缺血性脑血管病规范化外科治疗课件.pptx

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1、,缺血性脑血管病规范化外科治疗,苏州大学附属第一医院神经外科 Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo,黄亚波,要按规矩办事,卫计委的红头文件,缺血性脑血管病的外科治疗Surgery for ischemic cerebrovascular disease,MoyaMoya，烟雾病 STA-MCA Bypass 颅内外动脉闭塞性脑血管病 STA-MCA Bypass颈动脉狭窄 颈动脉内膜剥脱术（CEA）大面积脑梗死 去骨瓣减压术,Department of Neurosurg

2、ery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,第一部分：CEA,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,传统式CEA,术前 术后,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,外翻式CEA,术前 术后,

3、Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,补片式CEA,术前 术后,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,多种方式CEA,术前 术后,R,L,R,L,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Hu

4、angyabo 苏州大学附属第一医院神经外科,颈动脉斑块,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,双侧颈动脉重度狭窄 Emergency Carotid Endarterectomy(CEA)一期：急诊L-CEA二期：择期R-EEA,苏州大学附属第一医院神经外科,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神

5、经外科,颈动脉内膜剥脱术（CEA）,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,典型病例 患者 周某某 女性 72岁 因“右侧肢体无力2月，加重20天”在神经内科保守治疗，当时查体：神清，右侧肢体肌力级。CTA（2013-06-12）示双侧颈动脉狭窄。颈部彩超提示双侧颈动脉斑块。过去史：有高血压病，糖尿病史20余年。,颈动脉内膜剥脱术（CEA）,Department of Neurosurgery,Affiliated First Hosptial

6、,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,治疗经过：患者在住院期间TIA发作两次，建议手术治疗，家属拒绝。2013-06-15患者出现右侧肌力0级，4-5小时后变为级，MRI（2013-06-17）示左侧分水岭梗塞；家属同意手术后转入神经外科。2013-06-20患者出现右侧下肢肌力级，右侧上肢肌力0级，急查MRI示左侧分水岭梗塞，面积未明显增大；2013-06-21行左侧CEA,CEA的学习曲线循序渐进，渐入佳境,Department of Neurosurgery,Affiliated First Hosptial,Suzhou Univers

7、ity Huangyabo 苏州大学附属第一医院神经外科,左侧颈动脉近全闭塞，右侧颈动脉重度狭窄一期：左侧颈内动脉残端结扎术+左侧颈外动脉内膜剥脱术+左侧颈外动脉补片修补术二期：右侧外翻式颈动脉内膜剥脱术,苏州大学附属第一医院神经外科,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,颈动脉内膜剥脱术（CEA）,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University H

8、uangyabo 苏州大学附属第一医院神经外科,典型病例 患者 李某某 男性 70岁 因“肢体乏力伴行走不稳四年，加重一周”入院，查体：神清，四肢肌力+级，NS(一)。过去史：高血压，糖尿病十余年，均未正规服药,个人体会：适者生存，夹缝中求生存 在我国治疗颈动脉狭窄这一领域，神经内科和神经介入科占据明显的优势，有着丰富的临床治疗经验。虽然目前国外大量临床随机对照试验仍然证实“CEA是治疗颈动脉狭窄的金标准”，但是我尊重国情，把治疗重点放在以下两个方面，希望可以和神经内科及介入科合作，为患者的康复多提供一种选择：,Department of Neurosurgery,Affiliated Fir

9、st Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,个人体会：1.对于严重狭窄，尤其是伴有明显钙化的患者（术前经过高分辨率磁共振和CTA判断斑块的性质），CEA可能更加有益2.支架术后再狭窄，可以通过CEA来解决问题,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,第二部分：烟雾病,Department of Neurosurgery,Affiliated First Hosptial,Suzh

10、ou University Huangyabo 苏州大学附属第一医院神经外科,实践是检验真理的唯一标准，理论与实践结合，探索烟雾病的手术治疗方法,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,直接血管重建术 Direct revascularizationBypass of superficial temporal artery to middle cerebral artery（STA-MCA Bypass)间接血管重建术 In direct re

11、vascularization Drilling of burr holes without vessel synangiosis Encephalomyoarteriosynangiosis(EMAS)Encephaloduroarteriosynangiosis(EDAS)Others直接、间接血管重建术相结合 Combination of direct and indirect revascularization,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第

12、一医院神经外科,烟雾病的手术治疗方法 Surgical treatment of moyamoya disease,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,At several months after surgical treatment,the blood supply fromthe external carotid artery to intracranial vessels(MCA area)wasgenerally confirme

13、d by angiography in any kind of anastomosis.There are various patterns of revascularization depending on thedominancy of the donor arteries,such as STA,middle meningealartery(MMA),or deep temporal artery.In the case of directanastomosis,the STA grows larger and more robust than beforesurgery.In the

14、case of indirect or combined anastomosis,thedominancy of the donor arteries varies in each case.Some casesshowed dominant STA compared with the deep temporal arteryor MMA.Others showed the same dominancy of the STA andMMA.A question emerges:What is the key factor that determinesthe dominancy or pate

15、ncy of the donor artery?,Insights on the Revascularization Mechanism for Treatment of Moyamoya DiseaseBased on the Histopathologic Concept of Angiogenesis and Arteriogenesis,成人缺血型烟雾病 In direct revascularization,苏州大学附属第一医院神经外科,烟雾病 moyamoya disease,Department of Neurosurgery,Affiliated First Hosptial,

16、Suzhou University Huangyabo 苏州大学附属第一医院神经外科,典型病例患者 顾某某 男性 49岁 因“突发头痛伴肢体乏力二周”入院，行DSA检查提示左侧颈内动脉逐渐变细，末端闭塞，闭塞处可见新生烟雾状血管形成；右侧颈内动脉M1、A1段稍细，诊断：烟雾病。查体：神清，四肢肌力肌张力正常，NS（一）。,成人缺血型烟雾病 Combination of direct and indirect revascularization,苏州大学附属第一医院神经外科,烟雾病 moyamoya disease,Department of Neurosurgery,Affiliated Fi

17、rst Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,典型病例（缺血型）患者 李某某 女性 25岁 因“右侧肢体活动障碍一年伴头痛半年”入院。查体：神清，言语不清，右侧肢体肌力-级。过去史：甲状腺功能亢进9月，一直正规服药治疗，T3T4正常；高血压病史一年，服药后血压正常。,第三部分：颅内外动脉闭塞性脑血管病,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,对于颅内外闭塞性疾病，当内科治疗效果差

18、，无法行介入治疗时，请考虑：EC-IC Bypass是一种好的可供选择的治疗方法！,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,严格的手术适应症反复短暂性脑缺血发作（TIA）；认知功能障碍（RIND），或已恢复的患者再次发生卒中DSA示颈动脉闭塞，颈内动脉或M

19、1段重度狭窄或闭塞，且侧支循环不充分MRI示典型分水岭梗塞SPECT，CTP或MRP以及TCD提示存在脑血流动力学障碍,颅外段颈内动脉闭塞合并同侧大脑中动脉M1段狭窄 STA-MCA Bypass,苏州大学附属第一医院神经外科,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,缺血性脑血管病的外科治疗Surgery for ischemic cerebrovascular disease,Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo 苏州大学附属第一医院神经外科,典型病例患者 张某 男性 43岁 因“左侧肢体偏瘫45天”入院。头颅MRI示右侧基底节区脑梗塞，DSA示右侧颈内动脉（颅外段）闭塞，右侧M1段狭窄。查体：神清，左侧鼻唇沟变浅，伸舌右偏，左侧肢体肌力0级，双侧病理征阴性。过去史：高血压病史三年，糖尿病病史两年,致谢,苏州大学附属第一医院神经外科 黄亚波 Department of Neurosurgery,Affiliated First Hosptial,Suzhou University Huangyabo,