简介
卒中是指一种由脑血管病变引起的急性神经系统功能障碍,持续时间超过 24 小时。它被细分为缺血性卒中(由血管闭塞或狭窄引起)和出血性卒中(由血管破裂引起,导致脑实质内和/或蛛网膜下腔出血)。缺血性卒中占所有卒中病例的 87%,出血性脑卒中占 10%,蛛网膜下腔出血占 3%。[1]Benjamin EJ, Virani SS, Callaway CW, et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics - 2018 update: a report from the American Heart Association. Circulation. 2018 Mar 20;137(12):e67-492. [Erratum in: Circulation. 2018 Mar 20;137(12):e493.] https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000558 http://www.ncbi.nlm.nih.gov/pubmed/29386200?tool=bestpractice.com
相关疾病
无论具体病因是什么,当脑血管供血区域血供由于某条脑动脉重度狭窄或堵塞而出现严重减少时,就可发生缺血性卒中。少数缺血性卒中由脑窦或皮质静脉血栓形成所致。与缺血性卒中密切相关的危险因素包括:高龄、短暂性脑缺血发作史、缺血性卒中史、低龄卒中家族史、高血压、吸烟、糖尿病,心房颤动、合并心脏病、颈动脉狭窄,镰刀细胞病和血脂异常。[1]Benjamin EJ, Virani SS, Callaway CW, et al; American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics - 2018 update: a report from the American Heart Association. Circulation. 2018 Mar 20;137(12):e67-492. [Erratum in: Circulation. 2018 Mar 20;137(12):e493.] https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000558 http://www.ncbi.nlm.nih.gov/pubmed/29386200?tool=bestpractice.com [2]Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med. 2016 Apr 21;374(16):1533-42. https://www.doi.org/10.1056/NEJMoa1412981 http://www.ncbi.nlm.nih.gov/pubmed/27096581?tool=bestpractice.com [3]Giles MF, Rothwell PM. Risk of stroke early after transient ischaemic attack: a systematic review and meta-analysis. Lancet Neurol. 2007 Dec;6(12):1063-72. http://www.ncbi.nlm.nih.gov/pubmed/17993293?tool=bestpractice.com [4]Simons LA, McCallum J, Friedlander Y, et al. Risk factors for ischemic stroke: Dubbo study of the elderly. Stroke. 1998 Jul;29(7):1341-6. https://www.doi.org/10.1161/01.str.29.7.1341 http://www.ncbi.nlm.nih.gov/pubmed/9660384?tool=bestpractice.com [5]Flossmann E, Schulz UG, Rothwell PM. Systematic review of methods and results of studies of the genetic epidemiology of ischemic stroke. Stroke. 2004 Jan;35(1):212-27. https://www.doi.org/10.1161/01.STR.0000107187.84390.AA http://www.ncbi.nlm.nih.gov/pubmed/14684773?tool=bestpractice.com [6]Kannel WB, Wolf PA, Verter J, et al. Epidemiologic assessment of the role of blood pressure in stroke. The Framingham study. JAMA. 1970;214:301-10. http://www.ncbi.nlm.nih.gov/pubmed/5469068?tool=bestpractice.com [7]Wolf PA, D'Agostino RB, Kannel WB, et al. Cigarette smoking as a risk factor for stroke: the Framingham study. JAMA. 1988 Feb 19;259(7):1025-9. http://www.ncbi.nlm.nih.gov/pubmed/3339799?tool=bestpractice.com [8]Kannel WB, McGee DL. Diabetes and cardiovascular disease: the Framingham study. JAMA. 1979 May 11;241(19):2035-8. http://www.ncbi.nlm.nih.gov/pubmed/430798?tool=bestpractice.com [9]Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham study. Stroke. 1991 Aug;22(8):983-8. http://www.ncbi.nlm.nih.gov/pubmed/1866765?tool=bestpractice.com [10]Best JG, Bell R, Haque M, et al. Atrial fibrillation and stroke: a practical guide. Pract Neurol. 2019 Jun;19(3):208-24. http://www.ncbi.nlm.nih.gov/pubmed/30826740?tool=bestpractice.com [11]Goldstein LB, Adams R, Becker K, et al. Primary prevention of ischemic stroke: a statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke. 2001 Jan;32(1):280-99. https://www.ahajournals.org/doi/10.1161/01.STR.32.1.280 http://www.ncbi.nlm.nih.gov/pubmed/11136952?tool=bestpractice.com [12]Chambers BR, Norris JW. Outcome in patients with asymptomatic neck bruits. N Engl J Med. 1986 Oct 2;315(14):860-5. http://www.ncbi.nlm.nih.gov/pubmed/3528855?tool=bestpractice.com [13]Barnett HJ, Taylor DW, Haynes RB, et al; North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med. 1991 Aug 15;325(7):445-53. https://www.nejm.org/doi/10.1056/NEJM199108153250701 http://www.ncbi.nlm.nih.gov/pubmed/1852179?tool=bestpractice.com [14]Adams RJ, McKie VC, Hsu L, et al. Prevention of a first stroke by transfusions in children with sickle cell anemia and abnormal results on transcranial Doppler ultrasonography. N Engl J Med. 1998 Jul 2;339(1):5-11. https://www.nejm.org/doi/10.1056/NEJM199807023390102 http://www.ncbi.nlm.nih.gov/pubmed/9647873?tool=bestpractice.com [15]Boehme AK, Esenwa C, Elkind MS. Stroke risk factors, genetics, and prevention. Circ Res. 2017 Feb 3;120(3):472-95. https://www.doi.org/10.1161/CIRCRESAHA.116.308398 http://www.ncbi.nlm.nih.gov/pubmed/28154098?tool=bestpractice.com
少数缺血性卒中的原因。高危险因素包括高龄、吸烟和心血管疾病家族史。[16]Ricotta JJ, Aburahma A, Ascher E, et al; Society for Vascular Surgery. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011 Sep;54(3):e1-31. https://www.jvascsurg.org/article/S0741-5214(11)01635-1/fulltext http://www.ncbi.nlm.nih.gov/pubmed/21889701?tool=bestpractice.com 针对最近出现的中度或高度症状性颈动脉狭窄进行颈动脉血运重建术可预防将来发生卒中。 对无症状狭窄患者进行血运重建的益处尚不确定。
出现突然发作、局灶性神经功能缺损,且在发作后 24 小时内彻底消退,无法用其他情况(例如低血糖)解释者,均应怀疑短暂性脑缺血发作(transient ischaemic attack, TIA)。短暂性脑缺血发作 (Transient ischaemic attack, TIA) 发生早期复发性脑缺血事件的风险相当大。[2]Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med. 2016 Apr 21;374(16):1533-42. https://www.doi.org/10.1056/NEJMoa1412981 http://www.ncbi.nlm.nih.gov/pubmed/27096581?tool=bestpractice.com 强危险因素包括心房颤动、心脏瓣膜病、充血性心力衰竭、高血压、糖尿病、颈动脉狭窄、其他重大疾病(例如高凝状态或血管炎[例如颞动脉炎])、吸烟、酒精使用障碍和高龄。[17]Whisnant JP, Brown RD, Petty GW, et al. Comparisons of population-based models of risk factors for TIA and ischemic stroke. Neurology. 1999 Aug 11;53(3):532-6. http://www.ncbi.nlm.nih.gov/pubmed/10449116?tool=bestpractice.com [18]Brott TG, Brown RD, Meyer FB, et al. Carotid revascularization for prevention of stroke: carotid endarterectomy and carotid artery stenting. Mayo Clin Proc. 2004 Sep;79(9):1197-208. http://www.ncbi.nlm.nih.gov/pubmed/15357045?tool=bestpractice.com [19]Sacco RL. Risk factors for TIA and TIA as a risk factor for stroke. Neurology. 2004 Apr 27;62(8 Suppl 6):S7-11. http://www.ncbi.nlm.nih.gov/pubmed/15111649?tool=bestpractice.com [20]Reynolds K, Lewis B, Nolen JD, et al. Alcohol consumption and risk of stroke: a meta-analysis. JAMA. 2003 Feb 5;289(5):579-88. http://www.ncbi.nlm.nih.gov/pubmed/12578491?tool=bestpractice.com [21]Bots ML, van der Wilk EC, Koudstaal PJ, et al. Transient neurological attacks in the general population. Prevalence, risk factors, and clinical relevance. Stroke. 1997 Apr;28(4):768-73. https://www.doi.org/10.1161/01.str.28.4.768 http://www.ncbi.nlm.nih.gov/pubmed/9099194?tool=bestpractice.com [22]Khare S. Risk factors of transient ischemic attack: An overview. J Midlife Health. 2016 Jan-Mar;7(1):2-7. https://www.doi.org/10.4103/0976-7800.179166 http://www.ncbi.nlm.nih.gov/pubmed/27134474?tool=bestpractice.com [23]Larsson SC, Wallin A, Wolk A, et al. Differing association of alcohol consumption with different stroke types: a systematic review and meta-analysis. BMC Med. 2016 Nov 24;14(1):178. https://www.doi.org/10.1186/s12916-016-0721-4 http://www.ncbi.nlm.nih.gov/pubmed/27881167?tool=bestpractice.com [24]Flemming KD, Brown RD Jr, Petty GW, et al. Evaluation and management of transient ischemic attack and minor cerebral infarction. Mayo Clin Proc. 2004 Aug;79(8):1071-86. http://www.ncbi.nlm.nih.gov/pubmed/15301338?tool=bestpractice.com 应尽快进行评估和启动二级预防。
脑出血是由血管破裂、血液流入脑实质所致,导致脑组织原发性机械损伤。2017 年,脑出血(intracerebral haemorrhage, ICH)全球患病人数为 1790 万人。[25]Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics - 2020 update: a report from the American Heart Association. Circulation. 2020 Mar 3;141(9):e139-e596. https://www.doi.org/10.1161/CIR.0000000000000757 http://www.ncbi.nlm.nih.gov/pubmed/31992061?tool=bestpractice.com 强危险因素包括高血压、高龄、ICH 家族史、血友病、淀粉样脑血管病、接受抗凝治疗、使用非法拟交感神经药物、血管畸形和烟雾综合征。[6]Kannel WB, Wolf PA, Verter J, et al. Epidemiologic assessment of the role of blood pressure in stroke. The Framingham study. JAMA. 1970;214:301-10. http://www.ncbi.nlm.nih.gov/pubmed/5469068?tool=bestpractice.com [26]Woo D, Sauerbeck LR, Kissela BM, et al. Genetic and environmental risk factors for intracerebral hemorrhage: preliminary results of a population-based study. Stroke. 2002 May;33(5):1190-5. http://www.ncbi.nlm.nih.gov/pubmed/11988589?tool=bestpractice.com [27]Antithrombotic Trialists' Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ. 2002 Jan 12;324(7329):71-86. [Erratum in: BMJ 2002 Jan 19;324(7330):141.] https://www.bmj.com/content/324/7329/71.long http://www.ncbi.nlm.nih.gov/pubmed/11786451?tool=bestpractice.com [28]Hart RG, Boop BS, Anderson DC. Oral anticoagulants and intracranial hemorrhage. Facts and hypotheses. Stroke. 1995 Aug;26(8):1471-7. https://www.ahajournals.org/doi/full/10.1161/01.str.26.8.1471 http://www.ncbi.nlm.nih.gov/pubmed/7631356?tool=bestpractice.com [29]Wojak JC, Flamm ES. Intracranial hemorrhage and cocaine use. Stroke. 1987 Jul-Aug;18(4):712-5. http://www.ncbi.nlm.nih.gov/pubmed/3603597?tool=bestpractice.com [30]Barnes B, Cawley CM, Barrow DL. Intracerebral hemorrhage secondary to vascular lesions. Neurosurg Clin N Am. 2002 Jul;13(3):289-97. http://www.ncbi.nlm.nih.gov/pubmed/12486919?tool=bestpractice.com [31]Takahashi JC, Funaki T, Houkin K, et al; JAM Trial Investigators. Significance of the hemorrhagic site for recurrent bleeding: prespecified analysis in the Japan Adult Moyamoya trial. Stroke. 2016 Jan;47(1):37-43. https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.115.010819 http://www.ncbi.nlm.nih.gov/pubmed/26645256?tool=bestpractice.com [32]Dastur CK, Yu W. Current management of spontaneous intracerebral haemorrhage. Stroke Vasc Neurol. 2017 Mar;2(1):21-9. https://www.doi.org/10.1136/svn-2016-000047 http://www.ncbi.nlm.nih.gov/pubmed/28959487?tool=bestpractice.com
血管破裂导致蛛网膜下腔出血前,通常无症状。建议对危险人群进行无创神经血管成像筛查。强危险因素包括吸烟、中高水平酒精摄入、家族史、既往蛛网膜下腔出血和遗传性结缔组织病。[33]Juvela S, Hillbom M, Numminen H, et al. Cigarette smoking and alcohol consumption as risk factors for aneurysmal subarachnoid hemorrhage. Stroke. 1993 May;24(5):639-46. http://www.ncbi.nlm.nih.gov/pubmed/8488517?tool=bestpractice.com [34]Schievink WI. Intracranial aneurysms. N Engl J Med. 1997 Jan 2;336(1):28-40. [Erratum in: N Engl J Med 1997 Apr 24;336(17):1267.] http://www.ncbi.nlm.nih.gov/pubmed/8970938?tool=bestpractice.com
为一种医学急症,即出血进入蛛网膜下腔空间。非创伤性蛛网膜下腔出血最常见原因为颅内动脉瘤。强危险因素包括年龄 ≥50 岁、性别为女性、高血压、吸烟、家族史、酒精滥用和常染色体显性遗传性多囊肾病。[35]Rinkel GJ. Intracranial aneurysm screening: indications and advice for practice. Lancet Neurol. 2005 Feb;4(2):122-8. http://www.ncbi.nlm.nih.gov/pubmed/15664544?tool=bestpractice.com [36]Steiner T, Juvela S, Unterberg A, et al. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis. 2013;35(2):93-112. https://www.doi.org/10.1159/000346087 http://www.ncbi.nlm.nih.gov/pubmed/23406828?tool=bestpractice.com [37]Teunissen LL, Rinkel GJ, Algra A, et al. Risk factors for subarachnoid hemorrhage: a systematic review. Stroke. 1996 Mar;27(3):544-9. https://www.doi.org/10.1161/01.str.27.3.544 http://www.ncbi.nlm.nih.gov/pubmed/8610327?tool=bestpractice.com
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