腦中風的預防之道

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1 腦中風頭頸部血管檢查台東馬偕神經內科洪國華醫師

2 腦中風腦中風 (Stroke) 是指腦血管或腦循環出現異常, 導致腦部組織受到傷害所造成的各類臨床表現主要分為出血性中風 (Hemorrhagic stroke) 與缺血性中風 (Ischemic stroke) 兩大類

3 為何要作頭頸部血管檢查? 出血性中風找出非高血壓性腦內出血, 如動靜脈畸瘤及動脈瘤缺血性中風

4 之常見部位高血壓性腦內出血

5 自發性腦內出血作腦血管攝影之時機 1. 不尋常之出血部位 2. 腦室內出血

6 動靜脈畸瘤

7 自發性腦內出血作腦血管攝影之時機 3. 蛛網膜下腔出血

8 動脈瘤

9 為何要作頭頸部血管檢查? 出血性中風找出非高血壓性腦內出血, 如動靜脈畸瘤及動脈瘤缺血性中風

10 病人突發左側無力,CT 如下 : 到底是大中風還是小中風?

11 預後大大不同 VS 非小洞中風小洞中風

12 缺血性中風之分類 (TOAST 分類 ) 1. 大動脈血管粥樣硬化 (Large-artery atherosclerosis) 2. 心源性栓塞 (Cardioembolism) 3. 小動脈血管阻塞 ( 又稱小洞中風 ) (Small-artery occlusion;lacunar infarction) 4. 其他原因之中風 (Stroke of other determined etiology) 5. 原因未明之中風 (Stroke of undetermined etiology)

13 大動脈粥樣硬化之診斷支配梗塞區域之主要動脈或其分枝有 50% 以上血管狹窄或阻塞在神經影像學 (CT/MRI) 上, 看到大腦皮質或小腦腦幹或皮質下區有大於 1.5cm 的病灶必須排除心臟產生栓子造成中風之可能同一狹窄血管支配區曾發生過 TIA 或其他缺血症狀的病史

14 大動脈血管粥樣硬化白種人頸動脈狹窄多 ; 中大腦動脈狹窄少亞洲人頸動脈狹窄少 ; 中大腦動脈狹窄多

15 心源性栓塞之診斷最少要有一個可能來源之心臟病才能作此診斷必須排除大動脈粥樣硬化造成血管阻塞或血管栓塞之可能性電腦斷層掃描若低密度病灶處多或有出血性梗塞則幾乎可以診斷若患者病史顯示在不同的動脈支配區或身體其他部位也有栓塞現象, 則更能支持此診斷

16 TOAST 對心源性栓塞的高危險源與中度危險源的分類 High-risk sources Probable cardioembolism Mechanical prostheic valve Mitral stenosis with atrial fibrillation Atrial fibrillation (other than lone Af) Left atrial/atrial appendage thrombus Sick sinus syndrome Recent myocardial infarction (<4 week) Left ventricular thrombus Dilated cardiomyopathy Akinetic left ventricular segment Atrial myxoma Infective endocarditis Medium-risk sources Mitral valve prolapse Mitral annulus calcification Mitral stenosis without Af Left atrial turbulence (smoke) Atrial septal aneurysm Patent foramen ovale Atrial flutter Lone atrial fibrillation Bioprosthetic cardiac valve Nonbacterial thrombotic endocarditis Congestive heart failure Possible cardioembolism Hypokinetic left ventricular segment Myocardial infarction (>4 weeks, <6months)

17 小動脈血管阻塞中風臨床症狀必須為傳統小洞中風症狀群 (lacunar syndrome) 的其中之一項, 且不可以有皮質功能之障礙患者之 CT/MRI 應為正常或在腦幹或皮質下區有小於 1.5cm 的症灶心源性栓塞之可能必須排除, 另在其患側之顱外大動脈不可有大於 50% 的狹窄, 顱內基底動脈或中大腦動脈不可有 40% 以上的狹窄患者如有糖尿病或高血壓, 則可支持此診斷

18 Classical Lacunar Syndrome Sensorimotor stroke Pure motor hemiparesis Pure sensory stroke Dysarthria clumsy-hand syndrome Ataxic hemiparesis

19 診斷小洞中風須排除 Cortical dysfunction, e.g. a. Dysphasia b. Hemineglect Visual field defect Conjugate deviation of eyeballs

20 其他已知原因之急性中風包括一些少見的中風原因, 如非粥樣硬化之血管病變, 凝血能力過強 (hypercoagulable state) 及一些血液科疾病急性中風病灶部位及大小不限血液檢查或血管攝影必須符合該診斷必須排除心源性栓塞及大動脈粥樣硬化之可能

21 動脈剝離

22 原因未明之中風作完所有的檢查但還是無法肯定中風原因為何檢查不詳盡可能找出多種原因, 但還難以下最後診斷如患者有心房顫動, 但又有同側的大動脈 50% 以上狹窄小洞中風但又有同側頸動脈 50% 以上的狹窄

23 Risk for being severely disabled or dead (Rankin status IV, V, or VI) At 90 Days after Infarction Large artery atherosclerosis 30% Cardioembolism 55% Lacunar (small vessel disease) 5% Stroke of unknown cause 35%

24 Prognosis Risk for recurrent stroke at 1 year Large artery atherosclerosis 25% Cardioembolism 15% Lacunar (small vessel disease) 5% Stroke of unknown cause 15% 5-year mortality Large artery atherosclerosis 30% Cardioembolism 80% Lacunar (small vessel disease) 35% Stroke of unknown cause 50%

25 為何要作頭頸部血管檢查? 出血性中風找出非高血壓性腦內出血, 如動靜脈畸瘤及動脈瘤缺血性中風分類以便提供更適切的治療

26 腦部之循環系統分兩大系統前循環 = 頸動脈系統中大腦動脈前大腦動脈後循環 = 脊椎基底動脈系統支配腦幹及小腦之循環形成後大腦動脈

27 頭頸部血管的檢查工具 Digital subtraction angiography ( 數位血管攝影 ) Computerized Tomography Angiography (CTA, 電腦斷層血管攝影 ) Magnetic Resonance Angiography (MRA, 磁振血管攝影 ) Neurovascular sonography ( 神經血管超音波檢查 )

28 傳統 / 數位血管攝影 Advantages Gold standard Hemodynamics Images head and neck Disadvantages Stroke risk 1.4% Contrast Radiation

29 電腦斷層血管攝影 (CTA) Advantages Perform with CT-head Available, accurate Images head and neck Disadvantages Cost Contrast Radiation Reformatting

30 磁振血管攝影 (MRA) Advantages Completed with DWI and entire sequence Covers head and neck Disadvantages Availability, cost Patient exclusion, tolerance Gadolinium Image acquisition time

31 神經血管超音波檢查頸部動脈之檢查 Color-coded Duplex Sonography 彩色雙重探頭超音波顱內動脈之檢查 Transcranial Color-coded Duplex Sonography 穿顱彩色雙重探頭超音波 Transcranial Doppler Sonography 穿顱都卜勒超音波

32 彩色雙重探頭超音波 B-mode + Doppler flow velocity = Duplex sonography

33 內頸動脈狹窄診斷標準 * * N method = NASCET = 北美症狀性頸動脈內膜切除術試驗 = distal degree of stenosis

34 頸部動脈之超音波檢查 Doppler US is the standard initial evaluation Advantages Inexpensive Reliably excludes critical stenosis,< 50% Disadvantages Operator dependant Over-estimates stenosis Can be limited by severe calcifications 88% sensitivity, 76% specificity

35 血管檢查之選擇順序 Literature review with expert panel (41 studies, 2404 pts, 22 different strategies) For 70-99% Stenosis CE-MRA most accurate: 94% sens, 93% specific DUS, CTA, MRA all similar 89% sens, 84% specific For 50-69% Stenosis Literature overestimates accuracy because the sensitivity/specificity is better in asymptomatic arteries 1 st : DUS Confirm with CE-MRA Wardlaw JM, Health Technol Asses 2006;30:1-182

36 內頸動脈狹窄之測量標準 Currently, three methods (NASCET, ECST and CC) predominate worldwide.

37 何謂症狀性頸動脈狹窄? 症狀性頸動脈狹窄顱外頸動脈狹窄超過 50% 在最近 (180 日內 ) 發生過頸動脈狹窄側的缺血性腦血管症狀

38 症狀性頸動脈狹窄頸動脈內膜切除術之適應症頸動脈狹窄為 70-99% 神經症狀不嚴重 CEA 的術中的重要倂發症 ( 腦中風與死亡 ) 小於 6% (Level I) 頸動脈狹窄為 50-69% 較低的術中倂發症 ( 小於 3%) 男性近期 (2 星期內 ) 發生同側大腦半球之缺血性腦中風 (Level III)

39 無症候性嚴重頸動脈狹窄之治療懷疑有可能增加心肌梗塞危險性時仍應考慮使用 aspirin 積極控制危險因子, 包括高血壓高血脂抽煙等以 CEA 治療無症狀的頸動脈狹窄最好以病患年齡小於 80 歲頸動脈狹窄超過 80% 預期餘命大於 5 年 CEA 術中倂發症小於 3%

40 頸動脈內膜切除術 Carotid stenosis > 70% 和內科治療比較兩年後發生同側腦梗塞之機率 NASCET (NNT=6) 絕對危險性 17% 相對危險性 65% ECST (NNT=15) 絕對危險性 6.5% 相對危險性 39%

41 頸動脈成型術併支架置放 2006 年 EVA-3S ( 法國 ) 和 SPACE ( 德國 ) : 施行頸動脈內膜切除術 30 天內中風及死亡率比較低症狀性頸動脈狹窄而無法施行頸動脈內膜切除術

42 為何要作頭頸部血管檢查? 出血性中風找出非高血壓性腦內出血, 如動靜脈畸瘤及動脈瘤缺血性中風分類以便提供更適切的治療監測腦血流

43 神經血管超音波檢查頸部動脈之檢查 Color-coded Duplex Sonography 彩色雙重探頭超音波顱內動脈之檢查 Transcranial Color-coded Duplex Sonography 穿顱彩色雙重探頭超音波 Transcranial Doppler Sonography 穿顱都卜勒超音波

44 穿顱彩色雙重探頭超音波檢查

45 穿顱都卜勒超音波檢查眼窗顳窗枕骨大孔窗 Advantages Noninvasive Easy to perform / follow-up Disadvantages Operator dependant Rely on appropriate bone windows

46 穿顱都卜勒超音波檢查 Three approaches 1. Transtemporal

47 穿顱都卜勒超音波檢查 2. Transorbital 3. Transforaminal

48 穿顱都卜勒超音波檢查以探頭的位置杜卜勒的深度及血流的方向來確定動脈 Vm = 59 cm/sec PI = 0.59

49 前中後大腦動脈相對關係

50 正常顱內血管血流之平均速度

51 TCD Monitoring: Acute M1 MCA near-occlusion MCA blunted signal Flow diversion

52 Thrombolysis in Brain Ischemia (TIBI) Flow Grades

53 TCD monitoring: Emboli Detection & Right-to-left Cardiac Shunt MCA Multiple high-intensity transient signals (HITS=MES) after intravenous injection of agitated saline in a patient with right-to-left cardiac shunt (sensitivity=68~100%; specificity= 67~100%) Characteristics of Microembolic Signals (MES) 1. Random occurrence (cardiac cycle) 2. Brief duration (usually< 0.1 s) 3. High intensity (> 3 db over background) 4. Primarily unidirectional signals 5. Audible component (chirp, pop)

[ ] (National Institute of Health Stroke Scale, NIHSS) 12 "Rapidly developing clinical signs of focal disturbance of cerebral function, l

[ ] (National Institute of Health Stroke Scale, NIHSS) 12 Rapidly developing clinical signs of focal disturbance of cerebral function, l [] 41 1962 38 0 (National Institute of Health Stroke Scale, NIHSS) 12 "Rapidly developing clinical signs of focal disturbance of cerebral function, lasting more than 24 hours or leading to death with no