFARCTION

• Time course of involvementTime course of involvement

• Collateral blood supplyCollateral blood supply

• Perfusion pressure (MAP)Perfusion pressure (MAP)

• Tissue oxygen supplyTissue oxygen supply

• Glucose supplyGlucose supply

• Accumulation of lactic acid, Accumulation of lactic acid, neurotransmitters, free radicals, neurotransmitters, free radicals, superoxidessuperoxides

Anatomy and pathologyAnatomy and pathology病理机制病理机制

• Reversal of neurological function Reversal of neurological function within minutes or hours gives within minutes or hours gives rise to the clinical picture of a rise to the clinical picture of a transient ischemic attack.transient ischemic attack.

Classification of Classification of StrokeStroke

Hemorrhagic (20% of Strokes)

Ischemic (80% of Strokes)

Thrombotic

53%

Embolic

31%

Intracerebral Hemorrhage 1

0%

Subarachnoid

Hemorrhage 6%

Stroke

Classification of Classification of StrokeStroke

• According to According to the lasting timethe lasting time of of neurological deficit neurological deficit

TIA: <24hTIA: <24h Stroke: >24hStroke: >24h• According to According to the severitythe severity of neurological of neurological

deficit:deficit: minor strokeminor stroke major strokemajor stroke silent strokesilent stroke

The Major Types of The Major Types of CVDCVD• Cerebral ischemia and infarctionCerebral ischemia and infarction 脑缺血和脑梗死脑缺血和脑梗死 -Transient Ischemic Attacks-Transient Ischemic Attacks 短暂性脑缺血发作短暂性脑缺血发作 -Atherosclerotic thrombosis-Atherosclerotic thrombosis 动脉粥样硬化性血栓形成动脉粥样硬化性血栓形成 -Lacunas -Lacunas 腔隙性脑梗死腔隙性脑梗死 -Embolism -Embolism 脑栓塞脑栓塞

Cerebral InfarctionCerebral Infarction

The Major Types of The Major Types of CVDCVD

•Hemorrhage Hemorrhage 脑出血脑出血 -Hypertensive hemorrhage-Hypertensive hemorrhage -Ruptured aneurysms and vascular m-Ruptured aneurysms and vascular m

alformationsalformations

Intracerebral HemorrhageIntracerebral Hemorrhage

The Major Types of CVDThe Major Types of CVD• Spontaneous Subarachnoid HemorrhaSpontaneous Subarachnoid Hemorrha

gege 蛛网膜下腔出血蛛网膜下腔出血

1. Transient Ischemic Attacks 1. Transient Ischemic Attacks (TIA)(TIA)

短暂性脑缺血发作短暂性脑缺血发作

OutlineOutline• DefinitionDefinition• TIA-Etiology and Mechanism TIA-Etiology and Mechanism • Clinical features Clinical features • Diagnosis and DifferentiationDiagnosis and Differentiation• Treatment and PreventTreatment and Prevent

Definition of TIADefinition of TIA•TIA is TIA is brief, repeated, reversible epibrief, repeated, reversible epi

sodessodes of focal ischemic neurologic of focal ischemic neurologic disturbancedisturbance ．．

• The The duration duration shouldshould bebe less than 24 h less than 24 h• Repeated TIAS of uniform type are morRepeated TIAS of uniform type are mor

e often a warning sign of ischemic stroke often a warning sign of ischemic strokee

TIA-Etiology and TIA-Etiology and MechanismMechanism

• There is little doubt that they are due There is little doubt that they are due to to transient focal ischemiatransient focal ischemia..

• Their mechanism might be :Their mechanism might be : --Micro-emboli Micro-emboli 微栓子微栓子 --Vascular spasm Vascular spasm 血管痉挛血管痉挛 -Hemotologic disorder and blood co-Hemotologic disorder and blood co

nstituent changesnstituent changes -Others-Others

Clinical featuresClinical features临床表现临床表现

• Age of onset, 50-70, Male>femaleAge of onset, 50-70, Male>female• Basic featuresBasic features -Transient episode (<24h)-Transient episode (<24h) 短暂发作短暂发作 -Reversible -Reversible 可逆性可逆性 -Resolve completely -Resolve completely 完全恢复完全恢复 -Repeated and uniform type -Repeated and uniform type 反复发作，反复发作，

形式多样 形式多样

Clinical featuresClinical features临床表现临床表现

• It may last a few seconds or up to It may last a few seconds or up to 12 to 24 h, Most of them last 2 to 15 12 to 24 h, Most of them last 2 to 15 min.min.There are only a few attacks or sevThere are only a few attacks or several hundred.eral hundred.

•Between attacks, the neurologic exBetween attacks, the neurologic examination may disclose no abnormamination may disclose no abnormalities.alities.间歇期无神经系统阳性体征间歇期无神经系统阳性体征

Clinical featuresClinical features临床表现临床表现

•Transient Ischemic Attacks caTransient Ischemic Attacks can reflect the involvement of n reflect the involvement of anany cerebral arteryy cerebral artery. The loss of f. The loss of function entirely depends on thunction entirely depends on the influenced artery.e influenced artery.

•临床表现取决于病变血管临床表现取决于病变血管

Conditions Caused by Conditions Caused by OcclusionOcclusionAnterior CerebralAnterior Cerebral

Middle CerebralMiddle Cerebral

Posterior CerebralPosterior Cerebral

Contralateral hemiplegiContralateral hemiplegia (leg greater than arm a (leg greater than arm

• 对侧偏瘫，下肢为重对侧偏瘫，下肢为重Aphasia (dominant hemiAphasia (dominant hemi

sphere) sphere) 失语失语

Contralateral hemiplegiContralateral hemiplegia (arm, face greater tha (arm, face greater than leg), sensory loss, vian leg), sensory loss, visual loss sual loss

Clinical features of Clinical features of Carotid artery TIACarotid artery TIA

• Common symptoms /signsCommon symptoms /signs --weakness of opposite limbsweakness of opposite limbs 对侧肢体无力对侧肢体无力• Characteristic symptoms /signsCharacteristic symptoms /signs --ophthalmic artery crossing paralysisophthalmic artery crossing paralysis 眼动脉交叉瘫眼动脉交叉瘫 - - Horner’s crossing paralysis Horner’s crossing paralysis （（ Horner’sHorner’s 交叉瘫）交叉瘫） -Aphasia( dominant hemisphere is involved) -Aphasia( dominant hemisphere is involved)

失语失语

Clinical features of Clinical features of Carotid artery TIACarotid artery TIA

•Possible symptoms /signsPossible symptoms /signs --contralateral single limb- or hemisencontralateral single limb- or hemisen

sory deficitsory deficit 对侧单肢或偏身感觉障碍对侧单肢或偏身感觉障碍 - contralateral homonymous hemiano- contralateral homonymous hemiano

pia.pia. 对侧同向偏盲对侧同向偏盲

Clinical features ofClinical features of

Vertebral-basilar arteryVertebral-basilar artery TIATIA • Common symptoms /signsCommon symptoms /signs --vertigo, dysequilibrium, usually no tinnitvertigo, dysequilibrium, usually no tinnit

us us ，眩晕，平衡障碍，眩晕，平衡障碍•Characteristic symptoms /signsCharacteristic symptoms /signs - drop attack - drop attack 跌到发作跌到发作 - transient global amnesia - transient global amnesia 短暂性全面遗忘短暂性全面遗忘 - bioccular vision disorder - bioccular vision disorder 双眼视力障碍双眼视力障碍

Clinical features ofClinical features of

Vertebral-basilar arteryVertebral-basilar artery TIATIA •Possible symptoms /signsPossible symptoms /signs --swallowing disorder swallowing disorder 吞咽障碍 吞咽障碍 -dysarthria/dysphasia -dysarthria/dysphasia 构音不清构音不清 -incoordination -incoordination 共济失调共济失调 -disturbance of consciousness with/-disturbance of consciousness with/

without small pupils without small pupils 意识障碍伴意识障碍伴 // 不伴不伴瞳孔缩小瞳孔缩小

Clinical features ofClinical features of

Vertebral-basilar arteryVertebral-basilar artery TIATIA •Possible symptoms /signsPossible symptoms /signs --unilateral/bilateral ficial/perioral unilateral/bilateral ficial/perioral numbness or crossing sensory deficitnumbness or crossing sensory deficit一侧或双侧面一侧或双侧面 //口周麻木或交叉性感觉障碍口周麻木或交叉性感觉障碍 -extraocular palsy or diplopia -extraocular palsy or diplopia 眼外肌麻痹或复视眼外肌麻痹或复视 -crossed paralysis -crossed paralysis 交叉性瘫痪交叉性瘫痪

Investigative StudyInvestigative Study• Physical examination:Physical examination:

For carotid bruitsFor carotid bruits

• Brain imaging (cranial CT and/or MRI)Brain imaging (cranial CT and/or MRI)

• Doppler Doppler ltrasonography/Angiography: ltrasonography/Angiography:

Detect large vessel Detect large vessel atherosclerosisatherosclerosis

• ECG/Echocardiography:ECG/Echocardiography:

Detect cardiac embolismDetect cardiac embolism

• Blood TestBlood Test

Ischemic stroke diagnostic Ischemic stroke diagnostic algorithmalgorithm

Acute focal brain deficit

Head CT

Ischemic Stroke

ECGEcho

CARDIACEMBOLISM

LARGE ARTERYATHEROSCLEROSIS

SMALLVESSEL DISEASE

OTHER DETERMINEDCAUSE

DopplerMRAAngiogram

MRICT

VasculopathyCoagulopathy

CRYPTOGENICSTROKE

Excluded hypoglycemia, migraine

with aura, post-seizure deficit

TIA (if CT/MR brain imagingwithout ischemic lesion)

< 1 hour

Lacunar syndromeCortical syndrome

Diagnosis and Diagnosis and Differentiation Differentiation

of TIA of TIA• DiagnosisDiagnosis : Mainly depend on history. : Mainly depend on history.

But the cause of TIA are very importanBut the cause of TIA are very importantt

• Differential diagnosis:Differential diagnosis: -partial seizure-partial seizure局灶性癫痫局灶性癫痫 -Heart disease: Adams-stokes syndro-Heart disease: Adams-stokes syndro

me, arrhythmia, etc.me, arrhythmia, etc.

TIA-Treatment and TIA-Treatment and PreventPrevent

• Treatment in terms of etiologyTreatment in terms of etiology• Drugs for Drugs for preventionprevention - - Antiplatelet agentsAntiplatelet agents: Aspirin , C: Aspirin , Clopilopi

dogrel, Ticlopidine or Dipyridamoledogrel, Ticlopidine or Dipyridamole - - AnticoagulantsAnticoagulants:: Heparin Heparin 肝素肝素 , ,

lower molecule heparin , warfarin lower molecule heparin , warfarin 华法华法林 林

--OthersOthers: : vasodilatation agents, vasodilatation agents, cerebral protective agentscerebral protective agents

The Brain Attack Team: the need for investment• Ambulance Service

• Casualty Dept

• Radiology/Neuroradiology/Physicians/Radiographers

• Acute stroke units

• Pharmacy & Laboratory

• Large RCT’s

• Admissions

• Administration

• Public Relations/CommunityEducation

AMBULANCEAMBULANCE

PrognosisPrognosis

•1/3 Cerebral 1/3 Cerebral infarction infarction

•1/3 Recurrence1/3 Recurrence

•1/3 Resolved1/3 Resolved

• TIAs in carotid territory predict severe atherosclerosis in the proximal internal carotid artery. • Tests can determine actual blood flow in the carotid. • The odds of stroke in the next 1-2 weeks are great!• If severe narrowing is present, surgical and medical treatments can help to reduce stroke risk.

Patients may ignore TIAs! Patients may ignore TIAs!

Stroke Stroke ISIS an Emergency! an Emergency! Stroke is a

“Brain Attack”

Brain Attack is an emergency

“Time is Brain”