Yin Mei Department of Neurology The No.2 Hospital Affiliated Kunming Medical College

1. Yin MeiDepartment of NeurologyThe No.2 Hospital Affiliated Kunming Medical College

2. 脑 血 管 疾 病Cerebralvascular Disease CVD

3. Outline • Definition • Epidemiology • Etiology • Risk Factors • Blood Supply to the Brain • Anatomy and pathology • Classification • Transient Ischemic Attacks (TIA)

4. Definition of CVD Cerebrovascular disease(CVD) is designated any abnormality of the brain resulting from various pathologic process of the blood vessels. Loss of neurological function is the hallmark of CVD. 脑血管疾病指由于脑部血管病变所导致的 各种脑功能异常。

5. Definition of Stroke • Stroke - a neurological deficit with sudden onset due to vascular disease. It is a clinical diagnosis (not pathological). • 脑卒中是由于血管病变导致的 急性神经功能缺损

6. Epidemiology of CVD流行病学 • The first most common cause of death in city (the second in country) • The most common disabling neurological disorder

7. Epidemiology of CVD • High incidence:高发病率 2,000,000 new patients per year • High morbidity: 高患病率 7,500,000-10,000,000 patients in China • High mortality: 高死亡率 1,500,000 patients died of CVD per year • High disability高致残率 50%-70% of survivors show disability in deferent degree • High costs 高额负担 40 billion RMB per year

8. Etiology of CVD病因学 • Vascular disorder 血管疾病 Atherosclerosis 动脉粥样硬化 Inflammatory disorder (TB, syphilitic arteritis, SLE, etc.)炎性疾病 Congenital vascular malformation (aneurysm动脉瘤, AVM动静脉畸形) Lesions of any cause

9. Image courtesy of the Internet Stroke Center at Washington University - www.strokecenter.org

10. Image courtesy of the Internet Stroke Center at Washington University - www.strokecenter.org

11. Cerebral Aneurysms

12. Etiology of CVD 病因学 • Heart disease and blood kinetics changes 心脏病及血流动力学改变 Hypertension or hypotension Atrial fibrillation , Rheumatic heart disease , Arrhythmias etc.

13. Etiology of CVD • Changes in blood constituent 血液成分改变 Increase in blood viscosity血粘度增加 Abnormality in blood coagulation mechanism 凝血机制异常 • Others Emboli of air, fat, cancer cells etc.栓子

14. Non-Modifiable Risk Factors不可干预危险因素 • Age 年龄 • Gender性别 • Race种族 • Family history家族史 • Low birth weight (<2500g)

15. ModifiableRisk Factors可干预危险因素 • Cardiovascular disease心血管疾病 • Hypertension高血压 • Lifestyle modifications • Drugs if still >140/90 • Isolated systolic hypertension • Smoke exposure

16. ModifiableRisk Factors可干预危险因素 • Diabetes糖尿病 • Tight control of blood pressure (goal <130/80) • Tight control of blood sugar? • Statin therapy • Dyslipidosis 脂代谢紊乱 • Lifestyle modifications • Statin therapy

17. ModifiableRisk Factors可干预危险因素 • Heavy alcohol consumption • Diet, Activity, Obesity • High homocysteine高同型半胱氨酸 • Oral contraceptive use

18. Blood Supply to the BrainAnterior Circulation • Int. Carotid • arises from common carotid • Branches: anterior cerebral, anterior communicating, middle cerebral, posterior communicating

19. Blood Supply to the Brain Int. Carotid • Anterior Cerebral (blue) • Basal ganglia, corpus callosum, medial surface of cerebral hemispheres; superior surface frontal and parietal lobes • Middle Cerebral (red) • Frontal lobe, parietal lobe, cortical surface of the temporal lobe

20. Internal Carotid Artery颈内动脉系统 • 主要供应眼部及大脑半球前3/5部分即额叶、颞叶、顶叶及基底节的血液

21. Blood Supply to the BrainPosterior Circulation • Vertebral-basilar • arises from subclavian and joins at lower border of pons to form basilar • Branches: posterior cerebral, superior cerebella, posterior inferior cerebella, anterior spinal

22. Vertebral-basilar Artery椎基底动脉系统 • 主要供应脑干、小脑及大脑半球后2/5部分即枕叶及颞叶的基底面，枕叶的内侧及丘脑等

23. Blood Supply to the Brain • Circle of Willis Willis循环 • Anastomosis of arteries at base of brain • Permits collateral circulation • Formed by 6 vessels • internal carotid • anterior and posterior cerebral • anterior communicating • two posterior communicating

24. Anatomy and pathology病理机制 • Occlusion leads to sudden severe ischemia in the area of brain tissue supplied by the occluded artery, and recovery depends upon rapid lyses or fragmentation of the occluding material

25. PATHOPHYSIOLOGY Complete interruption of cerebral blood flow • Suppression of electrical activity within 12– 15 sec • Inhibition of transsynaptic excitation after 2- 4 min • Inhibition of electrical excitability after 4- 6 min • Breakdown of metabolism shortly thereafter

26. Effects of Reduced CBF Infarction脑梗死 Ischemia 脑缺血 Penumbra　半暗带 50 – 55 25 20 15 8 Normal ml/100g/min Edema Loss of Na/K+ pump ↑lactate electrical failure; ↓ ATP activity Cell Death

27. 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 PATHOPHYSIOLOGIC MECHANISMS

28. FACTORS INFLUENCING THE SIZE OF ISCHEMIC INFARCTION • Time course of involvement • Collateral blood supply • Perfusion pressure (MAP) • Tissue oxygen supply • Glucose supply • Accumulation of lactic acid, neurotransmitters, free radicals, superoxides

29. Anatomy and pathology病理机制 • Reversal of neurological function within minutes or hours gives rise to the clinical picture of a transient ischemic attack.

30. Classification of Stroke Stroke Ischemic (80% of Strokes) Hemorrhagic (20% of Strokes) Intracerebral Hemorrhage 10% Subarachnoid Hemorrhage6% Thrombotic 53% Embolic 31%

31. Classification of Stroke • According to the lasting time of neurological deficit TIA: <24h Stroke: >24h • According to the severity of neurological deficit: minor stroke major stroke silent stroke

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

33. Cerebral Infarction

34. The Major Types of CVD • Hemorrhage 脑出血 -Hypertensive hemorrhage -Ruptured aneurysms and vascular malformations

35. Intracerebral Hemorrhage

36. The Major Types of CVD • Spontaneous Subarachnoid Hemorrhage蛛网膜下腔出血

37. 1. Transient Ischemic Attacks (TIA)短暂性脑缺血发作

38. Outline • Definition • TIA-Etiology and Mechanism • Clinical features • Diagnosis and Differentiation • Treatment and Prevent

39. Definition of TIA • TIA is brief, repeated, reversible episodes of focal ischemic neurologic disturbance． • The duration shouldbe less than 24 h • Repeated TIAS of uniform type are more often a warning sign of ischemic stroke

40. TIA-Etiology and Mechanism • There is little doubt that they are due to transient focal ischemia. • Their mechanism might be : -Micro-emboli 微栓子 -Vascular spasm 血管痉挛 -Hemotologic disorder and blood constituent changes -Others

41. Clinical features临床表现 • Age of onset, 50-70, Male>female • Basic features -Transient episode (<24h)短暂发作 -Reversible 可逆性 -Resolve completely 完全恢复 -Repeated and uniform type 反复发作，形式多样

42. Clinical features临床表现 • It may last a few seconds or up to 12 to 24 h, Most of them last 2 to 15 min.There are only a few attacks or several hundred. • Between attacks, the neurologic examination may disclose no abnormalities.间歇期无神经系统阳性体征

43. Clinical features临床表现 • Transient Ischemic Attacks can reflect the involvement of any cerebral artery. The loss of function entirely depends on the influenced artery. • 临床表现取决于病变血管

44. Anterior Cerebral Middle Cerebral Posterior Cerebral Contralateral hemiplegia (leg greater than arm 对侧偏瘫，下肢为重 Aphasia (dominant hemisphere) 失语 Contralateral hemiplegia (arm, face greater than leg), sensory loss, visual loss Conditions Caused by Occlusion

45. Clinical features of Carotid artery TIA • Common symptoms /signs -weakness of opposite limbs 对侧肢体无力 • Characteristic symptoms /signs -ophthalmic artery crossing paralysis 眼动脉交叉瘫 - Horner’s crossing paralysis （Horner’s交叉瘫） -Aphasia( dominant hemisphere is involved) 失语

46. Clinical features of Carotid artery TIA • Possible symptoms /signs -contralateral single limb- or hemisensory deficit 对侧单肢或偏身感觉障碍 - contralateral homonymous hemianopia.对侧同向偏盲

47. Clinical features ofVertebral-basilar arteryTIA • Common symptoms /signs -vertigo, dysequilibrium, usually no tinnitus ，眩晕，平衡障碍 • Characteristic symptoms /signs - drop attack 跌到发作 - transient global amnesia 短暂性全面遗忘 - bioccular vision disorder 双眼视力障碍

48. Clinical features ofVertebral-basilar arteryTIA • Possible symptoms /signs -swallowing disorder 吞咽障碍 -dysarthria/dysphasia 构音不清 -incoordination 共济失调 -disturbance of consciousness with/without small pupils 意识障碍伴/不伴瞳孔缩小

49. Clinical features ofVertebral-basilar arteryTIA • Possible symptoms /signs -unilateral/bilateral ficial/perioral numbness or crossing sensory deficit 一侧或双侧面/口周麻木或交叉性感觉障碍 -extraocular palsy or diplopia 眼外肌麻痹或复视 -crossed paralysis 交叉性瘫痪

50. Investigative Study • Physical examination: For carotid bruits • Brain imaging (cranial CT and/or MRI) • Doppler ltrasonography/Angiography: Detect large vessel atherosclerosis • ECG/Echocardiography: Detect cardiac embolism • Blood Test