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1、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: 66733 颈动脉夹层的模式图N Engl J Med. 2001 22;344(12):898-9064 病例分享5 病例分享6 病例分享Neurosurgery. 43(2):357-3597 病例分享8 病例分享9 DSA常见征象10 卒中或者卒中或者TIA的的发病机制病机制栓子？血流动
2、力学？11 TCD 栓子监测TraumaticSpontaneousTotalNo.10717TCD Emboli6（60%）4（58%）10（59%）Stroke.1996;27:1226-123012 影像学特点与发病机制Stroke. 1998;29:2646-2648.13 抗栓开始和抗栓开始和结束的束的时间14 局部症状和缺血的时间间隔Time Interval Between First Local and Ischemic SignsStudyTIACompleted strokesFisher(1982)Mins to 5 mo1 hour to several weeksMe
3、an: 2645 dMean: 7.89 dHart and Easton(1983)Several hours or daysBiller(1986)A few hours to 7 days from trauma to symptomsMokri(1990)A few mins to 2 wksBiousseMins to 66 dMins to 31 dMean: 10.513.5 dMean: 56.5 dStroke. 1995;26:235-23915 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16 颈动脉脉夹层抗凝抗凝 vs 抗血小板抗血小板17 很多学
4、者倾向于抗凝Stroke. 2007;38:2605-261118 19 2008 meta-analysisMedline and PubMed were searched from 1966 to 8 April 2007cervical artery dissection34 non-randomised studies762 patientsJNNP,2008;79;1122-112720 Outcome:StrokeJNNP,2008;79;1122-112721 Outcome:TIA+StrokeJNNP,2008;79;1122-112722 Outcome:Stroke+De
5、athJNNP,2008;79;1122-112723 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;1122-112724 Aspirin vs anticoagulation in carotid artery dissectionNeurology 2009;72:18101815Prospectively collected data from 298 consecutive patients with sICAD，nonrando
6、mizedAnticoagulation(n96)AspirinProspectively collecteddata of consecutive patients with sICAD(n202)new cerebral ischemic eventsOutcomeOutcomesymptomatic intracranial hemorrhagemajor extracranial bleeding25 OutcomeNeurology 2009;72:1810181526 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
7、抗栓治疗的方法可能无关（抗凝 vs 抗血小板）27 最大型的研究CADISS仍在进行中CADISSCervical Artery Dissection in Stroke Studyprospective multicentre randomised controlled trialin acute (within 7 days of onset) carotid and vertebral artery dissectionIntracerebral artery dissection is excludedInt J Stroke. 2007 Nov;2(4):292-6 28 CADIS
8、S- DesignAntiplatelet therapyaspirin, dipyridamole or clopidogrel alone or in dual combinationAnticoagulation therapyheparin followed by warfarin aiming for an International Normalised Ratio (INR) in the range 23 for at least 3 monthsSample size-3000Int J Stroke. 2007 Nov;2(4):292-6 29 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 - 27630 31
