颈动脉狭窄的诊断、支架治疗的病例选择、围手术用药

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1、颈动脉狭窄的诊断支架治疗的病例选择围手术用药脑动脉系统缺血性脑血管病的病因AlbersGW,Chair;J.CHEST1998;114:683S–698S颈动脉狭窄的诊断颈动脉狭窄定义PaulHLKao颈总动脉(CCA)、分叉或颈内动脉(ICA)近段动脉硬化斑块形成斑块溃疡、血栓形成、或远端栓塞是引起症状(TIA/stroke/AF)的主要原因动脉粥样硬化纤维肌发育不良(fibromusculardysplasia)高安氏病（Takayasu‘sArteritis）血管炎（vasculitis）(包括放疗后)与神经纤维瘤病相关的狭窄颈动脉狭窄的原因临床表现无症状性狭窄无神经系

2、统症状和体征，影像学无阳性发现有症状性狭窄Amaurosisfugax一过性黑朦Transientischemicattack(TIA)Reversibleischemicneurologicaldeficit(RIND)可逆性缺血性神经功能神经缺失Completedstroke完全中风B-modePowerangioColormappingDopplerTCD颈动脉狭窄的诊断Duplex超声MRA&CTADSA-黄金标准狭窄度形态学-钙化、血栓、溃疡NASCETNorthAmericanSymptomaticCarotidEndarterectomyTrialECSTEurop

3、eanCarotidStenosisTrial颈动脉狭窄率的测定颈动脉狭窄与缺血性卒中的关系约40%的前循环系统TIA或中风存在同侧颈动脉的重度狭窄(>75%)其中8%完全闭塞10%症状性颈内动脉狭窄者1年内发生脑梗死，5年内发生梗死的危险性高达40%无症状性颈内动脉狭窄(80%)每年发生中风的危险性为6%约有80%的中风发生前无任何症状(如TIA等)颈动脉狭窄与缺血性卒中的关系Figure3.Annualriskofstrokeorvasculardeathamongpatientsinvarioushighrisksubgroups.WilterdinkJL,EastonJ

4、D.ArchNeurol1992;49:857–863.颈动脉狭窄支架治疗的病例选择颈动脉狭窄的治疗EstablishedforselectedpatientsAnti-platelettherapy抗血小板Statinagents他丁类药物Carotidendarterectomy颈动脉内膜剥离术AngioplastyandstentingUnderinvestigation正在确立的新疗法ExtracranialtoIntracranialbypassAtherectomy动脉狭窄旋切术LaserAssistedAngioplasty激光辅助的血管成型术Thrombolys

5、is–Angiojet血管射频消融术Carotidendarterectomy(CEA)isasurgicalprocedureremovingplaquematerialfromtheliningofanarteryTheproceduretoremoveplaquebuild-upfromanartery.Asurgeonscrapesawaythearteriallining,whereplaquehasformed,andthearteryisstitchedclosed.Endarterectomy:researches研究结果NorthAmericanSymptoma

6、ticCarotidEndarterectomyTrial(NASCET)EuropeanCarotidStenosisTrial(ECST)Results:Dramaticriskreductionwithsurgeryforseverestenosis结果:CEA明显降低颈动脉严重狭窄患者的中风危险性NASCET.NEnglJMed1991;325:445-453ECST.Lancet1991;337:1235-1243Contralateralocclusion对侧CCA闭塞Highorbifurcationlesions高位或分叉部病变LoworostialCCAlesi

7、ons低位或靠近CCA开口处Neckradiation颈部放射治疗Priorradicalneckdissection既往颈部切开术Priorcarotidendarterectomy既往CEAShort,obesenecks颈部粗短Spinalimmobilityduetocongenital/acquiredconditions先天或后天性颈椎不稳定Additionalstenosesinvolvingtheipsilateralsiphon伴随有同侧虹吸段狭窄Highana