CSA&TISC 2019丨楼之茵教授:2019 CSVD相关认知功能障碍中国诊疗指南解读

2019-06-30 国际循环编辑部 国际循环

编者按:近年来,脑小血管病(CSVD)相关认知功能障碍备受关注,国内外血管性认知功能障碍指南相继发表。2019年4月中国CSVD相关认知功能障碍诊疗指南正式发布,为中国CSVD相关认知功能障碍的诊疗提供重要指导。CSA&TISC 2019大会上,上海交通大学医学院附属新华医院楼之茵教授就CSVD相关认知功能障碍中国诊疗指南2019作了全面解读。

编者按:近年来,脑小血管病(CSVD)相关认知功能障碍备受关注,国内外血管性认知功能障碍指南相继发表。2019年4月中国CSVD相关认知功能障碍诊疗指南正式发布,为中国CSVD相关认知功能障碍的诊疗提供重要指导。CSA&TISC 2019大会上,上海交通大学医学院附属新华医院楼之茵教授就CSVD相关认知功能障碍中国诊疗指南2019作了全面解读

指南背景与概述

CSVD是引起血管性认知功能障碍的重要亚型,也是临床上导致血管性痴呆的最常见原因。随LADIS、RUN DMC和SPS3三大经典研究的开展,越来越多的研究证据奠定认知研究在CSVD临床研究中的核心地位。CSVD相关认知功能障碍是临床中常见认知障碍之一,发病率高、社会负担重,在临床实践中给予合理诊疗至关重要。因此,该指南由来自国内多个医疗单位的3位顾问专家及30位专家组成员共同编写,旨在为临床医生诊治CSVD认知共脑功能障碍提供参考。

CSVD定义

CSVD是指各种病因影响脑内小动脉、微动脉、毛细血管、微静脉和小静脉导致的一系列临床、影像学和病理综合征,可呈现典型的磁共振成像影像学改变(腔隙、新发皮质下小梗死、脑白质病变、扩大的血管周围间隙、脑微出血和脑萎缩等),其常见的病因类型包括小动脉硬化性、脑淀粉样血管病、遗传性CSVD变、炎症和免疫介导的小血管病、静脉胶原病和其他小血管病等。

认知功能障碍依据程度不同可分为轻度认知功能障碍和痴呆。前者是指记忆力或其他认知功能进行性减退,尚未影响日常生活能力,未达到痴呆的诊断标准;后者是指认知功能损害已导致患者日常生活能力、学习能力、工作能力及社会交往能力明显减退的综合征。

CSVD认知功能障碍可呈现出相似的认知功能减退模式,常累及注意力、加工速度和执行功能等领域,而记忆任务受损相对较轻。


流行病学研究数据显示,我国缺血性脑卒中中CSVD所引起的腔隙性梗死所占比例显著高于西方国家,脑白质高信号的患病率在45~80岁人群中达95%。此外,脑微出血的患病率达24%,且随年龄增长而逐渐增加,在年龄≥80岁人群中达38.8%。血管性痴呆中,CSVD引起的认知功能障碍所占比例达36%~67%。更加不容乐观,CSVD可导致多项不良结局(突发性缺血性和出血性卒中、全因痴呆、抑郁症、死亡等)。

CSVD的诊断

2019年中国指南强调,该病要进行依据临床特点与评估、实验室检查及影像学检查进行综合诊断。关于临床特点,多数CSVD起病隐匿,临床表现多样,主要包括无症状性CSVD、腔隙性卒中和认知功能障碍。CSVD认知功能障碍可出现特征性的认知减退模式(注意力、加工速度及执行功能具有特征性的早期受累,记忆功能相对完整),可进展为轻度认知功能损害和血管性痴呆,可伴随其他非认知障碍临床表现(如步态障碍、情绪和行为障碍和膀胱功能障碍等)。诊断时,指南推荐采用适合我国的神经心理测验进行全面认知功能域(包括记忆功能、执行/注意功能、语言功能、视空间结构功能、日常生活能力和精神行为等)评估,具体推荐的筛查量表见下图。



此外,指南强调目前临床上无直接显示CSVD的检查方法,头颅MRI是重要的首选检查手段之一;推荐所有首次就诊的患者行血液学检测(包括血糖、血脂、血电解质、肝肾功能等)以协助病因诊断和鉴别诊断。诊断该病时应详细询问病史并进行神经系统查体,寻找CSVD的证据及与认知功能障碍间的相关性,排除其他引起认知功能障碍的疾病。其诊断的主要要素包括:①存在认知功能障碍(主观报告的认知功能障碍下降及客观检查存在的认知功能损害);②存在CSVD(白质和深部灰质中有多处腔隙性梗死、缺血性白质改变、血管周围间歇扩大或皮质微梗死和微出血);③CSVD是引起认知功能障碍的主要因素。需强调,CSVD相关认知功能障碍的诊断需排除足以解释记忆或其他认知损害的其他影像学改变或疾病。

治疗推荐

对CSVD相关认知功能障碍预防性干预非常重要,主要措施包括改善生活方式、控制血管危险因素和治疗原发血管疾病。其中,生活方式干预可从教育及体育锻炼入手,控制血管危险因素主要包括降压治疗、控制血糖及应用他汀类药物。关于CSVD的初级或二级预防,双联抗血小板治疗或强化降压治疗对认知终点均无显著治疗效果。此外,目前,尚缺乏针对CSVD相关认知障碍进行多个危险因素和生活方式干预的综合干预临床试验,但有针对血管性认知障碍高危人群的综合干预研究。指南认为,综合方式干预可能有助于患者获得更好的认知结果(IIb级证据)。药物治疗方面,指南认为,认为抗痴呆治疗药物胆碱酯酶抑制剂对患者有明确治疗作用。



总之,中国2019年指南推荐应采用适合我国的神经心理测验对CSVD患者行全面认知功能域评估;强调MRI是目前检测SCVD认知功能障碍最重要的工具;建议所有首次就诊的患者行血液学检测以协助病因诊断和鉴别诊断;认为控制血管性危险因素可能有益,但仍需进一步开展大规模临床试验证实;认为抗痴呆治疗药物胆碱酯酶抑制剂对患者有明确治疗作用。

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    2019-07-02 yankaienglish
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    2019-06-30 百草

    666

    0

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