1例脑小血管病的“健-全-专”诊疗思考

章桂芬; 童钰铃; 郭谊

doi:10.16766/j.cnki.issn.1674-4152.003401

1例脑小血管病的“健-全-专”诊疗思考

doi: 10.16766/j.cnki.issn.1674-4152.003401

章桂芬¹,
童钰铃¹,
郭谊^{1, 2, ,}

1.
浙江大学医学院附属第二医院全科医学科及国际医学部，浙江杭州 310009
2.
浙江大学医学院附属第二医院神经内科

详细信息

通讯作者:
郭谊，E-mail：yiguo@zju.edu.cn

中图分类号: R743 R499
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- 文章访问数: 66
- HTML全文浏览量: 22
- PDF下载量: 4
- 被引次数: 0
出版历程
- 收稿日期: 2023-02-11
- 网络出版日期: 2024-03-27

Application of health management, general practice and specialty joint management mode in a patient with cerebral small vessel disease

ZHANG Guifen¹,
TONG Yuling¹,
GUO Yi^{1, 2
, ,}

1.
Department of General Practice and International Medicine, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, China

摘要

摘要: 我国小动脉闭塞所致的脑小血管病约占缺血性卒中病因的30%，脑小血管病多起病隐匿，其治疗、预后与大动脉粥样硬化型脑卒中有所不同。近年来，对于脑小血管病的认知越来越深入，2021年中国脑小血管病诊治专家共识进行了更新，但是全科医生对此疾病还没有足够的认识，在实际工作中对该疾病的诊断、治疗及管理存在盲点。本文通过介绍1例脑小血管病患者的诊治及随访过程，以帮助全科医师提高对于这种疾病的认识，尤其是针对脑微出血的处理，同时展示“健-全-专”一体化管理模式在此类患者管理上的运用。
- 脑小血管病 /
- 全科医生 /
- 病例管理
Abstract: Small vessel disease caused by small artery occlusion accounts for about 30% of the aetiology of ischaemic stroke in China. Many small vessel diseases are hidden, and their treatment and prognosis are different from those of large atherosclerotic stroke. In recent years, the understanding of cerebrovascular disease has become more profound. In 2021, the consensus of Chinese experts on the diagnosis and treatment of cerebrovascular disease was updated, but general practitioners still do not have enough understanding of this disease, and there are blind spots in the diagnosis, treatment and management of this disease in practice. By presenting the diagnosis, treatment and follow-up of a patient with cerebrovascular disease, we can help general practitioners improve their understanding of this disease, particularly in the treatment of cerebral microbleeds, and demonstrate the application of our "sound professional" integrated management model in the management of such patients.
- Cerebral small vessel disease /
- General practitioners /
- Case management

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图 1 患者脑梗死及脑小血管病影像所见

注：A为DWI序列右侧侧脑室旁见斑状高信号(箭头所示); B为T₁序列两侧脑室旁腔隙灶(箭头所示); C为T₂序列两侧脑室旁广泛脑白质高信号; D为SWI示脑实质内多发微出血灶。

Figure 1. Imaging findings of cerebral infarction and small vessel disease in patients

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表 1 健康问题和风险评估表

Table 1. Health issues and risks assessment form

健康问题和健康风险评估	目前存在的问题
健康问题
急性脑梗死	左侧肢体偏瘫和吞咽障碍，头颅核磁提示右侧侧脑室旁新近梗死, 见图 1。
脑小血管病	头颅核磁提示两侧脑室旁、半卵圆区、基底节丘脑和脑桥广泛脑白质高信号、散在腔隙灶，SWI提示脑实质内多发微出血灶，见图 1。
肺炎	咳嗽，少许咳痰；胸部CT提示：两肺散在炎症渗出。
肾功能不全	肌酐99.1 μmol/L，肾小球滤过率66.12 mL/min。
危险因素
血压	发现高血压8 d，入院血压140/76 mmHg(厄贝沙坦降压中)。
血糖	在院期间空腹血糖波动在6.09~6.9 mmol/L, 餐后2 h血糖6.3~9.8 mmol/L。
血脂	低密度脂蛋白2.16 mmol/L。
动脉粥样硬化	颈部CTA提示动脉粥样硬化。
其他	入院后第4天出现右下肢第一足趾关节红肿热痛，考虑痛风发作。
一般情况
年龄	70岁，老龄患者
体重	BMI为24.7，超重
相关评估
卒中风险	非瓣膜性心房颤动患者卒中风险CHA2DS2-VASc积分：4分
出血风险	出血风险评估HAS-BLED评分：3分
MMSE	22分(小学文化)
汉密尔顿焦虑量表	8分
汉密尔顿抑郁量表	6分
NIHSS	11分
ADL	四级
mRS	4分
生活方式
吸烟	吸烟40年，约每日25支，现未戒烟。
饮酒	饮酒40年，每次“白酒”50~100 mL，现未戒酒。
运动	缺乏运动。
饮食	饮食习惯重油重盐。
心理
心理	情绪躁动，对今后生活质量担心、焦虑、恐惧。
依从性	依从性差，对疾病缺乏认知。
家庭及社会
工作	已退休
家庭	1弟患有高血压，1弟有脑卒中史，家庭关系和睦。
经济	医保支付
社会	有社会支持

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表 2 全科管理方案及控制目标

Table 2. General management plan and control objectives

治疗方式	项目	健康宣教及控制目标
非药物治疗	低盐低脂低嘌呤高膳食纤维饮食	建议每日饮食种类多样化，使能量和营养的摄入趋于合理；采用包括水果、蔬菜和低脂奶制品以及总脂肪与饱和脂肪酸含量较低的均衡食谱；保证丰富的维生素、矿物质和膳食纤维摄入，降低钠摄入量和增加钾摄入量，推荐食盐摄入量≤6 g/d，钾摄入量≥4.7 g/d^[11]。
	康复锻炼	康复师指导康复锻炼，3个月后再次康复评估调整方案。
	吸烟	戒烟
	饮酒	戒酒
	控制体重	BMI控制在18.5~23.9^[8]。
	心理	患者卒中后有焦虑和抑郁情绪，与患者和家属积极沟通，进行心理支持和疏导，提高其对疾病的认识，预防卒中后抑郁。
	认知功能	定期随访认知功能。
药物治疗	抗血小板	阿司匹林胶囊出院后调整为100 mg/d，患者脑小血管病，有大量微出血灶，恢复期慎用抗血小板药物。阿司匹林有出血风险，如出现牙龈出血、鼻出血、黑便、便血、头晕、头痛，及时就诊。
	血脂	阿托伐他汀钙片40 mg/晚，建议低密度脂蛋白控制于1.8 mmol/L以下^[11]，注意有无乏力、肌肉酸痛等情况，并每3个月复查血肝肾功能、血脂、肌酸激酶，每年复查颈动脉B超。
	血压	厄贝沙坦150 mg/d，每日监测血压，根据具体情况血压降至＜140/90 mmHg，若能耐受收缩压降至＜130 mmHg^[12]。
	血糖	每月监测空腹和餐后血糖，3个月监测糖化血红蛋白。
	降尿酸	患者在院期间痛风发作，急性暂予止痛等对症治疗，待疼痛好转，可加用降尿酸药物，监测尿酸＜360 μmol/L，建议每日饮水量维持在2 000 mL以上，应避免饮用含果糖饮料或含糖软饮料、果汁和浓汤，可以饮用水、茶或不加糖的咖啡^[13]。

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参考文献(20)

[1]	LITAK J, MAZUREK M, KULESZA B, et al. Cerebral small vessel disease[J]. Int J Mol Sci, 2020, 21(24): 9729. doi: 10.3390/ijms21249729
[2]	HAN F, ZHAI F F, WANG Q, et al. Prevalence and risk factors of cerebral small vessel disease in a Chinese population-based sample[J]. J Stroke, 2018, 20(2): 239-246. doi: 10.5853/jos.2017.02110
[3]	CANNISTRARO R J, BADI M, EIDELMAN B H, et al. CNS small vessel disease: a clinical review[J]. Neurology, 2019, 92(24): 1146-1156. doi: 10.1212/WNL.0000000000007654
[4]	XIA Y W, SHEN Y, WANG Y, et al. White matter hyperintensities associated with progression of cerebral small vessel disease: a 7-year Chinese urban community study[J]. Aging (Albany NY), 2020, 12(9): 8506-8522.
[5]	中国研究型医院学会脑小血管病专业委员会《中国脑小血管病诊治专家共识》编写组. 中国脑小血管病诊治专家共识2021[J]. 中国卒中杂志, 2021, 16(7): 716-726. https://www.cnki.com.cn/Article/CJFDTOTAL-ZUZH202107015.htm Disease Professional Committee Consensus Writing Group, Chinese Research Hospital Association. Chinese Consensus on Diagnosis and Therapy of Cerebral Small Vessel Disease 2021[J]. Chinese Journal of Stroke, 2021, 16(7): 716-726. https://www.cnki.com.cn/Article/CJFDTOTAL-ZUZH202107015.htm
[6]	CHEN H M, PAN Y S, ZONG L X, et al. Cerebral small vessel disease or intracranial large vessel atherosclerosis may carry different risk for future strokes[J]. Stroke Vasc Neurol, 2020, 5(2): 128-137. doi: 10.1136/svn-2019-000305
[7]	蒋程序. "互联网+医疗"大背景下厦门市慢病管理的模式研究[D]. 福州: 福建中医药大学, 2018. JIANG C X. Research on the model of chronic disease management in Xiamen under the background of "Internet plus+medical"[D]. Fuhzou: Fujian University of Traditional Chinese Medicine, 2018.
[8]	中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2018[J]. 中华神经科杂志, 2018, 51(9): 666-682. https://www.cnki.com.cn/Article/CJFDTOTAL-XDJB201911024.htm Chinese Society of Neurology; Chinese Stroke Society. Chinese guidelines for diagnosis and treatment of acute ischemic stroke 2018[J]. Chinese Journal of Neurology, 2018, 51(9): 666-682. https://www.cnki.com.cn/Article/CJFDTOTAL-XDJB201911024.htm
[9]	中华医学会老年医学分会老年神经病学组, 脑小血管病认知功能障碍诊疗指南中国撰写专家组. 脑小血管病相关认知功能障碍中国诊疗指南(2019)[J]. 中华老年医学杂志, 2019, 38(4): 345-354. https://www.cnki.com.cn/Article/CJFDTOTAL-AAEC201903002.htm The Elderly neurology Group of the Geriatrics Branch of the Chinese Medical Association, the expert group written in China on the diagnosis and treatment guidelines for cognitive impairment of cerebrovascular diseases. The Chinese diagnosis and treatment guidelines for cognitive impairment related to cerebrovascular diseases (2019)[J]. Chinese Journal of Geriatrics, 2019, 38(4): 345-354. https://www.cnki.com.cn/Article/CJFDTOTAL-AAEC201903002.htm
[10]	张淑红, 凌迎春, 盛高扬. 老年脑梗死患者不同时机康复治疗对神经功能的影响比较[J]. 中华全科医学, 2022, 20(4): 678-680, 695. doi: 10.16766/j.cnki.issn.1674-4152.002428 ZHANG S H, LING Y C, SHENG G Y. Effects of rehabilitation treatment at different time points on neurological function in elderly patients with cerebral infarction[J]. Chinese Journal of General Practice, 2022, 20(4): 678-680, 695. doi: 10.16766/j.cnki.issn.1674-4152.002428
[11]	中华医学会, 中华医学会杂志社, 中华医学会全科医学分会, 等. 缺血性卒中基层诊疗指南(2021年)[J]. 中华全科医师杂志, 2021, 20(9): 927-946. Chinese Medical Association, Journal of Chinese Medical Association, General Practice Branch of Chinese Medical Association, et al. Guidelines for Grassroots Diagnosis and Treatment of Ischemic Stroke (2021)[J]. Chinese Journal of General Practitioners, 2021, 20(9): 927-946.
[12]	中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国缺血性卒中和短暂性脑缺血发作二级预防指南2022[J]. 中华神经科杂志, 2022, 55(10): 1071-1110. https://xuewen.cnki.net/CCND-YSBZ20221103B043.html Chinese Society of Neurology; Chinese Stroke Society. Chinese guideline for the secondary prevention of ischemic stroke and transient ischemic attack 2022[J]. Chinese Journal of Neurology, 2022, 55(10): 1171-1110. https://xuewen.cnki.net/CCND-YSBZ20221103B043.html
[13]	中华医学会, 中华医学会杂志社, 中华医学会全科医学分会, 等. 痛风及高尿酸血症基层诊疗指南(2019年)[J]. 中华全科医师杂志, 2020, 19(4): 293-303. Chinese Medical Association, Journal of Chinese Medical Association, General Practice Branch of Chinese Medical Association, et al. Guidelines for Basic Level Diagnosis and Treatment of Gout and Hyperuricemia (2019)[J]. Chinese Journal of General Practitioners, 2020, 19(4): 293-303.
[14]	MARKUS H S, DE LEEUW F E. Cerebral small vessel disease: recent advances and future directions[J]. Int J Stroke, 2023, 18(1): 4-14. doi: 10.1177/17474930221144911
[15]	PATEL A R, PATEL A R, DESAI S. The underlying stroke etiology: a comparison of two classifications in a rural setup[J]. Cureus, 2019, 11(7): e5157. DOI: 10.7759/cureus.5157.
[16]	张炎, 钱小燕, 沈芳, 等. 大动脉粥样硬化型和小动脉闭塞型脑梗死患者Lp-PLA2水平与颈动脉粥样硬化斑块的关系[J]. 中国循证心血管医学杂志, 2020, 12(10): 1227-1230. https://www.cnki.com.cn/Article/CJFDTOTAL-PZXX202010018.htm ZHANG Y, QIAN X Y, SHEN F, et al. The relationship between Lp-PLA2 level and carotid atherosclerotic plaque in patients with cerebral infarction of large atherosclerosis and small artery occlusion[J]. Chinese Journal of Evidence-Based Cardiovascular Medicine, 2020, 12(10): 1227-1230. https://www.cnki.com.cn/Article/CJFDTOTAL-PZXX202010018.htm
[17]	中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国脑小血管病诊治指南2020[J]. 中华神经科杂志, 2022, 55(8): 807-818. Neurology Branch of Chinese Medical Association, Cerebrovascular Disease Group of neurology Branch of Chinese Medical Association. Chinese Guidelines for the Diagnosis and Treatment of Cerebrovascular Diseases 2020[J]. Chinese Journal of Neurology, 2022, 55(8): 807-818.
[18]	ZHANG Y, GUAN Y L, ZHANG Y J, et al. Recurrence rate and relevant associated factors of stroke among patients with small artery occlusion in northern China[J]. Sci Rep, 2019, 9(1): 2834. doi: 10.1038/s41598-019-39207-0
[19]	田佳禾, 刘翔, 陈红, 等. 慢性非传染性疾病社区健康管理模式的内涵及对我国的启示[J]. 中华全科医学, 2022, 20(12): 1995-1999. doi: 10.16766/j.cnki.issn.1674-4152.002754 TIAN J H, LIU X, CHEN H, et al. Connotation of the community health management models of chronic non-communicable diseases and its revelations to our country[J]. Chinese Journal of General Practice, 2022, 20(12): 1995-1999. doi: 10.16766/j.cnki.issn.1674-4152.002754
[20]	曾玉潇, 高韬, 柯大智. 新医科背景下全科医学人才培养探讨[J]. 现代医药卫生, 2023, 39(1): 152-154, 157. https://www.cnki.com.cn/Article/CJFDTOTAL-XYWS202301033.htm ZENG Y X, GAO T, KE D Z. Exploration of General Practitioner Training in the Context of New Medical Sciences[J]. Modern Medicine and Health, 2023, 39(1): 152-154, 157. https://www.cnki.com.cn/Article/CJFDTOTAL-XYWS202301033.htm