1、Cerebral Infarction Associated With Anemia贫血概论贫血概论上消化道出血诱发脑梗死上消化道出血诱发脑梗死SAH后脑梗死后脑梗死血液系统疾病合并脑梗死血液系统疾病合并脑梗死其他类型贫血相关性脑梗死其他类型贫血相关性脑梗死治疗治疗贫血概述v定义：外周血液单位体积中血红蛋白浓度，红细胞计数和(或)红细胞比积低于正常最低值者称为贫血。v贫血是一组综合征，不是独立的疾病。可由很多原因引起，很多疾病可伴有贫血。贫血概述v诊断标准：我国成年男性：RBC 4.0 1012/L H b 120 g/L Het 40%我国成年女性：RBC 3.5 1012/L H b 11
2、0 g/L Het 1003232-35巨幼细胞性贫血某些溶血性贫血正常细胞性贫血80-10026-3231-35再生障碍性贫血急性失血性贫血小细胞性贫血 80 2631-35缺铁性贫血铁粒幼细胞性贫血海洋性贫血贫血概论v(三)、按贫血程度分级Hb含量(g/l)临床表现轻度90 120症状轻微中度60 90 活动后心慌气短重度30 60休息时心慌气短极重度 30合并贫血性心脏病贫血概论v诊断步骤 1、明确是否贫血以及贫血的严重程度。2、明确贫血类型。3、查明贫血原因或引起贫血原发病。贫血概论v对人体的影响神经系统临床表现：头晕、耳鸣、记忆力减退、思想不集中、疲倦，严重贫血可发生昏迷及脑水肿。查
3、体：注意皮肤、粘膜苍白，黄疸，出血点，瘀斑，淋巴结，肝脾，脊髓后索和侧索变性体征（腱反射亢进，共济失调，感觉障碍）。肛门及妇科检查不可忽视。贫血概论v治疗1、一般治疗：适当休息，改善饮食，高蛋白质、维生素、矿物质饮食。2、病因治疗：治疗原发病很重要。3、补充造血要素：维生素B12、叶酸、铁剂4、激素和免疫抑制剂：肾上腺皮质激素5、输血：贫血极为严重或在短期内手术者，可酌情输血。慢性贫血，Hb60g/l无明显症状者，一般不必输血。6、手术治疗：脾切除、胸腺切除7、骨髓移植：同种异型基因骨髓移植治疗重型再障。vCerebral infarction results from acute impai
4、rment of oxygenated blood flow either due to a thrombotic or embolic occlusion.Aside from several likely contributing factors,anemia is an overlooked risk factor for cerebral infarction.vAlthough the relationship between anemia and cerebral infarction has not been well established,several researcher
5、s reported an association between these two conditions.Tsai CF,Yip PK,Chen CC,Yen SJ,Chung ST,Jeng JS(2010)Cerebral infarction in acute anemia.J Neurol 257:20442051Stroke due to anemia after severe menstrual bleeding causedby a uterine myomavA 43-year-old woman，a sudden onset of weakness on her left
6、 side.vHer medical history did not disclose any risk factor like systemic hypertension,vascular malformation,coagulopathy,hyperlipidemia,smoking,diabetes mellitus,prior stroke history or positive family history.vHer cardiac examination including electrocardiography and echocardiography was also norm
7、al.vThe laboratory findings were as follows:hemoglobin(Hb):5.7 g/dL(12.8 g/dL 1 month ago),hematocrit(Hct):21.0,serum iron:11.9 mg/dL(50150)and platelet count:594,000/lL.Acta Neurol Belg(2013)113:357358Stroke due to anemia after severe menstrual bleeding causedby a uterine myomaStroke due to anemia
8、after severe menstrual bleeding causedby a uterine myomav Overall,the patient was diagnosed to have an ischemic cerebral infarction associated with severe anemia.vThereafter,she was given anti-thrombolytic treatment and blood transfusion twice for anemia.vFurther evaluations regarding etiology were
9、not contributory except hypochromic microcytic anemia（低色素小细胞贫血）.vOn detailed questioning,she declared that her complaints started within the 2 days after a major bleeding during menstruation.She added that she usually had similar menstrual bleedings before as well.vUpon consultation to the gynecolog
10、y department,she was diagnosed with a huge uterine myoma.She was then scheduled for hysterectomy（子宫切除）in a week after hemodynamic stabilization.After a 2-week rehabilitation program,the patient discharged was almost independent in her daily living.AssociationvSelective decrease in hematocrit(血容量)lea
11、ds to a decrease in the oxygen supply relative to the metabolic demand,and thus resulting in increased incidence of infarction.vAnother possible mechanism that may explain the association between IDA and stroke is through the secondary thrombocytosis（血小板增多）as a result of iron deficiency.上消化道出血诱发脑梗死v
12、以消化性溃疡后出血为主要类型，应激性糜烂出血、胃癌后出血v好发于 50 70 岁男性，男女发病为 2 4 1v多发生在出血后第 2 5 d，平均为 3 d，大部分位于基底节区及大脑皮层区v82%的患者伴有高血脂、高血压、冠心病、糖尿病等危险因素上消化道出血诱发脑梗死可能的机制v上消化道出血后血容量下降，循环血量减少，血压下降，脑供血减少，致脑梗死。v出血后大剂量使用抗纤维蛋白溶解药物，更易使脑血栓形成。v出血后血容量减少，交感神经兴奋，血管收缩甚至痉挛，加重脑缺血、缺氧，形成血栓。因此：有高危因素的消化道大出血老年患者，使用止血药物需慎重，以免诱发脑梗死，可使用抑酸药物治疗胃肠道出血。SAH后
13、脑梗死后脑梗死v多发生在出血后 4 12 d，平均 8 d。v年龄 52 81 岁，平均 65岁。v有动脉粥样硬化、高血压、糖尿病及TIA等危险因素的 SAH患者更易合并脑梗死。v存在两种类型，（1）出血后早期，脑梗死引起的功能障碍较明显;（2）出血后晚期，表现为无症状性腔隙性脑梗死。v许多患者在治疗早期没有明显的脑梗死表现，但在复查颅脑 CT 时却发现有明显的脑梗死灶。SAH后脑梗死后脑梗死可能的机制v脑血管痉挛导致脑供血不足。v短期内脑血流量急剧下降，脑血流重新分配，部分痉挛的血管闭塞。v大量使用脱水药物，加重血容量不足，致血液高凝。v为预防再出血大量应用抗纤维蛋白溶解药物，使血液高凝。v
14、为预防 再出血，绝对卧床，减少活动，镇静药物，使患者全身血流缓慢。血液系统疾病合并脑梗死血液系统疾病合并脑梗死v再生障碍性贫血、维生素 K 缺乏出血、自身溶血性贫血、缺铁性贫血等，致血小板升高。v报道病例较少，可能与血液系统疾病本身发病率不高有关。v急性贫血引起脑梗死患者的平均Hb是 58 g/L，仅为基准正常Hb的46%。v血液系统疾病患者多较年轻，合并高血压、高血脂等血管危险因素较少。v血液系统疾病患者，病史多较长，对脑缺血可产生慢性耐受和代偿；而上消化道出血、SAH患者由于短期内出血量大，可引起较严重的贫血。血液系统疾病合并脑梗死血液系统疾病合并脑梗死vStroke in Sickle
15、Cell Anemia（镰状细胞贫血）缺铁性贫血与缺铁性贫血与PLt相关性相关性v实验室检查发现缺铁性贫并发脑梗死患者血红蛋白（Hb）一般小于 65 g/L，血小板计数高于 400109/L，且与单纯缺铁性贫血比较，其差异有显著性（P 300 109/L 时随着 Plt数的增高而增加。并发脑梗死的可能机制：缺铁性贫血直接导致的血液高凝状态；血小板增高；贫血性缺氧导致脑终末动脉氧供下降。缺铁性贫血与缺铁性贫血与PLt相关性相关性vSome researchers have stated that iron deficiency status is considered a risk factor
16、 for thrombocytosis and should,wherever possible,be avoided.Lawler PR,Filion KB,Dourian T,Atallah R,Garfinkle M,et al.(2013)Anemia and mortality in acute coronary syndromes:A systematic review and meta-analysis.Am Heart J 165:143-153.e5其他类型贫血相关性脑梗死v脑出血后脑梗死，手术后脑梗死，多合并危险因素。v肿瘤出血诱发脑梗死，如胃肠道肿瘤出血后脑梗死。v尿道出
17、血后脑梗死，如因长期留置尿管的患者，因长期慢性尿道黏膜出血后贫血引起脑梗。贫血与分水岭脑梗死可能的机制v贫血时,血液总的携氧能力降低，缺血缺氧而导致神经细胞酸性代谢产物增多、细胞水肿等,进而导致神经系统功能障碍。v贫血时心输出量减少和体循环血压降低均会导致脑灌注不足,局部血流动力学改变,尤其直接影响分水岭区的血供。v短期内大量出血,反射性引起血管运动中枢及交感-肾上腺髓质系统兴奋,儿茶酚胺、5-羟色胺、ADP等大量释放,促发小血管痉挛和血小板聚集,纤溶抑制,阻碍了微血栓的及时溶解清除。v thrombocytosis Anemia hypercoagulable state hypovolemia Cerebral Infarction贫血 血小板升高 血液高凝状态 脑梗死 血容量减少vpotential mechanism治疗v按常规的活血化瘀治疗效果不佳，甚至使病情进一步恶化，这与活血化瘀引起出血而加重贫血有关。v病情多较危重，疾病预后差，是否行活血化瘀治疗存在矛盾，且目前缺少其他有效的治疗手段。v给予及时、足量的输血治疗，常能收到意想不到的良好效果。所以，贫血相关性脑梗死的早期诊断，对早期输血治疗显得尤为重要。v输血治疗的奇效也从侧面说明贫血引起的脑低血流量灌注可能是引起贫血相关性脑梗死的最主要原因。v将贫血相关性脑梗死单独归类，进行系统深入的研究意义重大。
