脑梗死的分型及其治疗原则
中山大学附属第一医院神经科 (510080)
1.分型目的
为了准确诊断、个体化治疗和改善脑梗死的预后。
2.分型原因
脑梗死是一组常见而病因复杂的疾病，其病理生理、临床表现、合并症、治疗效果和预后也不尽相同甚至完全不同，须分出亚型进行研究和治疗。
3.分型现状
分型日益受到了重视，但迄今尚不统一。目前，牛津郡社区卒中项目(Oxfordshire community stroke project,OCSP，1991 )分型(临床分型)和治疗急性卒中试验(Trial of in acute stroke treatment,TOAST，1993)分型(病因分型)应用较广泛。1998年我科在国内首先提出急性脑梗死临床分型、分期治疗。
, 百拇医药
4.如何分型
众所周知，OCSP分型为临床分型，其简便、快捷，临床实用，但其精确度较CT等的低。TOAST分型可反映病因，但临床可操作性差。在超急性期，尽管DWI、PWI等可检出责任病灶，但因这些检查费时、昂贵、临床难以推广应用。CT临床应用广泛，超急性期不易明确病灶，但可有助提高判断，发病24h则很有助于临床调整治疗方案和判断预后。故临床实际出发，我们建议采用OSCP分型和结构性影像CT分型。
4.1 OCSP分型及治疗原则
在超急性期，结构性影像分型准确性差，OCSP分型法则不依赖于辅助检查的结果, 但要重视CT的早期征象。有条件可在超急性期行MRA或DWI，PWI、DSA、SPECT及TCD等检查来协助分型，以提高分型的准确性。
4.1.1 完全前循环梗死(TACI)：表现为三联征，即完全大脑中动脉综合征的表现：大脑较高级神经活动障碍；同向偏盲；偏身运动和/或感觉障碍。多为MCA近段主干，少数为颈内动脉虹吸段闭塞引起的大片脑梗死。
, 百拇医药
治疗上建议抗脑水肿、降颅内压、重症监护，时间窗内的溶栓复流。
4.1.2 部分前循环梗死(PACI)：有以上三联征的两个，或只有高级神经活动障碍，或感觉运动缺损较TACI局限。提示是MCA远段主干、各级分支或ACA及分支闭塞引起的中、小梗死。
建议缓和的改善脑血循环；合并大血管病变者降压时要慎重、缓和必要时扩容升压。
4.1.3 后循环梗死(POCI)：表现为各种程度及不同组合的椎基动脉综合征。可有椎基动脉及分支闭塞引起的大小不等的脑干、小脑梗死。
治疗见后。
4.1.4 腔隙性梗死(LACI)：多是基底节或桥脑小穿通支病变引起的小腔隙灶。
治疗见后。
, http://www.100md.com
4.2临床和影像相结合的分型及治疗
超急性期后不能仅满足于OCSP的分型，要努力结合影像将各亚型进一步深入分型，使诊疗更具针对性。因CT可快速检出梗死灶的部位和推测所受累的血管，临床医生也常参考复查结果调整临床治疗方案和判断预后，故我们建议采用基于梗死灶的受累的血管和影像结果(CT为主)行如下分型及治疗：
4.2.1幕上：以颈内动脉系统为主，兼顾大脑后动脉
4.2.1.1大梗死：超过一个脑叶，5cm以上。以MCA为中心可分2组：
大于MCA分布区和局限于MCA分布区两组；MCA组可进一步分为4个亚型：MCA；MCA+皮层侧枝循环较好；MCA-皮层；MCA-深穿枝；
治疗上建议抗脑水肿、降颅内压、重症监护，时间窗内的溶栓复流。第1组和第2组的第1型需要开颅减压的比率高，死亡率高；第2组的后3个亚型保守监护治疗多可以成功。
, http://www.100md.com
4.2.1.2 中梗死：梗死小于一个脑叶，3.1～5cm。可分为5型：
MCA皮层型、MCA中央型、MCA深穿枝型、大脑前、大脑后。
建议时间窗内的溶栓，有脑水肿征象者须抗脑水肿、降颅内压；很少需要手术处理。
4.2.1.3 小梗死：梗死在1.6～3.0cm之间。推测大血管病变和小血管病变均可导致小梗死。
建议缓和的改善脑血循环；合并大血管病变者降压时要慎重、缓和必要时扩容升压。
4.2.1.4 腔隙性梗死：1.5cm以下。推测大血管病变和小血管病变均可导致腔隙性梗死。
建议改善脑血循环；合并大血管病变者要注意治疗时降压要慎重、缓和。
, 百拇医药
4.2.2 幕下：椎基底动脉系统
4.2.2.1小脑梗死：其处理和幕上不同。可分3型：
4.2.2.1.1良性型：直径3.0cm以内, 临床上可无症状或表现为小脑症状。一般无高颅压及脑室受压表现, 无症状者多直径≤ 1.0 cm,多位于小脑后下动脉供血区域。
4.2.2.1.2假肿瘤型：梗死直径在3.1～5.0cm。临床表现有脑干受压、意识障碍上多伴头痛、呕吐等颅高压症状。
4.2.2.1.3恶性型：直径>5.0cm梗死灶均为脑室受压,部分合并脑干严重梗死(脑干+小脑)或受压,临床表现危重。
4.2.2.2脑干梗死：按主要病灶的部位可分为3型：
中脑、脑桥、延髓。病灶可以中、小、甚至是腔隙性，但临床症状和病灶大小可不一致，与病灶部位关系密切。建议部分病例溶栓时间窗可适当延长、放宽；应行重症监护，警惕意识变化和是否有进展。
, http://www.100md.com
4.2.3 多发性梗死
多个大、中、小及腔隙梗死；按部位分5型：双侧幕上；单侧幕上；双侧幕下；单侧幕下；幕下+幕上。
Classification and therapeutic protocol of cerebral infarction
Huang Ruxun, Zhu Liangfu.
Department of Neurology, The First Affiliated Hospital of Sun Yet-Sen University (510080)
1. Objective
To diagnose more exactly, to establish the individual therapeutic protocol, and to improve the prognosis of cerebral infartion.
, http://www.100md.com
2. Why do we classify the cerebral infarction
Stroke is the third most common cause of death in the united states and the most disabling neurologic disorder. Etiology of the stroke is various. Different patient has different pathophysiological process, clinical features and complications. As a resnlt, the therapeutic effect and the outcome following stroke are also influenced by a number of facters. Therefore, we have to establish the individual therapeutic protocol based on the classification and the stage of stroke.
, http://www.100md.com
3. The current status of the classification
More and more scholars have realized the importance of the classification, but there is no consensus yet. At present, there are two kinds of classifications widely used in the world. One is the Oxfordshire community stroke project (OCSP, clinical classification, 1991), another is Trial of in acute stroke treatment (TOAST, etiologic classification, 1993). In China, Our department was the first place that put forward the individual therapeutic protocol in 1998, and we also suggested that patients with stroke should be treated according to different classification and stage.
, 百拇医药
4. How to classify the cerebral infarction
As we know, OCSP classification does not depend on the imaging signs of infarction, it may be an ideal classification in the superacute stage of ischemic stroke, but the CT grouping of the infartion is more accurate than OCSP classification. TOAST classification is helpful to reveal the causes of the stroke, but it is not practice. Although we should be alert to the early CT signs of infarction in the superacute stage, the CT grouping is also not available in the superacute stage. Functional imaging (such as DWI, PWI, and so on) can investigate infarction scccussfully in this stage, however, those sdudies always need a lot of time and money. After 24 hours of the onset, CT reveals the location of the most of infarcts and suggests where the occluded arteries are. CT is also necessary for clinical doctors to decide their therapeutic protocal. In addition, CT is widely used in China. For the sake of clinical practice, we suggest that classification and therapeutic protocol should be based on the OCSP classification and the CT grouping.
, http://www.100md.com
4.1 OCSP classification and therapeutic protocol
As OCSP classification does not depend on the imaging signs of infarction, it may be an ideal classification in the superacute stage of ischemic stroke. In order to improve the accuracy of classification, we can also recur to other investigative methods, such as MRI, MRA, DWI, PWI, DSA, SPECT and TCD, and so on.
4.1.1 TACI (total anterior circulation infarction)
, 百拇医药
Clinical features Patients present with with total anterior circulation syndromes, including the triad of hemiparesis (or hemisensory loss), dysphasia (or other new higher cortical dysfunction) and homonymous hemianopia.
Therapeutic protocol It’s necessary to get the patient into the intensive care unit, Antiedema agents( such as mannitol and lasix) can be given to reduce the ICP when necessary .Intravenous administration of rt-PA may be applied within 3 hours of the onset or intravenous administration of urokinase within 6 hours of the onset. Sometimes surgical decompression must be considered.
, 百拇医药
4.1.2 PACI (partial anterior circulation infarction)
Clinical features Patients present with partial anterior circulation syndromes, including only two of the features of TACS, or isolated dysphasia or parietal lobe signs.
Therapeutic protocol Intravenous administration of rt-PA may be applied within 3 hours of the onset or intravenous administration of UK within 6 hours of the onset. Antiedema agents can be given to reduce the ICP when necessary. Few patient needs surgical decompression.
, http://www.100md.com
4.1.3 POCI posterior circulation infarction
Clinical features Patients present with posterior circulation syndromes, including brain stem or cerebellar signs, and/or isolated homonymous hemianopia. The posterior infarction can be divided into two groups, including the brainstem infarction and cerebellar infarction.
Therapeutic protocol Vide infra.
4.1.4 LACI
, 百拇医药 Clinical features Patients present with Lacunar syndromes (LACS), include pure motor stroke, pure sensory stroke, sensorimotor stroke and ataxic hemiparesis.
Therapeutic protocol Vide infra.
4.2 Clinical CT grouping and therapeutic protocol
After 24 hours of the onset, we could not be satisfied with the OCSP classification, and we should further divide infarctions into subtypes according to the imaging results and the clinical features. CT reveals the location of the infarcts and suggests where the occluded arteries are. CT is also necessary for clinical doctors to decide their therapeutic protocal. So we suggest that the ideal classification should be based on the distribution of occlusion artery and the location of infarct revealed by CT.
, 百拇医药
4.2.1 Supertentorial internal carotid artery and posterior cerebral artery
4.2.1.1 Large infarction
The lesion exceeded more than two lobes and the maximum diameter of the lesion is more than 5cm. We divide it into 2 groups based on the anatomic site of the lesion, the first group involves more than the MCA distribution, and the second group involves only MCA distribution. We further grade MCA group into 4 subtypes,including total MCA distribution, MCA distribution with good cortical collateral circulation, part of the MCA distribution sparing cortical, part of the MCA distribution sparing the basal ganglia.
, 百拇医药
Therapeutic protocol It’s necessary to get the patient into the intensive care unit, reduce the intracranial pressure (ICP) and treat cerebral edema with agents, such as mannitol, lasix and so on. Intravenous administration of rt-PA may be applied within 3 hours of the onset or intravenous administration of urokinase within 6 hours of the onset. Sometimes surgical decompression must be considered.
4.2.1.2 Moderate infarction
The diameter of the lesion is 3.1～5cm,and the lesion is focused within one lobe. We divide it into 5 subtypes based on the anatomic site of the lesion, including MCA distribution involving only superficial cortex, MCA distribution involving only subcortical white matter, MCA distrution involving only basal ganglia, ACA and PCA distribution.
, http://www.100md.com
Therapeutic protocol Intravenous administration of rt-PA may be applied within 3 hours of the onset or intravenous administration of UK within 6 hours of the onset. Antiedema aggents can be given to reduce the ICP when necessary. Few patient needs surgical decompression.
4.2.1.3 Small infarction
The diameter of the lesion is 1.6～3.0cm. we speculate that small infarction is due to two kinds of intracerebral arteries diseases,including large intracerebral artery disease and small intracerebral artery disease.
, 百拇医药
Therapeutic protocol The therapy to improve adjacent cerebral circulation lightly is recommended.,if the there is large arterial lesions, the high blood pressure should be controlled cautiously, and attempts to reduce the blood pressure unduely in stroke patient may lead to disastrous results. Sometimes it is necessary to improve the cerebral perfusion pressure by elevating the blood pressure through supplying proper liquid.
4.2.1.4 Lacunar infarction
, 百拇医药
The diameter of the lesion is less than 1.5cm. we speculate that lacunar infarction is due to two kinds of intracerebral arteries diseases,including large intracerebral artery disease and small intracerebral artery disease.
Therapeutic protocol. The therapy to improve adjacent cerebral circulation lightly is recommended. The blood pressure can not be lowered excessively in patients with serious occlusion of large intracranial arteris and poor collateral circulation as well.
, 百拇医药
4.2.2 Subtentorial Vertebral artery and Basilar artery
4.2.2.1 Cerebellar infarction
The manegment of cerebellar infarction is different from the above, Cerebellar infarction can be divided into 3 types, including benign subtype, pseudotumor subtype malignant subtype.
4.2.2.1.1 Benign subtype
The diameter of the infarction is always less than 3.0cm in size. Some cases do not show any clinical symptoms and signs, whose lesions distribute predominantly in the fields of the posterior inferior cerebral arteries and are usually less than 1.0 cm in size.
, 百拇医药
4.2.2.1.2 Pseudotumor subtype
The diameter of the lesion is 3.1～5.0cm. The clinial features include signs of brainstem depression, headache, vomiting, unconsciousness, etc.
4.2.2.1.3 Malignant subtype
The diameter of the lesion is more than 5cm. Both of the clinial features and the prognosis are serious. When patient deteriorates as a consequence of brainstem compression following cerebellar infarction, posterior fossa decompression with evacuation of infracted cerebellar tissue can be lifesaving.
, 百拇医药
4.2.2.2 Brainstem infarction
Brainstem infarction is classified by its location as midbrain, pons and medulla. The loci can be moderate, small and lacunar in size. The severity of brainstem infarctions is highly variable, which depends on location rather than the size.
Therapeutic protocol in some cases, the thrombolytic agents may be used even exceeding 6 hours of the onset. We should be alert to the changes of consciousness and should find out the progressing of neurological deficit as soon as possible.
4.2.3 Multiple infarctions
Multiple infarctions can be divided into large, moderate, small and lacunar infarcts according to the size, or into 5 subtypes according to the location, including bilateral supertentorial, unilateral supertentorial, bilateral subtentorial, unilateral subtentorial and supertentorial subtentorial., http://www.100md.com(黄如训 朱良付)
1.分型目的
为了准确诊断、个体化治疗和改善脑梗死的预后。
2.分型原因
脑梗死是一组常见而病因复杂的疾病，其病理生理、临床表现、合并症、治疗效果和预后也不尽相同甚至完全不同，须分出亚型进行研究和治疗。
3.分型现状
分型日益受到了重视，但迄今尚不统一。目前，牛津郡社区卒中项目(Oxfordshire community stroke project,OCSP，1991 )分型(临床分型)和治疗急性卒中试验(Trial of in acute stroke treatment,TOAST，1993)分型(病因分型)应用较广泛。1998年我科在国内首先提出急性脑梗死临床分型、分期治疗。
, 百拇医药
4.如何分型
众所周知，OCSP分型为临床分型，其简便、快捷，临床实用，但其精确度较CT等的低。TOAST分型可反映病因，但临床可操作性差。在超急性期，尽管DWI、PWI等可检出责任病灶，但因这些检查费时、昂贵、临床难以推广应用。CT临床应用广泛，超急性期不易明确病灶，但可有助提高判断，发病24h则很有助于临床调整治疗方案和判断预后。故临床实际出发，我们建议采用OSCP分型和结构性影像CT分型。
4.1 OCSP分型及治疗原则
在超急性期，结构性影像分型准确性差，OCSP分型法则不依赖于辅助检查的结果, 但要重视CT的早期征象。有条件可在超急性期行MRA或DWI，PWI、DSA、SPECT及TCD等检查来协助分型，以提高分型的准确性。
4.1.1 完全前循环梗死(TACI)：表现为三联征，即完全大脑中动脉综合征的表现：大脑较高级神经活动障碍；同向偏盲；偏身运动和/或感觉障碍。多为MCA近段主干，少数为颈内动脉虹吸段闭塞引起的大片脑梗死。
, 百拇医药
治疗上建议抗脑水肿、降颅内压、重症监护，时间窗内的溶栓复流。
4.1.2 部分前循环梗死(PACI)：有以上三联征的两个，或只有高级神经活动障碍，或感觉运动缺损较TACI局限。提示是MCA远段主干、各级分支或ACA及分支闭塞引起的中、小梗死。
建议缓和的改善脑血循环；合并大血管病变者降压时要慎重、缓和必要时扩容升压。
4.1.3 后循环梗死(POCI)：表现为各种程度及不同组合的椎基动脉综合征。可有椎基动脉及分支闭塞引起的大小不等的脑干、小脑梗死。
治疗见后。
4.1.4 腔隙性梗死(LACI)：多是基底节或桥脑小穿通支病变引起的小腔隙灶。
治疗见后。
, http://www.100md.com
4.2临床和影像相结合的分型及治疗
超急性期后不能仅满足于OCSP的分型，要努力结合影像将各亚型进一步深入分型，使诊疗更具针对性。因CT可快速检出梗死灶的部位和推测所受累的血管，临床医生也常参考复查结果调整临床治疗方案和判断预后，故我们建议采用基于梗死灶的受累的血管和影像结果(CT为主)行如下分型及治疗：
4.2.1幕上：以颈内动脉系统为主，兼顾大脑后动脉
4.2.1.1大梗死：超过一个脑叶，5cm以上。以MCA为中心可分2组：
大于MCA分布区和局限于MCA分布区两组；MCA组可进一步分为4个亚型：MCA；MCA+皮层侧枝循环较好；MCA-皮层；MCA-深穿枝；
治疗上建议抗脑水肿、降颅内压、重症监护，时间窗内的溶栓复流。第1组和第2组的第1型需要开颅减压的比率高，死亡率高；第2组的后3个亚型保守监护治疗多可以成功。
, http://www.100md.com
4.2.1.2 中梗死：梗死小于一个脑叶，3.1～5cm。可分为5型：
MCA皮层型、MCA中央型、MCA深穿枝型、大脑前、大脑后。
建议时间窗内的溶栓，有脑水肿征象者须抗脑水肿、降颅内压；很少需要手术处理。
4.2.1.3 小梗死：梗死在1.6～3.0cm之间。推测大血管病变和小血管病变均可导致小梗死。
建议缓和的改善脑血循环；合并大血管病变者降压时要慎重、缓和必要时扩容升压。
4.2.1.4 腔隙性梗死：1.5cm以下。推测大血管病变和小血管病变均可导致腔隙性梗死。
建议改善脑血循环；合并大血管病变者要注意治疗时降压要慎重、缓和。
, 百拇医药
4.2.2 幕下：椎基底动脉系统
4.2.2.1小脑梗死：其处理和幕上不同。可分3型：
4.2.2.1.1良性型：直径3.0cm以内, 临床上可无症状或表现为小脑症状。一般无高颅压及脑室受压表现, 无症状者多直径≤ 1.0 cm,多位于小脑后下动脉供血区域。
4.2.2.1.2假肿瘤型：梗死直径在3.1～5.0cm。临床表现有脑干受压、意识障碍上多伴头痛、呕吐等颅高压症状。
4.2.2.1.3恶性型：直径>5.0cm梗死灶均为脑室受压,部分合并脑干严重梗死(脑干+小脑)或受压,临床表现危重。
4.2.2.2脑干梗死：按主要病灶的部位可分为3型：
中脑、脑桥、延髓。病灶可以中、小、甚至是腔隙性，但临床症状和病灶大小可不一致，与病灶部位关系密切。建议部分病例溶栓时间窗可适当延长、放宽；应行重症监护，警惕意识变化和是否有进展。
, http://www.100md.com
4.2.3 多发性梗死
多个大、中、小及腔隙梗死；按部位分5型：双侧幕上；单侧幕上；双侧幕下；单侧幕下；幕下+幕上。
Classification and therapeutic protocol of cerebral infarction
Huang Ruxun, Zhu Liangfu.
Department of Neurology, The First Affiliated Hospital of Sun Yet-Sen University (510080)
1. Objective
To diagnose more exactly, to establish the individual therapeutic protocol, and to improve the prognosis of cerebral infartion.
, http://www.100md.com
2. Why do we classify the cerebral infarction
Stroke is the third most common cause of death in the united states and the most disabling neurologic disorder. Etiology of the stroke is various. Different patient has different pathophysiological process, clinical features and complications. As a resnlt, the therapeutic effect and the outcome following stroke are also influenced by a number of facters. Therefore, we have to establish the individual therapeutic protocol based on the classification and the stage of stroke.
, http://www.100md.com
3. The current status of the classification
More and more scholars have realized the importance of the classification, but there is no consensus yet. At present, there are two kinds of classifications widely used in the world. One is the Oxfordshire community stroke project (OCSP, clinical classification, 1991), another is Trial of in acute stroke treatment (TOAST, etiologic classification, 1993). In China, Our department was the first place that put forward the individual therapeutic protocol in 1998, and we also suggested that patients with stroke should be treated according to different classification and stage.
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4. How to classify the cerebral infarction
As we know, OCSP classification does not depend on the imaging signs of infarction, it may be an ideal classification in the superacute stage of ischemic stroke, but the CT grouping of the infartion is more accurate than OCSP classification. TOAST classification is helpful to reveal the causes of the stroke, but it is not practice. Although we should be alert to the early CT signs of infarction in the superacute stage, the CT grouping is also not available in the superacute stage. Functional imaging (such as DWI, PWI, and so on) can investigate infarction scccussfully in this stage, however, those sdudies always need a lot of time and money. After 24 hours of the onset, CT reveals the location of the most of infarcts and suggests where the occluded arteries are. CT is also necessary for clinical doctors to decide their therapeutic protocal. In addition, CT is widely used in China. For the sake of clinical practice, we suggest that classification and therapeutic protocol should be based on the OCSP classification and the CT grouping.
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4.1 OCSP classification and therapeutic protocol
As OCSP classification does not depend on the imaging signs of infarction, it may be an ideal classification in the superacute stage of ischemic stroke. In order to improve the accuracy of classification, we can also recur to other investigative methods, such as MRI, MRA, DWI, PWI, DSA, SPECT and TCD, and so on.
4.1.1 TACI (total anterior circulation infarction)
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Clinical features Patients present with with total anterior circulation syndromes, including the triad of hemiparesis (or hemisensory loss), dysphasia (or other new higher cortical dysfunction) and homonymous hemianopia.
Therapeutic protocol It’s necessary to get the patient into the intensive care unit, Antiedema agents( such as mannitol and lasix) can be given to reduce the ICP when necessary .Intravenous administration of rt-PA may be applied within 3 hours of the onset or intravenous administration of urokinase within 6 hours of the onset. Sometimes surgical decompression must be considered.
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4.1.2 PACI (partial anterior circulation infarction)
Clinical features Patients present with partial anterior circulation syndromes, including only two of the features of TACS, or isolated dysphasia or parietal lobe signs.
Therapeutic protocol Intravenous administration of rt-PA may be applied within 3 hours of the onset or intravenous administration of UK within 6 hours of the onset. Antiedema agents can be given to reduce the ICP when necessary. Few patient needs surgical decompression.
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4.1.3 POCI posterior circulation infarction
Clinical features Patients present with posterior circulation syndromes, including brain stem or cerebellar signs, and/or isolated homonymous hemianopia. The posterior infarction can be divided into two groups, including the brainstem infarction and cerebellar infarction.
Therapeutic protocol Vide infra.
4.1.4 LACI
, 百拇医药 Clinical features Patients present with Lacunar syndromes (LACS), include pure motor stroke, pure sensory stroke, sensorimotor stroke and ataxic hemiparesis.
Therapeutic protocol Vide infra.
4.2 Clinical CT grouping and therapeutic protocol
After 24 hours of the onset, we could not be satisfied with the OCSP classification, and we should further divide infarctions into subtypes according to the imaging results and the clinical features. CT reveals the location of the infarcts and suggests where the occluded arteries are. CT is also necessary for clinical doctors to decide their therapeutic protocal. So we suggest that the ideal classification should be based on the distribution of occlusion artery and the location of infarct revealed by CT.
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4.2.1 Supertentorial internal carotid artery and posterior cerebral artery
4.2.1.1 Large infarction
The lesion exceeded more than two lobes and the maximum diameter of the lesion is more than 5cm. We divide it into 2 groups based on the anatomic site of the lesion, the first group involves more than the MCA distribution, and the second group involves only MCA distribution. We further grade MCA group into 4 subtypes,including total MCA distribution, MCA distribution with good cortical collateral circulation, part of the MCA distribution sparing cortical, part of the MCA distribution sparing the basal ganglia.
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Therapeutic protocol It’s necessary to get the patient into the intensive care unit, reduce the intracranial pressure (ICP) and treat cerebral edema with agents, such as mannitol, lasix and so on. Intravenous administration of rt-PA may be applied within 3 hours of the onset or intravenous administration of urokinase within 6 hours of the onset. Sometimes surgical decompression must be considered.
4.2.1.2 Moderate infarction
The diameter of the lesion is 3.1～5cm,and the lesion is focused within one lobe. We divide it into 5 subtypes based on the anatomic site of the lesion, including MCA distribution involving only superficial cortex, MCA distribution involving only subcortical white matter, MCA distrution involving only basal ganglia, ACA and PCA distribution.
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Therapeutic protocol Intravenous administration of rt-PA may be applied within 3 hours of the onset or intravenous administration of UK within 6 hours of the onset. Antiedema aggents can be given to reduce the ICP when necessary. Few patient needs surgical decompression.
4.2.1.3 Small infarction
The diameter of the lesion is 1.6～3.0cm. we speculate that small infarction is due to two kinds of intracerebral arteries diseases,including large intracerebral artery disease and small intracerebral artery disease.
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Therapeutic protocol The therapy to improve adjacent cerebral circulation lightly is recommended.,if the there is large arterial lesions, the high blood pressure should be controlled cautiously, and attempts to reduce the blood pressure unduely in stroke patient may lead to disastrous results. Sometimes it is necessary to improve the cerebral perfusion pressure by elevating the blood pressure through supplying proper liquid.
4.2.1.4 Lacunar infarction
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The diameter of the lesion is less than 1.5cm. we speculate that lacunar infarction is due to two kinds of intracerebral arteries diseases,including large intracerebral artery disease and small intracerebral artery disease.
Therapeutic protocol. The therapy to improve adjacent cerebral circulation lightly is recommended. The blood pressure can not be lowered excessively in patients with serious occlusion of large intracranial arteris and poor collateral circulation as well.
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4.2.2 Subtentorial Vertebral artery and Basilar artery
4.2.2.1 Cerebellar infarction
The manegment of cerebellar infarction is different from the above, Cerebellar infarction can be divided into 3 types, including benign subtype, pseudotumor subtype malignant subtype.
4.2.2.1.1 Benign subtype
The diameter of the infarction is always less than 3.0cm in size. Some cases do not show any clinical symptoms and signs, whose lesions distribute predominantly in the fields of the posterior inferior cerebral arteries and are usually less than 1.0 cm in size.
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4.2.2.1.2 Pseudotumor subtype
The diameter of the lesion is 3.1～5.0cm. The clinial features include signs of brainstem depression, headache, vomiting, unconsciousness, etc.
4.2.2.1.3 Malignant subtype
The diameter of the lesion is more than 5cm. Both of the clinial features and the prognosis are serious. When patient deteriorates as a consequence of brainstem compression following cerebellar infarction, posterior fossa decompression with evacuation of infracted cerebellar tissue can be lifesaving.
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4.2.2.2 Brainstem infarction
Brainstem infarction is classified by its location as midbrain, pons and medulla. The loci can be moderate, small and lacunar in size. The severity of brainstem infarctions is highly variable, which depends on location rather than the size.
Therapeutic protocol in some cases, the thrombolytic agents may be used even exceeding 6 hours of the onset. We should be alert to the changes of consciousness and should find out the progressing of neurological deficit as soon as possible.
4.2.3 Multiple infarctions
Multiple infarctions can be divided into large, moderate, small and lacunar infarcts according to the size, or into 5 subtypes according to the location, including bilateral supertentorial, unilateral supertentorial, bilateral subtentorial, unilateral subtentorial and supertentorial subtentorial., http://www.100md.com(黄如训 朱良付)