頸動脈狹窄的診療支架頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)治療的病例選擇圍手術(shù)用藥用藥腦動脈系統(tǒng)腦動脈系統(tǒng)2頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥缺血性腦血管病的病因缺血性腦血管病的病因Albers GW,Chair;J.CHEST 1998;114:683S698S 3頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥頸動脈狹窄的診斷頸動脈狹窄的診斷4頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥頸動脈狹窄定義頸動脈狹窄定義Paul HL Kao頸總動脈頸總動脈(CCACCA)、分叉或頸內(nèi)動脈、分叉或頸內(nèi)動脈(ICAICA)近段動脈硬化斑塊形成近段動脈硬化斑塊形成斑塊潰瘍、血栓形成、或遠(yuǎn)端栓塞是斑塊潰瘍、血栓形成、或遠(yuǎn)端栓塞是引起癥狀引起癥狀(TIA/stroke/AF)(TIA/stroke/AF)的主要原的主要原因因5頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥l動脈粥樣硬化動脈粥樣硬化l纖維肌發(fā)育不良纖維肌發(fā)育不良(fibromuscularfibromuscular dysplasiadysplasia)l高安氏病高安氏?。═akayasusTakayasus ArteritisArteritis）l血管炎（血管炎（vasculitis）(包括放療后包括放療后)l與神經(jīng)纖維瘤病相關(guān)的狹窄與神經(jīng)纖維瘤病相關(guān)的狹窄頸動脈狹窄的原因頸動脈狹窄的原因6頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥臨床表現(xiàn)臨床表現(xiàn)無癥狀性狹窄無癥狀性狹窄 無神經(jīng)系統(tǒng)癥狀和體征，影像學(xué)無陽性發(fā)現(xiàn)無神經(jīng)系統(tǒng)癥狀和體征，影像學(xué)無陽性發(fā)現(xiàn)有癥狀性狹窄有癥狀性狹窄 Amaurosis fugax Amaurosis fugax 一過性黑朦一過性黑朦 Transient ischemic attack(TIA)Transient ischemic attack(TIA)Reversible ischemic neurological deficit Reversible ischemic neurological deficit (RIND)(RIND)可逆性缺血性神經(jīng)功能神經(jīng)缺失可逆性缺血性神經(jīng)功能神經(jīng)缺失 Completed stroke Completed stroke 完全中風(fēng)完全中風(fēng)7頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥B-modePower angioColor mappingDopplerTCD頸動脈狹窄的診斷頸動脈狹窄的診斷DuplexDuplex超聲超聲lMRA&CTAMRA&CTAlDSA-DSA-黃金標(biāo)準(zhǔn)黃金標(biāo)準(zhǔn) 狹窄度狹窄度 形態(tài)學(xué)形態(tài)學(xué)-鈣化、血栓、潰瘍鈣化、血栓、潰瘍8頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥9頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥10頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥11頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥12頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥13頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥14頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥NASCETNASCETNorth American Symptomatic North American Symptomatic North American Symptomatic North American Symptomatic Carotid Endarterectomy TrialCarotid Endarterectomy TrialCarotid Endarterectomy TrialCarotid Endarterectomy TrialECSTECSTEuropean Carotid Stenosis European Carotid Stenosis European Carotid Stenosis European Carotid Stenosis Trial Trial Trial Trial 頸動脈狹窄率的測定頸動脈狹窄率的測定15頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥頸動脈狹窄與缺血性卒中的關(guān)系頸動脈狹窄與缺血性卒中的關(guān)系l約約40%40%的前循環(huán)系統(tǒng)的前循環(huán)系統(tǒng)TIATIA或中風(fēng)存在同側(cè)頸或中風(fēng)存在同側(cè)頸動脈的重度狹窄動脈的重度狹窄(75%)(75%)其中其中8%8%完全閉塞完全閉塞 l10%10%癥狀性頸內(nèi)動脈狹窄者癥狀性頸內(nèi)動脈狹窄者1 1年內(nèi)發(fā)生腦梗年內(nèi)發(fā)生腦梗死，死，5 5年內(nèi)發(fā)生梗死的危險性高達(dá)年內(nèi)發(fā)生梗死的危險性高達(dá)40%40%l無癥狀性頸內(nèi)動脈狹窄無癥狀性頸內(nèi)動脈狹窄(80%)80%)每年發(fā)生每年發(fā)生中風(fēng)的危險性為中風(fēng)的危險性為 6%6%l約有約有80%80%的中風(fēng)發(fā)生前無任何癥狀的中風(fēng)發(fā)生前無任何癥狀 (如如TIATIA等等)16頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥頸動脈狹窄與缺血性卒中的關(guān)系頸動脈狹窄與缺血性卒中的關(guān)系Figure 3.Annual risk of stroke or vascular death among patients in various high risk subgroups.Wilterdink JL,Easton JD.Arch Neurol 1992;49:857 863.17頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥頸動脈狹窄頸動脈狹窄支架治療的病例選擇支架治療的病例選擇18頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥頸動脈狹窄的治療頸動脈狹窄的治療Established for selected patientsEstablished for selected patientsl lAnti-platelet therapy Anti-platelet therapy Anti-platelet therapy Anti-platelet therapy 抗血小板抗血小板抗血小板抗血小板l lStatin agents Statin agents Statin agents Statin agents 他丁類藥物他丁類藥物他丁類藥物他丁類藥物l lCarotid endarterectomy Carotid endarterectomy Carotid endarterectomy Carotid endarterectomy 頸動脈內(nèi)膜剝離術(shù)頸動脈內(nèi)膜剝離術(shù)頸動脈內(nèi)膜剝離術(shù)頸動脈內(nèi)膜剝離術(shù)l lAngioplasty and stentingAngioplasty and stentingAngioplasty and stentingAngioplasty and stentingUnder investigationUnder investigation正在確立的新療法正在確立的新療法ExtracranialExtracranialExtracranialExtracranial to Intracranial bypass to Intracranial bypass to Intracranial bypass to Intracranial bypassAtherectomyAtherectomyAtherectomyAtherectomy 動脈狹窄旋切術(shù)動脈狹窄旋切術(shù)動脈狹窄旋切術(shù)動脈狹窄旋切術(shù)Laser Assisted Angioplasty Laser Assisted Angioplasty Laser Assisted Angioplasty Laser Assisted Angioplasty 激光輔助的血管成型術(shù)激光輔助的血管成型術(shù)激光輔助的血管成型術(shù)激光輔助的血管成型術(shù)ThrombolysisThrombolysisThrombolysisThrombolysis AngiojetAngiojetAngiojetAngiojet 血管射頻消融術(shù)血管射頻消融術(shù)血管射頻消融術(shù)血管射頻消融術(shù)19頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥CarotidCarotidendarterecendarterectomytomy(CEA)(CEA)is a surgical procedure removing plaque material from the lining of an artery20頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥The procedure to remove plaque build-up from an artery.A surgeon scrapes away the arterial lining,where plaque has formed,and the artery is stitched closed.Endarterectomy:researches Endarterectomy:researches 研究結(jié)果研究結(jié)果lNorth American Symptomatic Carotid North American Symptomatic Carotid North American Symptomatic Carotid North American Symptomatic Carotid EndarterectomyEndarterectomyEndarterectomyEndarterectomy Trial(NASCET)Trial(NASCET)Trial(NASCET)Trial(NASCET)lEuropean Carotid European Carotid European Carotid European Carotid StenosisStenosisStenosisStenosis Trial(ECST)Trial(ECST)Trial(ECST)Trial(ECST)Results:Results:Results:Results:Dramatic risk reduction with surgery Dramatic risk reduction with surgery Dramatic risk reduction with surgery Dramatic risk reduction with surgery for severe for severe for severe for severe stenosisstenosisstenosisstenosis 結(jié)果結(jié)果結(jié)果結(jié)果:CEA:CEA:CEA:CEA明顯降低頸動脈嚴(yán)重狹窄患者的中風(fēng)危險性明顯降低頸動脈嚴(yán)重狹窄患者的中風(fēng)危險性明顯降低頸動脈嚴(yán)重狹窄患者的中風(fēng)危險性明顯降低頸動脈嚴(yán)重狹窄患者的中風(fēng)危險性NASCET.N Engl J Med 1991;325:445-453 ECST.Lancet 1991;337:1235-124321頸動脈狹窄的診療支架治療的病例選擇圍手術(shù)用藥l lContralateralContralateralContralateralContralateral occlusion occlusion occlusion occlusion 對側(cè)對側(cè)對側(cè)對側(cè)CCACCACCACCA閉塞閉塞閉塞閉塞lHigh or bifurcation lesions High or bifurcation lesions 高位或分叉部病變高位或分叉部病變lLow or Low or ostialostial CCA lesions CCA lesions 低位或靠近低位或靠近CCACCA開口處開口處lNeck radiation Neck radiation 頸部放射治療頸部放射治療lPrior radical neck dissection Prior radical neck dissection 既往頸部切開術(shù)既往頸部切開術(shù)lPrior carotid Prior carotid endarterectomyendarterectomy 既往既往CEACEAlShort,obese necks Short,obese necks。