<link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/css/video-js.min.css?v=1"><link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/article/css/base.css?v=5"><link rel="stylesheet" href="https://studioyszimg.yxj.org.cn/article/css/index.css?v=35"><link rel="stylesheet" href="https://ysz-web.yxj.org.cn/live/dist/static/base/index.css?ysz_v=2.0"><script src="https://studioyszimg.yxj.org.cn/js/dsbridge.js?v=13" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/dsBridge/main.js?v=26" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/live/dist/static/base/fun.js?ysz_v=3" type="text/javascript"></script><script src="https://ysz-web.yxj.org.cn/live/dist/static/js/nativeToWeb.js?v=1" type="text/javascript"></script><div id="ysz-header" style="margin:0;overflow:hidden;"><h1 style="font-size:24px;line-height:1.8;color:#333333;word-wrap:break-word;">脑小血管病的诊断和治疗,这些要点你不可不知!</h1><h2 style="font-size:16px;color:#999999;word-wrap:break-word;"><em style="font-style:normal;margin-right:10px;color:#7f7f7f;display:inline-block;">2022-08-05</em><em style="font-style:normal;margin-right:10px;color:#7f7f7f;display:inline-block;">原创:医学界神经病学频道</em></h2></div><p class="brief">不容错过的精彩内容~</p><p><br/></p><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">脑小血管病(cerebral small vessel disease,CSVD)是指病理改变主要累及直径约40-200μm的穿通入脑的小动脉、微动脉、小静脉、微静脉和毛细血管的一组疾病,表现为一系列相关的临床、影像、病理综合征。关于CSVD的诊断和治疗,你了解多少呢?</span></section><section><br/></section><p><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">2022年8月5日-8月7日,在中国卒中学会第八届学术年会暨天坛国际脑血管病会议上,来自武汉市第一医院神经内科的陈国华教授就《脑小血管病的诊断和治疗》这一话题做了精彩的讲座,一起学习!</span></p><p><br/></p><section><section><section><section><p><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">CSVD多隐匿起病,提高认识非常重要</span></p></section></section></section></section><p><br/></p><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">陈国华教授介绍,60%的CSVD患者为隐匿起病,80%患者为进展性病程,且CSVD与卒中、痴呆、运动功能障碍以及抑郁密切相关,因此,提高对CSVD的认识非常重要。</span></section><section><br/></section><section><section><section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">流行病学调查显示CSVD的患病率随年龄增长而增加,50岁患病率约5%,70岁以上人群MRI检查发现10%-30%都存在CSVD,90岁以上人群患病率几乎100%。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">CSVD的患者中发生卒中的风险是25%,发生痴呆的风险是45%,而血管性痴呆的患者中有90%存在CSVD。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">CSVD是血管性抑郁发生的重要原因。</span></section></section></section></section><section></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">陈国华教授指出,CSVD是一种动态变化的全脑功能紊乱性疾病,任何原因引起的脑血管结构或功能改变均可导致CSVD,CSVD的发生机制包括慢性脑缺血与低灌注、内皮功能障碍及血脑屏障破坏、组织间液回流障碍、炎症反应等,不同机制间存在交互作用。</span></section><section><br/></section><section><section><section><section><p><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">CSVD的危险因素与病因</span></p></section></section></section></section><p><br/></p><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">陈国华教授提到,关于CSVD的危险因素,最重要的可控危险因素是高血压,因此,要注意CSVD患者的血压管理。其他危险因素包括吸烟、糖尿病、阻塞性睡眠呼吸暂停、慢性肾脏疾病、分支动脉粥样硬化疾病并伴有相关的皮质下卒中。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">对于CSVD的病因学,目前大致可以分为以下6种:</span></section><section></section><section><section><section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">小动脉硬化性(约占80%,与年龄和血管危险因素相关);</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">脑淀粉样变(散发性或遗传性);</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">非淀粉样变的遗传性(CADASIL、CARASIL、Fabry病、COL4A1小血管病);</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">炎性或免疫因素介导性(系统性和脑血管炎,继发于感染的中枢神经系统血管炎等);</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">静脉胶原性;</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">其他(放射后血管病等)。</span></section></section></section></section><section></section><section><br/></section><section><section><section><section><p><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">CSVD的影像学标志物</span></p></section></section></section></section><p><br/></p><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">陈国华教授介绍,CSVD的诊断要基于脑影像学标志物,当血管病变继发多种脑组织损伤时可被神经放射学识别。CSVD在影像学上突出表现为:腔隙、脑白质病变、脑微出血、血管周围间隙扩大,这些被公认为CSVD的影像学标志(图1)。随着近年来影像学技术的发展,新的标志物也陆续出现。</span></section><section><br/></section><p style="text-align: center;"><img class="rich_pages wxw-img img_loading" data-src="https://studioyszimg.yxj.org.cn/AC14B06401826E01EF9B83F37BE26697.jpg" src="https://studioyszimg.yxj.org.cn/AC14B06401826E01EF9B83F37BE26697.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; border: 1px solid rgb(238, 237, 235); background-size: 22px ; background-position: center center ; background-repeat: no-repeat ; height: 524.271px ; width: 606px ;"/></p><section style="text-align: center;"><span style="line-height: 28px; font-size: 14px; color: rgb(136, 136, 136);">图1:CVSD的MRI表现汇总</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">陈国华教授强调,在临床中,血管周围间隙(Perivascular spaces,PVS)和腔梗(Lacunar infarction,LI)容易混淆,那么,如何进行两者的鉴别呢,这也需要找到两者在影像学上的差异(表1)。</span></section><section><br/></section><section style="text-align: center;"><span style="line-height: 28px; font-size: 14px; color: rgb(136, 136, 136);">表1:PVS和LI的影像标志物鉴别</span></section><p style="text-align: center;"><img class="rich_pages wxw-img" data-src="https://mmbiz.qpic.cn/mmbiz_png/JjUUPEWpIgtYOKsFUibXjXiauYU6P4bibSQr9ehGDFDGWicLTaMDXxtqae4riar7eLSukxjbzp8tDcpzk7icHLgJFQdA/640?wx_fmt=png" src="https://studioyszimg.yxj.org.cn/AC14B06401826E01F16C06B908CDACEC.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 677px ; visibility: visible ;"/></p><section></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">陈国华教授介绍,随着影像学技术的发展,新的影像学表现或许可以成为CSVD的其他标志物,对CSVD的诊断起到提示作用。血管壁成像(VW)是一种新兴的MRI技术,可能有助于诊断CSVD,高达50%的淀粉样脑血管病患者有血管壁强化,更先进的成像方式,如7T MRI和弥散张量成像(DTI),可以比标准的MRI序列更早地发现显微组织损伤。</span></section><section><br/></section><p style="text-align: center;"><img class="rich_pages wxw-img" data-src="https://mmbiz.qpic.cn/mmbiz_png/JjUUPEWpIgtYOKsFUibXjXiauYU6P4bibSQ5JapI2vFVhujX3mFIiamic2iapEjb6HCH5x93rK6uxvurnhZp8oULzYWg/640?wx_fmt=png" src="https://studioyszimg.yxj.org.cn/AC14B06401826E01F2C601894808AF79.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 677px ; visibility: visible ;"/></p><section style="text-align: center;"><span style="line-height: 28px; font-size: 14px; color: rgb(136, 136, 136);">图2:CSVD的新型影像学技术</span></section><section><br/></section><section><section><section><section><p><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">CSVD的临床表现</span></p></section></section></section></section><p><br/></p><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">陈国华教授指出,CSVD临床表现和病程变化很大,既可以有缺血和出血的双重倾向,也可以大、小血管同时受累,还要考虑到亚临床表现与急性发作的动态演变。此外,导致不同临床表现的相关因素也有很多,包括:血管损伤的位置、类型及程度,以及不同损伤的继发性神经退变。</span></section><section><br/></section><p style="text-align: center;"><img class="rich_pages wxw-img img_loading" data-src="https://studioyszimg.yxj.org.cn/AC14B06401826E01F4AC94F26790A8CE.jpg" src="https://studioyszimg.yxj.org.cn/AC14B06401826E01F4AC94F26790A8CE.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; border: 1px solid rgb(238, 237, 235); background-size: 22px ; background-position: center center ; background-repeat: no-repeat ; height: 338.838px ; width: 677px ;"/></p><section style="text-align: center;"><span style="line-height: 28px; font-size: 14px; color: rgb(136, 136, 136);">图3:CSVD临床表现的相关因素</span></section><section><br/></section><section><section><section><section><section><section><section><span class="ysz-ueditor-title-two" style="font-size: 16px; line-height: 22.5px; font-weight: bold; color: rgb(0, 0, 0); list-style-type: decimal; text-align: left;">腔隙性脑梗死</span><br/></section></section></section></section></section></section></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">小的穿支动脉病变导致管腔闭塞所致的梗死,经典的表现为腔隙综合征,典型的腔隙综合征在影像学上的阳性预测值为87%,其中,纯感觉性脑卒中(100%)和共济失调性轻偏瘫(95%)是最具预测价值的。</span></section><section><br/></section><section><section><section><section><section><section><span class="ysz-ueditor-title-two" style="font-size: 16px; line-height: 22.5px; font-weight: bold; color: rgb(0, 0, 0); list-style-type: decimal; text-align: left;">高血压性脑出血</span></section></section></section></section></section></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">最容易累及大脑中动脉和大脑后动脉的小穿支动脉。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">常见于基底节区(60%-65%)、丘脑(15%-25%),脑叶出血仅占高血压性脑出血病例的5%-15%。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">诊断主要根据高血压病史、累及基底节区及脑干等典型的出血部位以鉴别。</span></section><section><br/></section><section><section><section><section><section><span class="ysz-ueditor-title-two" style="font-size: 16px; line-height: 22.5px; font-weight: bold; color: rgb(0, 0, 0); list-style-type: decimal; text-align: left;">淀粉样脑血管病(CAA)</span></section></section></section></section></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">37%-74%的非外伤性脑出血与CAA有关,CAA脑叶出血更常见于枕部和颞叶后部,与Aβ沉积好发部位有关。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">短暂性局灶性神经系统症状发作是CAA特异性的急性临床事件,与局灶性蛛网膜下腔出血、脑表面铁沉积有关。</span></section><section><br/></section><p style="text-align: center;"><img class="rich_pages wxw-img" data-src="https://mmbiz.qpic.cn/mmbiz_png/JjUUPEWpIgtYOKsFUibXjXiauYU6P4bibSQuFBS9PtReRTgibY3AaLC5za3cvyks6GmIfXMdy4EEOGSKiaX5T7Bna1A/640?wx_fmt=png" src="https://studioyszimg.yxj.org.cn/AC14B06401826E01F6B8EAF7037586D1.jpg" alt="图片" style="margin: 0px; padding: 0px; outline: 0px; vertical-align: bottom; box-sizing: border-box ; overflow-wrap: break-word ; width: 479px ; visibility: visible ;"/></p><section style="text-align: center;"><span style="line-height: 28px; font-size: 14px; color: rgb(136, 136, 136);">图4:CAA影像学表现</span></section><section><br/></section><section><section><section><section><section><section><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">慢性脑小血管病</span></section></section></section></section></section></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">隐匿起病,具有与脑小血管病变相关的临床表现,如认知功能下降、步态障碍、精神情感异常、小便异常及总体功能下降等,影像学检查发现检查常发现脑小血管病变表现/影像标志物。</span></section><section><br/></section><section><section><section><section><p><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">CSVD的治疗</span></p></section></section></section></section><section></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">陈国华教授介绍,关于CSVD的治疗,首先要明确治疗目标,包括病理、影像和临床三个方面。</span></section><section><br/></section><section><section><section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">病理目标:防治CSVD的策略为靶向脑的微小血管内皮、血脑屏障、神经炎症的治疗。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">影像目标:预防新的腔隙性梗死、微出血和脑萎缩的发生,并延缓脑白质高信号的恶化。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">临床目标:减少首次或复发性卒中,预防认知功能减退和功能残疾,如平衡或步态受损或神经心理异常。</span></section></section></section></section><section><br/></section><section><section><section><section><section><section><section><span style="color: rgb(0, 0, 0); font-size: 16px;">降压</span></section></section></section></section></section></section></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">&nbsp;</span></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血压是CSVD最重要的可变危险因素,选择降压药时宜选用减少血压变异性的长效降压药如CCB或肾素血管紧张素系统(RAS)阻断剂。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">不主张使用β受体阻滞剂,因为可以降低心率的自动调节能力,会增加心率变异性。</span></section><section><br/></section><section><section><section><section><section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">抗血小板</span></section></section></section></section></section></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">随机试验的汇总分析表明,急性皮质下梗死后阿司匹林单药治疗可降低卒中复发风险30%。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">CHANCE研究和POINT研究进一步为双联抗血小板治疗(DAPT)在急性轻型缺血性卒中或高危短暂性脑缺血发作患者中的应用累积了证据。</span></section><section><br/></section><section><section><section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">CHANCE:与阿司匹林单药治疗相比,卒中发作24小时内进行21天DAPT治疗可减少90天内卒中复发。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">POINT:与阿司匹林单药治疗相比,卒中发作12小时内进行90天DAPT治疗可减少90天内卒中复发,但增加了出血性不良事件的发生率。</span></section></section></section></section><section></section><section><br/></section><section><section><section><section><section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">他汀类药物</span></section></section></section></section></section></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">他汀是缺血性卒中二级预防中的重要一环,具有降脂、抗炎、改善血管内皮细胞功能的作用。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">SPARCL研究结果显示:80mg/d阿托伐他汀对大血管病变和小血管病引起的缺血性卒中都有预防效果。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">ROCAS研究显示:辛伐他汀20mg/天可减少亚临床脑梗死的复发风险。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">有研究显示,他汀可以稳定血脑屏障,这在脑小血管病的治疗中可能有独特作用,还可以改善患者认知功能。</span></section><section><br/></section><section><section><section><section><span class="ysz-ueditor-title-one" style="font-size: 16px; line-height: 28px; font-weight: bold; color: rgb(215, 0, 15); text-align: left;">总结:</span></section><section><section><section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">CSVD好发于老年人,多种病因和危险因素及其发病机制。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">CSVD分为急性和慢性,有多种临床表现。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">治疗和预防重点是要把握好缺血和出血之间平衡。</span></section><section><br/></section><section><span class="ysz-ueditor-content" style="font-size: 16px; line-height: 28px; color: rgb(0, 0, 0);">血管壁成像、高场强MRI等的应用为CSVD的早期诊断和干预提供了可能。</span></section></section></section></section></section></section></section><p><br/></p><!--auditorInfo-->

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