颈动脉夹层抗凝vs抗血小板

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1、颈动脉夹层抗凝vs抗血小板北京天坛医院神经内科脑血管病中心一病房重症监护室杨中华动脉夹层的定义动脉剥离(arterdissection)是血液进入动脉壁形成血肿或动脉壁内自发性血肿,使血管壁间剥离,导致动脉管腔狭窄或血管破裂如果形成瘤样突起，称为夹层动脉瘤(dissectinganeurysm)动脉夹层模式图TheNeurologist2008;14:66–73颈动脉夹层的模式图NEnglJMed.200122;344(12):898-906病例分享病例分享病例分享Neurosurgery.43(2):357

2、-359病例分享病例分享DSA常见征象卒中或者TIA的发病机制栓子？血流动力学？TCD栓子监测TraumaticSpontaneousTotalNo.10717TCDEmboli6（60%）4（58%）10（59%）Stroke.1996;27:1226-1230影像学特点与发病机制Stroke.1998;29:2646-2648.抗栓开始和结束的时间局部症状和缺血的时间间隔TimeIntervalBetweenFirstLocalandIschemicSignsStudyTIACompletedstroke

3、sFisher(1982)Minsto5mo1hourto"severalweeks"Mean:26±45dMean:7.8±9dHartandEaston(1983)SeveralhoursordaysBiller(1986)Afewhoursto7daysfromtraumatosymptomsMokri(1990)Afewminsto2wksBiousseMinsto66dMinsto31dMean:10.5±13.5dMean:5±6.5dStroke.1995;26:235-239抗栓治疗的时限动脉

4、夹层最初3～6个月有再发卒中的风险6个月后很少再发颈动脉夹层抗凝vs抗血小板很多学者倾向于抗凝Stroke.2007;38:2605-26112008meta-analysisMedlineandPubMedweresearchedfrom1966to8April2007cervicalarterydissection34non-randomisedstudies762patientsJNNP,2008;79;1122-1127Outcome:StrokeJNNP,2008;79;1122-1127Outco

5、me:TIA+StrokeJNNP,2008;79;1122-1127Outcome:Stroke+DeathJNNP,2008;79;1122-11272008meta-analysisConclusions对于颈动脉夹层的患者，没有证据支持抗凝治疗优于抗血小板治疗需要前瞻性的随机对照试验对比抗凝治疗和抗血小板治疗的有效性JNNP,2008;79;1122-1127AspirinvsanticoagulationincarotidarterydissectionNeurology®2009;72:1810–

6、1815Prospectivelycollecteddatafrom298consecutivepatientswithsICAD，nonrandomizedAnticoagulation(n~96)AspirinProspectivelycollecteddataofconsecutivepatientswithsICAD(n~202)newcerebralischemiceventsOutcomeOutcomesymptomaticintracranialhemorrhagemajorextracrani

7、albleedingOutcomeNeurology®2009;72:1810–1815Conclusions局限性：非随机的研究自发颈动脉夹层的患者其新发生的脑和视网膜缺血事件的发生频率较低新发事件与抗栓治疗的方法可能无关（抗凝vs抗血小板）最大型的研究CADISS仍在进行中CADISSCervicalArteryDissectioninStrokeStudyprospectivemulticentrerandomisedcontrolledtrialinacute(within7daysofonset)c

8、arotidandvertebralarterydissectionIntracerebralarterydissectionisexcludedIntJStroke.2007Nov;2(4):292-6CADISS-DesignAntiplatelettherapyaspirin,dipyridamoleorclopidogrelaloneorindualcombinationAnticoagul