y**q
发帖数: 570 | 1 刚请教了国内瑞金医院的医生朋友，也建议行进一步检查。目前病人一般情况平稳，无
syncope。
最担心的是以后血栓脱落造成的栓塞。Welcome any commons! |
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A*******s
发帖数: 9638 | 2 I'll write you some answers in Chinese tonight. |
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s********p
发帖数: 1319 | 3 关键问题：目前患者血脂、血压、血糖等情况控制得如何？！相对于这患者的预后，对
可控危险因素的正确、果断、强硬控制，控制在理想水平，是核心问题。
——比如，正确使用Statin类调脂药，可用通过对血脂的调节、对易损斑块局部炎症反
应的抑制、降低易损斑块局部的血流剪切力损伤等机制，大大稳定易损斑块.......
保守还是手术：
那次“晕倒”的原因是什么？——是粥样硬化斑块脱落，引起的远端血管突然闭塞、脑
梗塞？还是严重严重颈椎病在运动过程中因为突然刺激了椎动脉，引起动脉突然的、反射性的收缩、痉挛，而导致的广泛的、可逆性的脑缺血？！等等，原因明确后，才能决
定进一步的干预手段。
国内上海、瑞金等医院的整体技术力量都比较强。如果他们解决不了，会给你们推荐其
它血管外科比较强的医院或者专家。
静息情况下，大中型动脉，狭窄一般要到70%以上，才会引起远端缺血症状。
版大已经指出：70%的斑块，需不需要放支架，放支架有没有得益，对远期预后的影响
究竟怎样，这些，还尚存在争议。
严重的狭窄，需要血管外科干预。但患者的右椎动脉血管已经闭塞，这需不需要外科手
术干预？应该由血管外科和神经外科的专家来定——... 阅读全帖 |
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s********p
发帖数: 1319 | 4 "最担心的是以后血栓脱落造成的栓塞"
答案——“铁血”降脂，抗血小板治疗。同时把一切可控的危险因素控制到满意水平。 |
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A*******s
发帖数: 9638 | 5 springstep的“铁血”， “强烈”降脂简直把医学汉语上升到了一个高度， 光想象一
下这些个形容词血脂就降一半了： 鼓舞人心， 心潮澎湃啊， 代谢率就这么上去了，
lol
以前我们的医学用词就太贫匮了。 |
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s********p
发帖数: 1319 | 6 版大，这个病例，我想，最重要的问题之一是降脂、稳定斑块治疗。这对患者以后的预
后非常重要。担心降脂强度不够，遣词就比较激烈——又一次偏离签名档，嘿！嘿！
， |
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A*******s
发帖数: 9638 | 7 晕厥（syncope）有很多原因， 心源性晕厥是一大原因， 应该首先排除。 其他原因比
较难以确诊， 最常见的是血管神经性晕厥。
颈动脉狭窄可以手术治疗， 问题是该不该手术？ 毕竟手术也有并发症， 而用药也可
以有效， 比方说springstep的强力铁血降脂。 我加一个就是强力铁血抗血小板， 呵呵
我们通常的做法是， 如果颈动脉狭窄>70%, 并且引起症状， 手术或者stenting就应该
考虑，
你母亲的晕厥一般不是因为颈动脉狭窄引起的，这样就让医生和病人陷入两难， 因为
手术可做可不做， 你要是问外科医生， 可能个个都做， 其他非手术医生， 可能会摇
头。 因为现在并没有统一的看法。
有一点是明确的， 手术并不可能防止晕厥复发， 因为他们没有因果关系。
至于血栓脱落， 有没有想到手术时并发症呢？ 我有一个病人， 本来活的好好的， 因
为手术， 一边完全瘫痪了。
我同意springstep的说法， 就是强力铁血的药物治疗同样有效。 |
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s********p
发帖数: 1319 | 8 Totally Agree On and With.....!!
呵呵 |
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L****n
发帖数: 12932 | 9 sorry, i disagree strongly. Not only i think she need surgery, she need it
quite urgently.
觉得这个病人首先的differential dx应该是symptomatic carotid sternosis which
is extactly what carotid endarteractomy is for， 其次，再怎么铁血， 沸腾，
药物治疗都没有手术那么definitive的, a symptomatic may not have time to wait
for medical treatment to take effect。 再三， i think it's ok to talk
inbetween ourselves with liberal choice of words, but be prudent when
talking to people coming here asking question about a patient.
for reference, from A... 阅读全帖 |
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L****n
发帖数: 12932 | 10 ----For medically treated patients with 70% to 99% stenoses, there was a
significantly increased risk of outcome events.----！！！ During the 3-year
follow-up, risk of ipsilateral stroke and perioperative death was 10.3% for
patients who had surgery and 16.8% for patients treated without surgery.
Risk of death due to carotid endarterectomy or stroke from any cause during
follow-up was 12.3% for surgical patients and 21.9% for nonsurgical patients
. |
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c**********m
发帖数: 2088 | 11 I am not a cardiology expert. using my common sense, I would say that once
the patient went through heart surgeries before, she must go through
surgeries again. this is a one-way road.
wait |
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L****n
发帖数: 12932 | 12 risk of surgery mainly comes from perioperative event - 找一个手术技术过硬的
地方是王道。 |
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L****n
发帖数: 12932 | 13 huh? what? where do u get that? |
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c**********m
发帖数: 2088 | 14 我的意思是：
心脏手术如果做过一次，以后如果再犯病，那么这个病人就将继续做心脏手术。药
物治疗为辅。克林顿就是个典型的例子。
hope this clarifies my meaning. |
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L****n
发帖数: 12932 | 15 that is not true, period. |
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A*******s
发帖数: 9638 | 16 again，we are talking about symptomatic and asymptomatic stenosis. For
asymptomatic carotid stenosis, although some data support surgery over drug,
the benefit is small and depend on life expectancy and surgical skills.
For this patient, her syncope is not caused by carotid stenosis. I always
question cardiology why order carotid u/s for syncope? Vascular surgeon may
say, r/o bilateral carotid stenosis, give me a break.
Asymptomatic carotid stenosis for CEA is controversial. The problem is th... 阅读全帖 |
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L****n
发帖数: 12932 | 17 that "syncopy" sounds much more like a TIA to me. it could be cardiogenic -
but without evident of dysrythmia - it's less likely.
drug,
may
the |
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A*******s
发帖数: 9638 | 18 TIA even stroke in the left carotid artery territory does not cause loss of
consicousness.
In Banzhu you can trust. :)
- |
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L****n
发帖数: 12932 | 19 ? r u sure? I thought TIA can be unconscious or coma.
----------from PubMed---------------
Symptoms begin suddenly, last only a short time (from a few minutes to 1 - 2
hours), and go away completely. They may occur again at a later time.
The symptoms of TIA are the same as the symptoms of a stroke and include
sudden:
Abnormal feeling of movement (vertigo) or dizziness
---->>> Change in alertness (sleepiness, less responsive, ***unconscious*
**, or in a coma)
Changes in feeling, includi... 阅读全帖 |
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A*******s
发帖数: 9638 | 20 That is why web MD can not replace physicians. :)
2
unconscious* |
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L****n
发帖数: 12932 | 21 not mean to doubt your expertise, physicians don't put themselves directly
against literature without evidences. I think in this patient "symptomatic
carotid sternosis" is a more logical explanation than a "innocent" carotid
sternosis with "syncopy" of unknown source. Basic rule is first try to
explain everything with one disease.
you can go hunt for other cause of "syncopy", but if nothing being done
about the carotid stenosis at the meanwhile, and the patient develop stroke
and die, u coul... 阅读全帖 |
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A*******s
发帖数: 9638 | 22 First of all, medicine is the science.
1. Unilateral carotid stenosis is not the cause of Syncope. People with
unilateral lobectomy are fully awake.
2. Asymptomatic carotid stenosis does not necessorily need surgical
intervention. I have seen patients with bilateral carotid occlusion without
any stroke or TIA.
Second, medicine is also the art.
When physicians order some nonsense tests and incidentally find some
abnormalities, it takes time for explanations. In her case, I'll tell her
what I hav... 阅读全帖 |
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L****n
发帖数: 12932 | 23 this is simple logic my friend, rather than sciences or art. our difference
focus on the "syncopy" episode, whether it's neurological cause,
cardiological cause or some other whacky causes. I don't see how you can
rule out neurological cause based on past experience only, and against well
published literature. at most, i'd only say it's less likely, rather than it
is NOT the cause.
your mention of ASYMPTOMATIC stenosis going for CEA carries no weight in our
discussion of this patient, it was als... 阅读全帖 |
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A*******s
发帖数: 9638 | 24 Man, you really have the time. :)
Regarding syncope, sorry, there is no less likely. It is just not. Not my personal experience, it is textbook.
I am aware of your study and other studies. The conclusion is CEA for
Asymptomatic carotid stonosis is still controversial.
Here is the most recent article about patient's decision on CEA. Only
46% choose to have surgery. Again, I am not against surgery, it really depends.
http://www.ncbi.nlm.nih.gov/pubmed/22218277
difference
well
it
our |
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m********4
发帖数: 607 | 25 你提供的病史：20 年高血压－》15 年 冠心病－》2年 CABG->一月前，晨练时， 晕厥。
你提供的体格检查－ 行走不稳， 但也提到了－严重颈椎病，腰椎间盘突出。那么这个
行走不稳，就需要进性鉴别诊断。是中枢性，还是外周性神经问题导致的？其它心脏，
神经系统等的体检结果没有提供。
实验室检查：仅有脑颈，基底动脉的检查。是很不完善的信息。脑部其它动脉情况如何
（大脑上，中，下动脉是否也有硬化，或定位狭窄？）。心脏功能如何，是否有心律
失常？从你的病史， 不能不考虑心源性因素。肾脏功能如何，有无内分泌系统功能紊
乱？
考虑下一步治疗，有无心，脑血管及神经系统的阳性体征，以及其它系统的功能情况是
很重要的参考。
任何治疗手段，都不会使已发生的病理解剖变化回复正常。保守，手术都是延缓病理生
理变化的过程，那一种更好，因人而异。但是，大规模临床实验为临床治疗原则的制定
提供了来源与实践, 科学的参考。
支架后的再狭窄问题仍然纯在。手术治疗效果的维持还是要依靠内科的治疗手段。
三期高血压，或任何疾病到了晚期阶段都没有什么特效的治疗手段，只是维持，延缓病
理变化的发展。
延年益寿，靠的是早期预防... 阅读全帖 |
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L****n
发帖数: 12932 | 26 Depend on what? I'd like to see under what circumstances u would refer a
patient for CEA? Obviously <50%, u don't need surgery, complete occlusion is
too late for surgery, what is your criteria?
Again, I am not against surgery, it really depends. |
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s********p
发帖数: 1319 | 27 主张手术的大虾请解释一下：
对这患者，手术的目的是什么？
手术能帮助患者解决什么问题？ |
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s********p
发帖数: 1319 | 29 给患者吃药的目的，是稳定动脉粥样硬化斑块，让它们不容易脱落。同时把血压这些危险因素压制到满意水平。
你手术的目的是什么？！ |
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L****n
发帖数: 12932 | 30 直接把粥样硬化斑块清除不更好么？
危险因素压制到满意水平。 |
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L****n
发帖数: 12932 | 31 if you were my doctor, i'm pretty sure i would get a stroke on the spot.
厥。 |
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A*******s
发帖数: 9638 | 32 我的病人除非有症状我才做carotid U/S， 如果over 70%, refer to surgeon。 这些
病人是symptomatic。
如果是syncope， 我从来不做carotid u/s。 因为将近90%是vasovagal 和
cardiogenic。 剩下的还要考虑orthostasis和seizure。 如果是TIA， 应该是基底动
脉的问题， carotid u/s不如MRA。
可恶的美国医疗体系是你order的test越多赚的钱就越多， 所以就有了过分的order
carotid， 一旦发现了超过70的stenosis， 就把他们refer到surgeon。 surgeon当然
求之不得， 可能是手术容易做， reimbursement高， 这些surgeon一看到我就提醒我
有没有case， 竞争不是一般的激烈。 可以想象他们的门槛会多低。
carotid stenosis并不见得一定是artery-to-artery amboli， 它的存在可能导致供血
不足， 而引起远端动脉的thrombosis。 所以清除plague只是改善血供， 不见得可以
消... 阅读全帖 |
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L****n
发帖数: 12932 | 33 什么样的症状？wait till patient actually had a stroke? and survive the
stroke? |
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r********n
发帖数: 48 | 34 Dear Dr. Lexian, I completely agree with Dr. Aplusplus on this case.
Unilateral carotid stenosis just does not do the job -- You just have to
have both sides of the brain out to make that person unconscious. If you
have to pick on stroke in this case, think about vertebral-basilar problems.
difference
well
it
our |
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L****n
发帖数: 12932 | 35 so you are saying pubmed, which is published by nih, is wrong? TIA can NEVER
present as loss of consciousness/coma? I would like to see your reference
on this particular point please? ie what Aplus refer to as text book.
problems. |
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A*******s
发帖数: 9638 | 36 Yes. You are absolutely right on that. TIA is another indication. |
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L****n
发帖数: 12932 | 37 hehe, 这听上去像修房子的看见火灾隐患不出声， 等人失火烧过了找你修房子，你再
跟人说啊， 街那头有个装灭火器的， 我给你介绍一哈？ |
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A*******s
发帖数: 9638 | 38 你误解了。
我是说我的病人没有TIA/Stroke， 我不会order carotid u/s。
对这个病人， 因为有人order了， 就得由这个人来address这个stenosis， 我已经帮
这个人address了。 |
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s********p
发帖数: 1319 | 39 蒙古大大，你着了我的“道”儿！
——动脉粥样硬化是个全身性、系统性病理过程。
直接把颈动脉系统的斑块拿掉，可以。但颈动脉的上游和下游的动脉粥样硬化的斑块又
怎么办？从哪里下刀子？！
版大，Futurehw, 赶快给我发钱，我要买大龙虾、King Crab吃！！ |
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c**********m
发帖数: 2088 | 42 我吃大龙虾吃腻过，一次吃了5只，一年之内不想吃它。 |
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s********p
发帖数: 1319 | 43 小弟，被鞋子挂啦？！
为什么？！
我帮你修理他！！ |
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L****n
发帖数: 12932 | 44 表那么激动， 你的神马降脂对全身性系统性的粥样硬化有什么作用还难说呢。 现在到
底什么脂引起粥样硬化还木有定论。 这些七七八八的statin真要管用， 也不会那么多
病人来手术室这里bypass, 那里stenting的了。 |
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s********p
发帖数: 1319 | 46 大大，我真的激动得很——为了帮你跳这“坑”，我一直忍了两天，差点就忍不住了，
好高兴！！
Statin类药对易损斑块的稳定作用、引起的一场“Statin”的“革命”，我就不罗嗦啦。
Stent正是我干的活，也是我们鄙视心外科大夫的活！
你现在跳不出这“坑”——嘿！嘿！！嘿！！！ |
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L****n
发帖数: 12932 | 48 闲话少说， i believe in evidence based medicine. I've shown reference to the
possibility of TIA presents as loss of consciousness, as well as study that
better long term outcome of CEA compare to conservative treatment in a
severely stenosed carotid artery (even if 1% better is 1% better), i have
yet to see any reference point the other way. Can you provide reference
support your argument pertain to:
1) this patient's loss of consciousness CAN'T POSSIBLY result from carotid
stenosis? this patient ac... 阅读全帖 |
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L****n
发帖数: 12932 | 49 easy easy, i think you need some versed to calm down first.
啦。 |
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A*******s
发帖数: 9638 | 50 1. Impossible.
2. Never said superior。 There were 3 clinical trials on asymptomatic
carotid stenosis, VACS, ACAS, ACST. The VACS included TIA so is not really
asymptomatic.
The data was pooled and the conclusion is: if surgical risk can be lower
than 3%, the benefit is about 1%/a year. You have to live long enough to see
real benefits.
From Neurology, feb 2012, in press:
It is important to emphasize that selection of asymptomatic patients for
carotid revascularization should include careful co... 阅读全帖 |
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