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李新毅:基于CISS分型的缺血性卒中的诊断思路

2020-11-30 《门诊》杂志 门诊新视野

缺血性卒中不是一个独立的疾病,而是一种异质性很强的疾病,不同类型的缺血性卒中的病因也各不相同。根据病因学分型基于病因对不同的缺血性卒中患者“对因施治”的意义重大。

随着人们对缺血性卒中的认识从一种“疾病”到一种“临床综合征”观念的转变,并开始基于病因对不同的缺血性卒中患者“对因施治”,缺血性卒中的病因学分型的意义也更加重要。2019年3月22日在山西召开的“136”兴医工程领军临床专科系学术系列活动/第四届三晋血栓论坛暨山西省血管疾病专科联盟年度会议上,来自山西大医院神经内科的李新毅医师就基于CISS分型的缺血性卒中的诊断思路这一话题进行了精彩的演讲。

CISS分型

缺血性卒中不是一个独立的疾病,而是一种异质性很强的疾病,不同类型的缺血性卒中的病因也各不相同。人们对缺血性卒中的认识从一种“疾病”到一种“临床综合征”观念的转变,并开始基于病因对不同的缺血性卒中患者“对因施治”。因此,缺血性卒中的病因学分型是临床试验、流行病学调查、基因研究以及临床实践中治疗决策制定的基础。

自1993年经典的TOAST分型发表以来,人们在使用过程中不断根据自己的认识对其进行改造,在演变发展过程中尽可能扬长避短。中国缺血性卒中亚型(CISS)这一标准体系的分型过程分为两步:第一步同经典的TOAST分型相似,亦将病因分为5种类型,即大动脉粥样硬化(LAA)、心源性卒中(CS)、穿支动脉疾病(PAD)、其他病因(OE)及病因不确定(UE),其中LAA还按照部位分为主动脉弓粥样硬化和颅内、外大动脉粥样硬化。第二步对颅内外大动脉粥样硬化性脑梗死的发病机制进行分型,分为4种类型:载体动脉(斑块或血栓) 堵塞穿支、动脉到动脉栓塞、低灌注/栓子清除下降及混合机制(图1)。CISS分型最大优点是将动脉粥样硬化所致缺血性卒中的病因及发病机制区分开来,更符合疾病发生发展的病理生理过程;同时将主动脉弓动脉粥样硬化作为大动脉粥样硬化的一个亚型而非心源性栓塞的一个病因,不仅对患者二级预防意义重大,也对开展研究时患者的分类筛选具有重要指导意义。

图1. CISS分型

诊断思路“四步曲”

1、临床表现

临床表现是患者就诊的直接原因和目的,也是患者最痛苦家属最关心的。缺血性卒中的临床表现是脑功能受损的表现/征象,属于疾病的表现层次,具有直观性、生动性、故事性、多样性、易变性、纷繁复杂性。包含症状学改变和神经系统阳性体征。有赖于全面细致、翔实可靠的问诊。

2、脑组织损害

缺血性脑血管病的发生起源于脑组织发生了缺血性损害,这是临床表现的直接根源,是脑功能改变的结构基础。脑组织损害的检测手段(脑结构影像)通常采用头颅CT(优点快速,对出血敏感;缺点为分辨率低,对皮层微小梗死灶不敏感)和头颅MRI(包括FLAIR和DWI等,分辨率更高)。

3、脑血管改变

缺血性脑血管病的脑病是因为供应脑组织的血管发生了改变,血管改变是脑损害的原因。但在我们过去的工作中,更多的只是关注了脑组织发生率什么样的损害,却忽略了相应的血管改变。2003年3月美国专科医师委员会批准设立血管神经病学资格考试,血管神经病学这一学科的产生把脑血管病的临床推向了全新的阶段,要重视血管的改变。如果我们现在还是只是根据临床表现和一张头颅CT来治疗脑梗死已经远远不够。

针对脑血管的评价手段包括:

(1)颈动脉超声可反映结构、狭窄程度、斑块性质。

(2)TCD可检测颅内血管,同时也是检测血流方向、MES斑块易损的可靠标志。

(3)MRA/头颈CTA/DSA提供形态学的直接证据,包括狭窄部位、程度、粥样硬化斑块性质等。

(4)HR-MRI用于了解管壁结构、病变扩张方向(向内/外)和判定病变性质。MRA安全、有夸大效应;CTA无创、同时显示骨质关系,可与DSA相媲美;DSA是金标准,为有创检查。

4、危险因素

血管之所以发生病理改变(主要是动脉粥样硬化和小血管玻璃样变性)有其始动因素,分为可干预因素和不可干预因素。可干预的危险因素有高血压、糖尿病、脂质代谢紊乱、房颤及其他心脏病、高同型半胱氨酸血症、吸烟、饮酒、肥胖、运动减少等;不可干预的危险因素包括年龄、性别等。只有积极干预、充分阻断引起血管发生病理改变的危险因素及其继发的病理过程,才能从根本上减少缺血性卒中的再发,否则无济于事。同时应尽早展开二级预防。

总 结

缺血性卒中不是一个独立的疾病,而是一种异质性很强的疾病,不同类型的缺血性卒中的病因也各不相同。根据病因学分型基于病因对不同的缺血性卒中患者“对因施治”的意义重大。

 

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    2020-12-04 ms6000000460743425

    对因施治特别有道理

    0

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    2020-12-01 健健

    卒中虽然是临床上常见病,溶栓,取栓等血管内治疗也很成熟,但是仍然有很多未知问题有待认知!

    0

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在特定饮酒方式的中年参与者中,缺血性卒中的风险降低,但仅限于早期。考虑到饮酒方式与缺血性卒中之间的长期联系,医师在对患者饮酒的教育方面应保持谨慎。

JAHA:伴侣逝世与缺血性卒中和脑出血风险的关系

IS和ICH风险的与伴侣逝世存在统计学显著正相关,特别是在短期内。但是,绝对风险差异很小。

Stroke:胃肠道疾病与首次缺血性卒中风险之间的关系

在调整了人口统计学特征和已知的卒中危险因素后,有些胃肠道疾病与未来缺血性卒中的风险增加相关。

Stroke:高血糖与缺血性卒中患者血管内治疗后不良结局相关

入院血糖升高与功能不良和血管内治疗后症状性颅内出血风险增加有关。

Stroke:抗磷脂抗体与缺血性卒中风险

aPL并不是成人RIS的独立预测因子。但是,考虑到非标准化的疾病标准,应考虑进一步设计良好的前瞻性试验以证实这些结果。

J INTERN MED:痴呆患者服用钙通道阻滞剂与生存率和缺血性卒中之间的关系

对于AD和DLB-PDD的痴呆患者服用氨氯地平可降低死亡风险。与其他CCB使用者相比,使用氨氯地平的AD患者发生缺血性卒中的风险较低。

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