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1、.,1,颈动脉夹层,.,2,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),.,3,动脉夹层模式图,The Neurologist 2008;14: 6673,.,4,颈动脉夹层的模式图,N Engl J Med. 2001 22;344(12):898-906,.,5,病例分享,.,6,病例分享,.,7,病例分享,Neurosurgery. 43(2):357-359,.,8,病例分享,.,9,病例分享,.,10
2、,DSA常见征象,.,11,卒中或者TIA的发病机制,栓子？ 血流动力学？,.,12,TCD 栓子监测,Stroke.1996;27:1226-1230,.,13,影像学特点与发病机制,Stroke. 1998;29:2646-2648.,.,14,抗栓开始和结束的时间,.,15,局部症状和缺血的时间间隔,Stroke. 1995;26:235-239,.,16,抗栓治疗的时限,动脉夹层最初36个月有再发卒中的风险 6个月后很少再发,.,17,颈动脉夹层抗凝 vs 抗血小板,.,18,很多学者倾向于抗凝,Stroke. 2007;38:2605-2611,.,19,.,20,2008 meta
3、-analysis,Medline and PubMed were searched from 1966 to 8 April 2007 cervical artery dissection 34 non-randomised studies 762 patients,JNNP,2008;79;1122-1127,.,21,Outcome:Stroke,JNNP,2008;79;1122-1127,.,22,Outcome:TIA+Stroke,JNNP,2008;79;1122-1127,.,23,Outcome:Stroke+Death,JNNP,2008;79;1122-1127,.,2
4、4,2008 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;1122-1127,.,25,Aspirin vs anticoagulation in carotid artery dissection,Neurology 2009;72:18101815,Prospectively collected data from 298 consecutive patients with sICAD，nonrandomized,Anticoagulat
5、ion,(n96),Aspirin,Prospectively collected data of consecutive patients with sICAD,(n202),new cerebral ischemic events,Outcome,Outcome,symptomatic intracranial hemorrhage major extracranial bleeding,.,26,Outcome,Neurology 2009;72:18101815,.,27,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
6、事件与抗栓治疗的方法可能无关（抗凝 vs 抗血小板）,.,28,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 artery dissection Intracerebral artery dissection is excluded,Int J Stroke. 2007 Nov;2(4):29
7、2-6,.,29,CADISS- Design,Antiplatelet therapy aspirin, dipyridamole or clopidogrel alone or in dual combination Anticoagulation therapy heparin followed by warfarin aiming for an International Normalised Ratio (INR) in the range 23 for at least 3 months Sample size-3000,Int J Stroke. 2007 Nov;2(4):292-6,.,30,2011 AHA 二级预防指南（总结）,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，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 (Class IIb; Level of Evidence B) (New recommendation),Stroke, Jan 2011; 42: 227 - 276,.,31,/10/29,.,32,
