腦動(dòng)脈支架治療相關(guān)的腦過(guò)度灌注綜合征

1、腦動(dòng)脈支架治療相關(guān)的腦過(guò)度灌注綜合征,廣東省人民醫(yī)院神經(jīng)科王 碩,腦過(guò)度灌注綜合癥 (Cerebral Hyperperfusion Syndrome, CHS）,1981年 sundt等 頸動(dòng)脈內(nèi)膜切除術(shù) 顱內(nèi)動(dòng)靜脈畸形切除術(shù)由于原先低灌注區(qū)腦血流量顯著增加超過(guò)腦組織代謝需要而引起的一種嚴(yán)重并發(fā)癥治療后5-7天,隨著頸動(dòng)脈成形和支架植入術(shù)的廣

2、泛開(kāi)展, 相關(guān)的病例報(bào)道逐漸增多, 術(shù)后的發(fā)生率在 1.1%-6.8%之間,,Intracranial hemorrhage associated with cerebral hyperperfusion syndrome following carotid endarterectomy and carotid artery stenting: retrospective review of 4494 patients.,J

3、 Neurosurg. 2007 Dec;107(6):1130-6.,Department of Neurosurgery, Iwate Medical University, Morioka, Japan.,Retrospective study for hyperperfusion syndrome in 4494(CEA1596,CAS2898)Rate of hyperperfusion:1.4% including he

4、morrhage(0.6%)Peak of hyperperfusion: CEA 6th day, CAS within 12hrsRate of hyperperfusion:CEA1.9%,CAS1.1%Rate of hemorrhage associated with hyperperfusion:CEA0.4%,CAS0.7%Pattern of hemorrhage: CEA ICH, CAS

5、ICH+-SAHPoor prognosis in cases associated with hemorrhage,男性， 56 歲診斷：右側(cè)腦梗塞 雙側(cè)頸內(nèi)動(dòng)脈狹窄 高血壓病3級(jí)、極高危,右頸內(nèi)動(dòng)脈重度狹窄,左側(cè)頸內(nèi)動(dòng)脈狹窄,右側(cè)頸內(nèi)動(dòng)脈支架術(shù)后,術(shù)后2小時(shí)頭顱CT,女性， 78 歲診斷：右側(cè)腦梗塞 右側(cè)頸內(nèi)動(dòng)脈狹窄

6、 高血壓病3級(jí)、極高危術(shù)后6小時(shí)：左側(cè)肢體無(wú)力3+ 0級(jí),,,男，47歲 高血壓、冠心病、陳舊性心肌梗死（2002年）及高血脂 診斷：短暫性腦缺血發(fā)作 左側(cè)大腦中動(dòng)脈重度狹窄 高血壓病2級(jí)（極高危） 冠心病 陳舊性心肌梗死,,,Hyperperfusion Syndrome After Stenting for Intra

7、cranial Vertebral Stenosis,Marco Tu´lio Rezende, MD; Laurent Spelle, MD, PhD; Charbel Mounayer, MD; Michel Piotin, MD;Daniel Giansante Abud, MD; Jacques Moret, MD Stroke. 2006;37:e12-e14.,

8、,Axial T2 gradient-echo MRI 24 hours after the procedure shows bilateral thalamic hemorrhage,Axial flair MRI shows no lesions in both thalami,Hemorrhagic complications after PTA/stenting for intracranial arterial stenosi

9、s,3/130 cases (2.3%)caused HemorrhageICH:2,SAH:1Hemorrhage apperede winthin 24 hoursAll case showed stageⅡ on SPECT2 cases (1.5%)recognized hyperperfusion syndrome,Japan.,臨床癥狀,頭痛（額顳）、面部和眼部疼痛惡心、嘔吐癲癇發(fā)作局灶性癥狀（腦水腫、腦出血）

10、精神癥狀？,發(fā)生機(jī)理,慢性、長(zhǎng)期------低灌注顱內(nèi)血管極度擴(kuò)張自動(dòng)調(diào)節(jié)機(jī)制受損血流動(dòng)力學(xué)儲(chǔ)備受損,Hyperacute Intracerebral Hemorrhage Complicating Carotid Stenting Should Be Distinguished from Hyperperfusion Syndrome,AJNR Am J Neuroradiol 27:1508 –13 Aug 2006,pr

11、imary ICH ?,預(yù)示CHS因素,長(zhǎng)期持續(xù)的高血壓高度狹窄病變側(cè)支循環(huán)代償不良血管反應(yīng)性--乙酰唑胺CBF—評(píng)估,高灌注的預(yù)測(cè)與評(píng)估,CBF檢測(cè)：SPECT、PET、Xe-CT、Perfusion-CTTCD,預(yù) 防,術(shù)后立即中和肝素嚴(yán)格控制血壓明確CHS狀態(tài)：TCD、灌注CT、SPECT依達(dá)拉奉？？鈣離子拮抗劑？,治 療,控制血壓抗凝和抗血小板治療的控制依達(dá)拉奉？？（抗自由基）大血腫----