急性期卒中ppt课件.pptx

1、As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性脑卒中北京大学第三医院神经内科张 燕As the only big agricultural village in Tianding Township, some achievements have been made

2、 through the beneficial exploration of villagers autonomy in family planning for more than a year.岗位练兵理论考题题库（神经内科）1. 患者，男性 67岁，近一个月来，反复出现右侧肢体乏力、言语不能来诊。 请问：社区全科团队应该如何接诊、处置病人？As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration

3、of villagers autonomy in family planning for more than a year.岗位练兵理论考题题库（神经内科）2. 患者男性，70岁，2小时前晨起感到右侧肢体麻木、无力，1小时前出现说话吐字不清，来社区中心就诊。 请问：社区全科团队应该如何接诊、处置病人？As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy

4、in family planning for more than a year.岗位练兵理论考题题库（神经内科）3. 辖区居民王某，男性，62岁，退休工人，半小时在家晾衣服时突然出现头晕，伴右侧肢体不能活动，数分钟后自行缓解，被家人送来社区卫生服务中心就诊。 请问：社区全科团队应该如何出诊、处置病人？As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy

5、in family planning for more than a year.岗位练兵理论考题题库（神经内科）4. 女性，67岁，右侧肢体麻木、无力6小时，说话吐字不清1小时，来社区中心就诊。 请问：社区全科团队应该如何出诊、处置病人？As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than

6、 a year.岗位练兵理论考题题库（神经内科）5. 患者，男性，57岁，主因“突发言语不利伴左侧肢体无力7小时”就诊。 请问：社区全科团队应该如何接诊、处置病人？As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.我国卒中死亡率逐年上升每年有250万中国人新发卒中每年有1

7、60万中国人死于卒中现存脑卒中患者近700万卒中致残率高达75%卒中复发率超过30%每年脑卒中治疗费用约400亿元人民币2009年卒中死亡粗率，相比2006年：城市地区上升1.41倍农村地区上升1.44倍城乡地区脑血管病粗死亡率变化趋势Liu L, et al. Stroke.2011;42(12):3651-4.王陇德.中国医学前沿杂志（电子版）.2011;3(3):1-3.中国心脑血管病报告2011As the only big agricultural village in Tianding Township, some achievements have been made throu

8、gh the beneficial exploration of villagers autonomy in family planning for more than a year.脑表面主要血管流域As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.脑表面主要血管流域A

9、s the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.脑表面主要血管流域As the only big agricultural village in Tianding Township, some achievements have been made through the

10、 beneficial exploration of villagers autonomy in family planning for more than a year.大脑半球表面和深部血液供应：冠状面As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.大脑半球表面和深

11、部血液供应：轴面As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.分水岭区（分水岭区（Watershed area）ACA 分布区分布区MCA 分布区分布区PCA 分布区分布区ICA ICA发出脉络膜前动脉发出脉络膜前动脉MCA豆纹动脉豆纹动脉( MCA深穿支深穿支)PC

12、A发出深穿支发出深穿支As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.ACA 分布区分布区ACA发出内侧纹状动脉发出内侧纹状动脉 (recurrent artery of Heubner)MCA 分布区分布区外侧纹状动脉外侧纹状动脉PCA 分布区分布区PCA深穿支深穿支

13、ICA发出脉络膜前动脉发出脉络膜前动脉As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.ACA的内侧纹状动脉的内侧纹状动脉 (recurrent artery of Heubner)MCA的外侧纹状动脉的外侧纹状动脉 ICA的脉络膜前动脉的脉络膜前动脉脉络膜前动脉液供应视

14、放射脉络膜前动脉液供应视放射内囊的血液供应As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.脑干的血液供应As the only big agricultural village in Tianding Township, some achievements have b

15、een made through the beneficial exploration of villagers autonomy in family planning for more than a year.小脑的血液供应 As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a ye

16、ar.小脑的血液供应As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.不同梗死形态意味不同的机制A. 皮层梗死流域性梗死：栓塞（心源性可能性大）B. 皮层下梗死：栓塞C. 多发皮层：栓塞（动脉源性可能性大）D. 低灌注栓子清除障碍梗死As the only big agr

17、icultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year. 急性缺血性脑卒中（急性脑梗死）是最常见的卒中类型； 约占全部脑卒中的60 80； 急性期一般指发病后2周内。急性缺血性脑卒中As the only big agricultural village in Tianding Township, some ach

18、ievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.p 急性缺血性脑卒中的处理应强调： 早期诊断 早期治疗 早期康复 早期预防再发急性缺血性脑卒中As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of v

19、illagers autonomy in family planning for more than a year.院前处理院前脑卒中的识别p迅速识别疑似患者并尽快送到医院，尽快对适合溶栓的患者进行溶栓治疗。若患者突然出现以下任一症状时应考虑脑卒中可能：(1)一侧肢体(伴或不伴面部)无力或麻木；(2)一侧面部麻木或口角歪斜；(3)说话不清或理解语言困难；(4)双眼向一侧凝视；(5)一侧或双眼视力丧失或模糊；(6)眩晕伴呕吐；(7)既往少见的严重头痛、呕吐；(8)意识障碍或抽搐。As the only big agricultural village in Tianding Township,

20、some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.院前处理现场处理及运送p 尽快进行简要评估和必要的急救处理。处理气道、呼吸和循环问题；心脏监护；建立静脉通道；吸氧；评估有无低血糖。As the only big agricultural village in Tianding Township, some achievements have been made through the

21、beneficial exploration of villagers autonomy in family planning for more than a year.院前处理现场处理及运送应迅速获取简要病史，包括：症状开始时间，若于睡眠中起病，应以最后表现正常的时间作为起病时间；近期患病史；既往病史；近期用药史。As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers a

22、utonomy in family planning for more than a year.急诊室处理p诊断：是否为卒中？是缺血性还是出血性卒中？是否适合溶栓治疗？p对疑似脑卒中患者进行快速诊断，尽可能在到达急诊室后60 min内完成脑CT等基本评估并做出治疗决定。As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planni

23、ng for more than a year.急诊室处理p处理密切监护患者基本生命体征需紧急处理的情况：颅内压增高，严重血压异常、血糖异常和体温异常，癫痫等。As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性脑卒中诊断流程应包括如下5个步骤：第一步：是否为脑卒

24、中?排除非血管性疾病。第二步：是否为缺血性脑卒中?进行脑CT/MRI检查排除出血性脑卒中。第三步：卒中严重程度?根据神经功能缺损量表评估。第四步：能否进行溶栓治疗?核对适应证和禁忌证。第五步：病因分型?参考TOAST标准，结合病史、实验室、脑病变和血管病变等影像检查资料确定病因。急性期诊断与治疗评估和诊断As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonom

25、y in family planning for more than a year.(1)对所有疑似脑卒中患者应进行头颅平扫CTMRI检查。(2)在溶栓等治疗前，应进行头颅平扫CTMRI检查，排除颅内出血。(3)应进行上述血液学、凝血功能和生化检查。(4)所有脑卒中患者应进行心电图检查，有条件时应持续心电监测。急性期诊断与治疗评估和诊断As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of v

26、illagers autonomy in family planning for more than a year.(5)用神经功能缺损量表评估病情程度。(6)应进行血管病变检查，但在起病早期，应注意避免因此类检查而延误溶栓时机。(7)根据上述规范的诊断流程进行诊断。急性期诊断与治疗评估和诊断As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in f

27、amily planning for more than a year.急性期诊断与治疗一般处理(1)准备溶栓者，血压应控制在收缩压180 mmHg、舒张压100 mmHg。(2)缺血性脑卒中后24 h内血压升高的患者应谨慎处理（紧张焦虑、疼痛、恶心呕吐及颅内压增高等情况）。血压持续升高，收缩压200 mmHg或舒张压110 mmHg，或伴有严重心功能不全、主动脉夹层、高血压脑病的患者，可予降压治疗，并严密观察血压变化。As the only big agricultural village in Tianding Township, some achievements have been m

28、ade through the beneficial exploration of villagers autonomy in family planning for more than a year.急性期诊断与治疗一般处理(3)卒中后若病情稳定，血压持续140 mmHg90 mmHg，无禁忌证，可于起病数天后恢复使用发病前服用的降压药物或开始启动降压治疗。(4)卒中后低血压的患者应积极寻找和处理原因，必要时可采用扩容升压措施。可静脉输注0.9氯化钠溶液纠正低血容量，处理可能引起心输出量减少的心脏问题。As the only big agricultural village in Tiand

29、ing Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性期诊断与治疗一般处理(1)血糖超过10 mmolL时可给予胰岛素治疗。应加强血糖监测，血糖值可控制在7.710 mmolL。(2)血糖低于3.3 mmolL时，可给予1020葡萄糖口服或注射治疗。目标是达到正常血糖。As the only big agricultural village in Tiandi

30、ng Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性期诊断与治疗 特异性治疗 改善脑血循环 溶栓 抗血小板 抗凝 降纤 扩容 神经保护As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial

31、 exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓纳入标准： 1. 诊断缺血性卒中导致的可评估的神经功能损害 2. 治疗前症状发生 3 h及3-4.5小时 3. 年龄 18岁 As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers

32、autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓绝对禁忌As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓绝对禁忌As the onl

33、y big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓绝对禁忌As the only big agricultural village in Tianding Township, some achievements have been made thr

34、ough the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓相对禁忌As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more tha

35、n a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓相对禁忌As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓相对禁忌As the only big agricultural village in Tianding T

36、ownship, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.急性缺血性卒中超早期（4.5小时内）静脉溶栓相对禁忌As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villa

37、gers autonomy in family planning for more than a year.短暂性脑缺血发作的诊治As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.2009年6月ASA的TIA新定义 一项荟萃分析表明，即使在症状持续时间140/90mmHg

38、(1分)单侧力弱(2分)或言语障碍不伴力弱(1分)症状持续时间60 min(2分)或10-59min(1分)As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.ESSEN : Essen Stroke Risk Score危危险险因素因素分分值值75岁岁2高血高血压压1糖尿

39、病糖尿病1既往既往MI1其他心血管疾病（除外心房其他心血管疾病（除外心房颤动颤动和和MI） ）1PAD1吸烟者吸烟者1既往缺血性卒中既往缺血性卒中/TIA史史1最高分最高分值值90123456789极高危高危：卒中危险4%低危：卒中危险4%1. 2010中国缺血性卒中/短暂性脑缺血发作二级预防指南，中华神经科杂志 2010；43（2）： 154160卒中复发风险评估-ESSEN评分As the only big agricultural village in Tianding Township, some achievements have been made through the bene

40、ficial exploration of villagers autonomy in family planning for more than a year.TIA早期评价与诊断流程As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.缺血性卒中二级预防评价：Essen评

41、分高危高危卒中风险卒中风险4中危中危卒中风险卒中风险4极高危极高危CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events Lancet 1996;348:1329-1339As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial e

42、xploration of villagers autonomy in family planning for more than a year.卒中发病数日后即开启降压二级预防治疗2014AHA/ASA卒中和TIA二级预防指南：卒中和TIA患者的血压管理 既往未接受降压治疗的缺血性卒中或TIA患者，若发病后数日血压持续高于140/90mmHg，应启动降压药物治疗 发病前患者已接受降压药物治疗，应在数日后恢复治疗 Stroke. 2014;45(7):2160-236Chin J Stroke.2014, 9(8):679-6852014中国卒中和TIA二级预防指南 最初发病的几天，血压140

43、/90 mmHg者，以前未治疗的缺血性卒中和TIA患者可启动降压治疗。但对于血压140/90 mmHg患者而言，启动降压治疗的获益尚不明确（b类建议；B级证据） 既往已知高血压并接受药物治疗的患者，本次缺血性卒中或TIA发病数天后，为预防卒中复发或其他血管事件，应恢复降压治疗（类建议；A级证据）As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in

44、family planning for more than a year.权威指南推荐：轻型卒中患者应尽早给予双抗治疗，此后氯吡格雷单药可作为长期二级预防一线用药1. 短暂性脑缺血发作中国专家共识组. 中华医学杂志 2014; 94(27):2092-2096. 2. 中华医学会神经病学分会. 中华神经科杂志 2015; 48(4):258-273. 轻型卒中(NIHSS评分3分)急性期患者(起病24h内)，应尽早给予氯吡格雷联合阿司匹林治疗21d ，随后氯吡格雷单药治疗(75mg/d)，总疗程为90天。此后氯吡格雷、阿司匹林可作为长期二级预防一线用药 (I/A)2014 TIA与轻型卒中抗血

45、小板治疗中国专家共识1 轻型缺血性脑卒中患者(NIHSS评分3分)给予阿司匹林联合氯吡格雷治疗21天后，可单用阿司匹林或氯吡格雷作为缺血性脑卒中长期二级预防一线用药(I/A)2014 中国缺血性脑卒中和TIA二级预防指南2As the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.

46、指南推荐的缺血性卒中他汀治疗策略：规范他汀治疗，积极管理ASCVD风险心肌梗死或其他急性冠脉综合征有证据的冠状动脉粥样硬化性疾病（如心绞痛）冠脉或其他血管重建手术短暂性脑缺血发作（TIA）缺血性卒中外周动脉粥样硬化性疾病其他有证据的动脉粥样硬化性疾病，如：肾动脉粥样硬化、继发于动脉粥样硬化的主动脉瘤、颈动脉斑块 管腔狭窄50%患者识别循证优化他汀治疗中-高强度他汀LDL-C参考值70mg/dL管理目标减少ASCVD事件（如，缺血性卒中/TIA）确诊的ASCVD患者Jacobson TA, et al. J Clin Lipidol. 2014 Sep-Oct;8(5):473-88As the

47、 only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.出血性脑血管病As the only big agricultural village in Tianding Township, some achievements have been made through the benefi

48、cial exploration of villagers autonomy in family planning for more than a year. 患者，男性，66岁 主因“突发头痛，伴恶心、呕吐，左侧肢体活动不利1天”于急诊收入院。 入院前1天在行走时突然出现头痛，伴恶心、呕吐，为喷射样，吐出咖啡样胃内容物，伴有左上肢不能抬起，左下肢力弱、不能行走。 既往：高血压史2个月，最高200/120mmHg，未予治疗。病例摘要病例摘要Case reportAs the only big agricultural village in Tianding Township, some ach

49、ievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year. 查体：血压180/100mmHg,嗜睡，言语不清 双瞳孔等大正圆，直径3.5mm，对光反射灵敏，双侧额纹对称，左侧鼻唇沟浅，伸舌左偏 左侧肢体肌张力低，左侧上下肢肌力II级，左侧深浅感觉减退，左侧病理征（+）病例摘要病例摘要Case reportAs the only big agricultural village in Tianding Towns

50、hip, some achievements have been made through the beneficial exploration of villagers autonomy in family planning for more than a year.头 CTAs the only big agricultural village in Tianding Township, some achievements have been made through the beneficial exploration of villagers autonomy in family pl