青年卒中的病因诊断课件.ppt

1、Risk factors for ischaemic stroke in young adultsSmokingMigrainePregnancy and puerperiumOral contraceptivesIllicit drugs The risk of ischaemic stroke in people who had migraine with aura was doubled compared with people without migraine.Infarcts induced by drugs(eg,ergotamine)might also be a contrib

2、uting factor.They mostly affect the posterior cerebral artery territory.Migrainous infarcts caused by severe hypoperfusion during an attack are rare and probably overdiagnosed.The risk of ischaemic stroke for pregnant women rises in the days before the birth and the 6 weeks post partum.A hypercoagul

3、able state and changes in vessel walls associated with pregnancy may have a role in the occurrence of these ischaemic strokes.A history of pregnancy-related stroke should not be a contraindication for subsequent pregnancy.The risk of stroke is increased by about four times for women who take pills w

4、ith a high content of oestrogen and is doubled for those who take pills with low oestrogen content.The frequency of illicit drug use in young adults with stroke can be as high as 12%.The intravenous use of drugs can produce embolisation of foreign material or endocarditis.Drugs with a sympathicomime

5、tic effect can cause ischaemic stroke through several mechanisms such as acute hypertension,enhanced platelet aggregation and vasculitis.Toxicology screening for illicit drugs should be done in young patients with stroke with no obvious cause.Aetiological diagnosis Extracranial or intracranial large

6、-vessel arterial disease Cadioembolism Small-vessel disease Other identifiable causes MRA,CTA,TCD can be used to confirm or rule out extracranial or intracranial arterial disease or an occlusion.Contrast-enhanced MRA is the most sensitive and specific non-invasive method for identification of caroti

7、d stenosis.Contrast-enhanced MRA and CTA offer better imaging of the vertebral and basilar arteries.If extracranial arterial dissection is suspected,cervical MRI with fat suppression is the best method to show the presence of an intramural haematoma.Holter ECG-paroxysmal atrial fibrillation Echocard

8、iography-high-risk sources of embolism(mechanical prosthetic valves,mitral stenosis,endocarditis,intracardiac thrombus,cardiac tumours)TCD monitoring-a right-to-left shunt Ultrasound or MRV-paradoxical embolism Small-vessel single perforator disease can produce small(15mm diameter)deep hemispherical

9、 or brainstem lacunar infarcts in young adults.Patients often have additional imaging evidence of small-vessel disease:old silent lacunar infarcts,leukoaraiosis on CT,periventricular white matter lesions on T2-weighted.When classifying a patient in the subgroup of small-vessel disease,two potential

10、pitfalls should be avoided:(1)proximal arterial or cardiac embolic source that can cause a small deep infarct should not be missed (2)atheroma of the wall of a large vessel impinging on the ostium of the perforator as the cause of the lacunar in farct should be excluded.DWI can detect acute small in

11、farcts High-resolution MRI and MRA can be used to distinguish between atheroma plaques of a large-vessel and penetrating vessel disease.Specific diseases and disorders associated withischaemic stroke in young adults Arterial dissection Patent foramen ovale Infections Vasculitis and connective tissue

12、 disorders Other rare non-inflammatory arteriopathies Haematological disorders Monogenic diseases Cryptogenic stroke Spontaneous arterial dissection is one of the most common causes of stroke in young adults.Dissection is usually subintimal and the resulting haematoma causes a long,irregular stenosi

13、s or even an occlusion.Sometimes,the dissection can form a pseudoanertysm.Intracranial dissection(eg,of the intracranial vertebral)might rupture into the subarachnoid space.Clinical featuresA history of head or neck trauma(even minor)Headache or neck pain Local signs(such as Horners syndrome or cran

14、ial nerve palsies)DiagnosisUltrasound-better for carotid dissectionMRA-Carotid dissectionCTA-vertebral arteriesCatheter angiography-doubtful cases/endovascular treatment Mechanism A shunt via a patent foramen ovale might allow passage of thrombotic material from the venous bed into the arterial circ

15、ulation-paradoxical embolisation.Clinical signs Stroke during Valsalvas manoeuvre Stroke after prolonged immobilisation Confirmatory test TEE TCD with microbubbles Syphilis Early phase:a sudden cerebral infarction cranial nerve palsies palm and sole cutaneous eruption Late phase:there is a transmura

16、l proliferative endarteritis Confirmatory tests CSF examinationHIV testsCSF-VDRL/RPR test CSF-treponemal antibody test Meningitis Bilateral basal ganglia infarcts are a characteristic feature of tuberculous meningitis.Varicella-zoster virus vasculopathy Clinical course is characterised by gradual re

17、solution of cutaneous herpes zoster ophthalmicus followed by the acute onset of contralateral hemiparesis,hemisensory symptoms,or aphasia.Confirmatory tests Angiography-irregular segmental narrowing MRI-infarcts occur at the grey-white matter junctions CSF-mononuclear cell counts,protein Cysticercos

18、is Stroke is one of the most feared complications of cysticercosis,which is more frequent in patients with subarachnoid neurocysticercosis.The middle and posterior cerebral arteries are affected by the inflammatory process.Transcranial doppler is a useful method for the diagnosis and follow-up of pa

19、tients with arteritis caused by neurocysticercosis.Systemic lupus erythematosusAntiphospholipid syndromeTakayasus diseaseClinicalsignsAnaemiaLow platelet countArthralgiasFeverHigh ESRSkin or kidney involvement MiscarriagesVenous thrombosisProlonged APTTAbsent pulses in upper limbsBlood pressure diff

20、erence between arms Confirmatory testsClinicla criteriaANAAnti-DNALupus anticoagulantAnticardiolipin and-2 glycoprotein antibodies CT OR MRAAortic PET Radiation arteriopathyFibromuscular dysplasiaMoyamoya syndromeSickle-cell anaemiaParoxysmal nocturnal haemoglobinuriaThrombotic thrombocytopenic pupu

21、raErthrocytosisLeukaemiasIntravascular lymphoma Drepanocytosis CADASILFabrys diseaseAn important cause of stroke in children and young adults.Confirmatory testsHg electrophoresisGenetic testingTCDFamily history Vascular dementia PsychosisMigraineRecurrent strokes Confirmatory testsSkin biopsyGenetic testing Skin,ocular,or kidney involvement Vertebrobasilar dolicoectasia Confirmatory testsGla activity Genetic testing