颈动脉夹层精品PPT课件
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板）
27
最大型的研究CADISS仍在进行中
CADISS
Cervical Artery Dissection in Stroke Study
prospective multicentre randomised controlled trial in acute (within 7 days of onset) carotid and vertebral
Mokri(1990)
A few mins to 2 wks
Biousse
Mins to 66 d
Mins to 31 d
Mean: 10.5±13.5 d
Mean: 5±6.5 d
Stroke. 1995;26:235-15239
抗栓治疗的时限
动脉夹层最初3～6个月有再发卒中的风险 6个月后很少再发
JNNP,2008;79;1122-210127
Outcome:Stroke
JNNP,2008;79;1122-121127
Outcome:TIA+Stroke
JNNP,2008;79;1122-122127
Outcome:Stroke+Death
JNNP,2008;79;1122-123127
颈动脉夹层
1
动脉夹层的定义
动脉剥离(arter dissection) 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 ( dissecting aneurysm)
2
动脉夹层模式图
The Neurologist 2008;14: 663–73
Int J Stroke. 2007 Nov;2(4):29292-6
20合1并1缺A血H性A卒中二或级者T预IA的防颅外指颈动南脉（或者总源自文库动结脉）夹
层的患者，抗栓治疗至少3-6个月
(Class IIa; Level of Evidence B).
合并缺血性卒中或者TIA的颅外颈动脉或者椎动脉夹 层的患者，应该选择抗血小板治疗还是抗凝治疗还不 清楚
16
17
很多学者倾向于抗凝
Stroke. 2007;38:2605-218611
19
2008 meta-analysis
Medline and PubMed were searched from 1966 to 8 April 2007
cervical artery dissection 34 non-randomised studies 762 patients
Anticoagulation therapy
heparin followed by warfarin aiming for an International Normalised Ratio (INR) in the range 2–3 for at least 3 months
Sample size-3000
Anticoagulation
Outcome
(n~202)
Neurology® 2009;72:1810–125815
Outcome
Neurology® 2009;72:1810–216815
Conclusions
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
(Class IIb; Level of Evidence B) (New recommendation)
Stroke, Jan 2011; 42: 227 -30276
Prospectively collected data of consecutive patients with sICAD
Outcome Aspirin
(n~96)
Prospectively collected data from 298 consecutive patients with sICAD，nonrandomized
Total
No. TCD Emboli
10 6（60%）
7 4（58%）
17 10（59%）
Stroke.1996;27:1226-112230
影像学特点与发病机制
Stroke. 1998;29:2646-261348.
14
局部症状和缺血的时间间隔
Time Interval Between First Local and Ischemic Signs
Study
TIA
Completed strokes
Fisher(1982)
Mins to 5 mo
1 hour to "several weeks"
Mean: 26±45 d
Mean: 7.8±9 d
Hart and Easton(1983)
Biller(1986)
Several hours or days A few hours to 7 days from trauma to symptoms
颈动脉夹层的模式图
N Engl J Med. 2001 22;344(12):898-94 06
病例分享
5
病例分享
6
病例分享
Neurosurgery. 43(2):357-7359
病例分享
8
病例分享
9
DSA常见征象
10
栓子？ 血流动力学？
11
TCD 栓子监测
Traumatic
Spontaneous
2008 meta-analysis Conclusions
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;1122-214127
Aspirin vs anticoagulation in carotid artery dissection
artery dissection Intracerebral artery dissection is excluded
Int J Stroke. 2007 Nov;2(4):29282-6
CADISS- Design
Antiplatelet therapy
aspirin, dipyridamole or clopidogrel alone or in dual combination
27
最大型的研究CADISS仍在进行中
CADISS
Cervical Artery Dissection in Stroke Study
prospective multicentre randomised controlled trial in acute (within 7 days of onset) carotid and vertebral
Mokri(1990)
A few mins to 2 wks
Biousse
Mins to 66 d
Mins to 31 d
Mean: 10.5±13.5 d
Mean: 5±6.5 d
Stroke. 1995;26:235-15239
抗栓治疗的时限
动脉夹层最初3～6个月有再发卒中的风险 6个月后很少再发
JNNP,2008;79;1122-210127
Outcome:Stroke
JNNP,2008;79;1122-121127
Outcome:TIA+Stroke
JNNP,2008;79;1122-122127
Outcome:Stroke+Death
JNNP,2008;79;1122-123127
颈动脉夹层
1
动脉夹层的定义
动脉剥离(arter dissection) 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 ( dissecting aneurysm)
2
动脉夹层模式图
The Neurologist 2008;14: 663–73
Int J Stroke. 2007 Nov;2(4):29292-6
20合1并1缺A血H性A卒中二或级者T预IA的防颅外指颈动南脉（或者总源自文库动结脉）夹
层的患者，抗栓治疗至少3-6个月
(Class IIa; Level of Evidence B).
合并缺血性卒中或者TIA的颅外颈动脉或者椎动脉夹 层的患者，应该选择抗血小板治疗还是抗凝治疗还不 清楚
16
17
很多学者倾向于抗凝
Stroke. 2007;38:2605-218611
19
2008 meta-analysis
Medline and PubMed were searched from 1966 to 8 April 2007
cervical artery dissection 34 non-randomised studies 762 patients
Anticoagulation therapy
heparin followed by warfarin aiming for an International Normalised Ratio (INR) in the range 2–3 for at least 3 months
Sample size-3000
Anticoagulation
Outcome
(n~202)
Neurology® 2009;72:1810–125815
Outcome
Neurology® 2009;72:1810–216815
Conclusions
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
(Class IIb; Level of Evidence B) (New recommendation)
Stroke, Jan 2011; 42: 227 -30276
Prospectively collected data of consecutive patients with sICAD
Outcome Aspirin
(n~96)
Prospectively collected data from 298 consecutive patients with sICAD，nonrandomized
Total
No. TCD Emboli
10 6（60%）
7 4（58%）
17 10（59%）
Stroke.1996;27:1226-112230
影像学特点与发病机制
Stroke. 1998;29:2646-261348.
14
局部症状和缺血的时间间隔
Time Interval Between First Local and Ischemic Signs
Study
TIA
Completed strokes
Fisher(1982)
Mins to 5 mo
1 hour to "several weeks"
Mean: 26±45 d
Mean: 7.8±9 d
Hart and Easton(1983)
Biller(1986)
Several hours or days A few hours to 7 days from trauma to symptoms
颈动脉夹层的模式图
N Engl J Med. 2001 22;344(12):898-94 06
病例分享
5
病例分享
6
病例分享
Neurosurgery. 43(2):357-7359
病例分享
8
病例分享
9
DSA常见征象
10
栓子？ 血流动力学？
11
TCD 栓子监测
Traumatic
Spontaneous
2008 meta-analysis Conclusions
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;1122-214127
Aspirin vs anticoagulation in carotid artery dissection
artery dissection Intracerebral artery dissection is excluded
Int J Stroke. 2007 Nov;2(4):29282-6
CADISS- Design
Antiplatelet therapy
aspirin, dipyridamole or clopidogrel alone or in dual combination