The diagnosis and treatment of chronic cerebral ischemia is done in one article

*It is only for medical professionals to read and reference, and cannot be ignored, the "invisible killer" of middle-aged and elderly people.

Chronic cerebral ischemia (CCH), also known as chronic cerebral hypoperfusion, is a group of chronic cerebral dysfunction syndromes caused by decreased cerebral perfusion.

CCH is a common clinical pathophysiological state, and one of the most important mechanisms of vascular-derived brain dysfunction.
It has become the forefront of neurological research.

Definition and diagnostic criteria CCH, as a result of multiple causes and as a cause of other related diseases, has long been difficult to reach a unified definition and diagnostic criteria.

The Neurology Branch of the Chinese Medical Association re-aggregated and classified cerebrovascular diseases in 2017, adding the concept of CCH, proposing that CCH refers to the state of reduced blood supply at the overall level of the brain [cerebral blood flow 25～45 ml/(100g·min) )] instead of focal cerebral ischemia.

Taking into account the diversity of the causes of CCH, it can be defined as a series of brain dysfunction syndromes caused by long-term vascular structural disease or circulatory disorders.

Diagnostic criteria for chronic cerebral ischemia (standards of the Society of Integrated Traditional Chinese and Western Medicine): In principle, the age of the patient is >60 years; the onset is hidden, the course of the disease is long, and the history of the disease is generally more than 3 months; the symptoms may be fluctuating; the performance of chronic brain insufficiency, Such as dizziness, dizziness, swelling and pain, memory loss, slow response, inattention, emotional instability, impaired work ability, sleep disturbance and mood disturbance, etc.
; with risk factors for cerebrovascular diseases, such as high blood pressure, diabetes, blood lipids Abnormalities and history of coronary heart disease; no focal neurological signs in the brain.

Epidemiology and risk factors According to the 2016 China Epidemiological Survey Report, 2/3 of people over 65 have a history of CCH, and about 50% of people aged 50-60 have a history of CCH, and among people aged 45-50 There is also 25% of CCH.

Age, sex, hypertension, diabetes, dyslipidemia, changes in intestinal flora caused by irrational diet, high homocysteine, smoking, drinking, and metabolic syndrome are the main risk factors for CCH.

Clinical manifestations of patients with CCH may have a variety of discomforts, such as headache, dizziness, dizziness, unsteady walking, and obvious general fatigue that last for several months.

In addition, CCH plays an important role in the occurrence and development of a variety of cerebrovascular-related diseases, and can lead to white matter demyelination, cerebral infarction, and vascular cognitive dysfunction.

1CCH and dementia CCH is closely related to dementia.

The Rotterdam study found that cerebral hypoperfusion precedes dementia and is likely to lead to cognitive dysfunction and dementia.

Magnetic resonance perfusion imaging arterial spin labeling (ASL) was used to measure Alzheimer’s disease and vascular dementia patients, and it was found that cerebral blood flow in the brain area related to cognitive function was significantly reduced.

2CCH and ischemic stroke CCH is closely related to ischemic stroke, but ischemic stroke does not necessarily develop from CCH, and CCH does not necessarily cause stroke.

3 Sleep and mood disorders.
Most CCH patients can have sleep abnormalities of varying degrees, such as difficulty falling asleep, dreaming, waking up early, and insomnia at night.

Most patients with CCH are depressed, irritable, and indifferent.
Some patients may experience depression and anxiety.

There is currently no evidence-based very accurate treatment for CCH, including drug intervention.

In terms of research, there is currently a lack of ideal animal models, and most studies are also under exploration.

The mechanism of stroke in CCH is complicated.
If there is large vessel occlusion or stenosis, a comprehensive assessment should be made during endovascular treatment, including the degree of stenosis, collateral circulation perfusion and the perforator of the stenosis. 1CCH with intracranial and extracranial large vessel stenosis (1) Antiplatelet: In the early onset of intracranial atherosclerotic stenosis (ICAS), aspirin combined with clopidogrel is recommended to reduce the risk of early stroke recurrence caused by thromboembolism, and reassess it after 1 week Risk, decide whether to continue the combination therapy, and the combination medication should not exceed 3 months after the onset; (2) Blood lipids: ICAS patients are recommended to start statin therapy early to reduce low-density lipoprotein cholesterol (LDL-C) to <1.
8 mmol /l or at least 50% reduction; (3) Blood glucose: For patients with ICAS with diabetes, the target of blood glucose control is glycosylated hemoglobin (HbA1c) <7% may be reasonable; (4) Indications for endovascular therapy: symptomatic ICAS stenosis Patients with a rate ≥70%, intensive drug therapy ineffective or poor cerebral collateral circulation, and hypoperfusion in the blood supply area of ​​the responsible blood vessel are indications for endovascular treatment.

2CCH combined with intracranial and extracranial large vessel occlusion interventional recanalization treatment cases selection Domestic commonly used CT perfusion imaging (CTP) to assess cerebral perfusion staging: Ⅰ1: Time to peak (TTP) prolonged, mean transit time (MTT), cerebral blood flow (rCBF) ) And cerebral blood volume (rCBV) are normal; Ⅰ2: TTP and MTT are prolonged, rCBF is normal, rCBV is normal or slightly increased; Ⅱ1: TTP, MTT is prolonged and rCBF is decreased, rCBV is basically normal or slightly decreased; Ⅱ2 : TTP and MTT are prolonged, rCBF and rCBV are decreased.

When the patient is in stage II, it indicates that the cerebral circulation reserve is decompensated, and interventional recanalization can be considered; if the perfusion injury is found to be aggravated during the follow-up of drug therapy, endovascular recanalization can also be considered.

Intracranial and extracranial large arteries are not acutely occluded.
After standard drug treatment, there are still symptom fluctuations or symptoms worsening, and there is hypoperfusion in the responsible vascular area for imaging assessment.
Interventional recanalization can be considered. 3 Endovascular treatment options (1) Drug therapy is the basic treatment for non-acute occlusion of intracranial and extracranial large vessels (non-acute occlusion of intracranial and extracranial large arteries can refer to the drug treatment plan for symptomatic intracranial artery stenosis), and non-acute intracranial and extracranial large arteries are non-acute.
For occlusive lesions, vascular recanalization is not recommended.
Patients with symptomatic non-acute occlusion of intracranial and extracranial large vessels with severe hemodynamic disorders may consider endovascular recanalization; (2) Non-acute occlusion is generally treated after 2 weeks of acute cerebral infarction.
In special circumstances, intravascular recanalization treatment within 2 weeks can also be considered; (3) The success rate and risk of occlusive lesion opening should be comprehensively estimated before surgery.
For extracranial vessels, it can be combined with the carotid artery occlusion (CAO) score.
(4) HR-MRI has the advantages of vascular wall imaging, and plays an important role in risk assessment and the choice of treatment methods.
It can not only display the length of the true occlusion segment, but also identify plaques based on the strength of the displayed signal.
Block composition and estimated time of vessel occlusion.

(5) In addition to paying attention to hypoperfusion and collateral circulation, it is also necessary to evaluate occluded or narrowed perforating vessels.

References: [1] Mu Haoyue, Ju Yi, Zhao Xingquan.
Progress in the study of the pathophysiological mechanism and clinical manifestations of chronic cerebral ischemia[J].
Chinese Journal of Medical Frontiers (Electronic Edition),2021,13(4):21-25 .
[2]Chinese Medical Association Neurology Branch, Chinese Medical Association Neurology Branch Cerebrovascular Disease Group.
Classification of Cerebrovascular Diseases in China 2015[J].
Chinese Journal of Neurology,2017,50(3):168-171.
[ 3]Li Baomin, Miao Zhongrong, Wang Yongjun, et al.
Chinese Expert Consensus on Endovascular Treatment of Symptomatic Intracranial Atherosclerotic Stenosis 2018[J].
Chinese Journal of Stroke,2018.
[4]Neurovascular Intervention Collaboration, Chinese Medical Association Neurology Branch Group, Chinese Medical Doctor Association Neurologist Branch Neurological Intervention Professional Committee, Chinese Research Hospital Association Interventional Neurology Professional Committee.
Expert consensus on endovascular interventional therapy for non-acute occlusion of intracranial and extracranial large arteries in China[J].
Chinese Journal of Internal Medicine 2020,59(12 ):932-941.
[5]Professor Huang Li'an Academic Report: Progress in the Treatment of Chronic Cerebral Ischemia.
Source of this article: Neural News Review of this article: Deputy Chief Physician Li Tuming Editor: Mr.
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