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Medicalpractice版 - 病案,请教各位医学专家
相关主题
求助:动脉硬化闭塞症,装支架是否有效?【征文活动】 有趣的临床综合症。
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相关话题的讨论汇总
话题: carotid话题: stenosis话题: cea话题: syncope
进入Medicalpractice版参与讨论
1 (共1页)
y**q
发帖数: 570
1
请教各位医学专家,看看此病人--我姨妈的病情及超声诊断结果,推荐下一步治疗方案
,保守还是手术。如果手术,在国内哪家医院比较好。多谢了!
病人:女,66岁,20年高血压,15年心脏病史。两年前行心脏搭桥手术。一月前,晨起
锻炼时,突然晕倒在地,昏迷,经医院超声检查:脑动脉硬化;动脉硬化,多发附壁斑
块,右椎动脉血管闭塞 (详见附件超声报告),经保守治疗,目前暂时清醒。
身体一般情况差,严重颈椎病,腰椎间盘突出,行走不稳。
c**********m
发帖数: 2088
2
中国治疗心脏病最好的医院
北京阜外医院
北京安贞医院
复旦大学附属中山医院
上海瑞金医院

【在 y**q 的大作中提到】
: 请教各位医学专家,看看此病人--我姨妈的病情及超声诊断结果,推荐下一步治疗方案
: ,保守还是手术。如果手术,在国内哪家医院比较好。多谢了!
: 病人:女,66岁,20年高血压,15年心脏病史。两年前行心脏搭桥手术。一月前,晨起
: 锻炼时,突然晕倒在地,昏迷,经医院超声检查:脑动脉硬化;动脉硬化,多发附壁斑
: 块,右椎动脉血管闭塞 (详见附件超声报告),经保守治疗,目前暂时清醒。
: 身体一般情况差,严重颈椎病,腰椎间盘突出,行走不稳。

L****n
发帖数: 12932
3
sounds like an Left carotid endarcterectomy is needed before it completely
occluded.
L****n
发帖数: 12932
4
晕倒, 人家心脏都搭过了。

【在 c**********m 的大作中提到】
: 中国治疗心脏病最好的医院
: 北京阜外医院
: 北京安贞医院
: 复旦大学附属中山医院
: 上海瑞金医院

A*******s
发帖数: 9638
5
Surgery/stenting for asymptomatic carotid artery stenosis over 70% is still
controversial.
The key is what caused syncope?
Left carotid artery stenosis usually is not the cause of syncope. Basilar
artery stenosis, however, could induce brain stem ischemia and cause vertigo
and syncope. I did not see basilar artery flow direction on the U/S. If retrograde, a
subclavian steal could cause the syncope.
So you may fix the carotid artery stenosis but not the syncope. The patient
has to be informed prior to such a procedure.

【在 L****n 的大作中提到】
: sounds like an Left carotid endarcterectomy is needed before it completely
: occluded.

y**q
发帖数: 570
6
如果是颈动脉狭窄行手术,是属心外科管吗? 需不需要骨科,神经外科?
综合考虑,下一步是手术还是保守治疗?
现在病情相对稳定,饮食起居有什么注意事项;如果暂时保守治疗,有什么药物推荐?
就当准备Step1,2,3的病例讨论吧。请各抒高见.....多谢了!
A*******s
发帖数: 9638
7
你看明白我说的了吗?

【在 y**q 的大作中提到】
: 如果是颈动脉狭窄行手术,是属心外科管吗? 需不需要骨科,神经外科?
: 综合考虑,下一步是手术还是保守治疗?
: 现在病情相对稳定,饮食起居有什么注意事项;如果暂时保守治疗,有什么药物推荐?
: 就当准备Step1,2,3的病例讨论吧。请各抒高见.....多谢了!

n*******c
发帖数: 501
8
I wonder if they have ruled out cardiogenic syncope. The patient has a
strong history of ischemic heart disease and had a CABG 2 years ago. How is
her LV function? If she has a poor LV function (say EF less than 40%) she is
at high risk of having ventricular arrhythmia which can present with
syncope or even sudden cardiac death. However, if posterior circulation
event is a concern, she will need a MRI+MRA. It does not convince me she had
a brain stem ischemic event with no other neurological signs/symptoms apart
from syncope.
y**q
发帖数: 570
9
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!
A*******s
发帖数: 9638
10
I'll write you some answers in Chinese tonight.

【在 y**q 的大作中提到】
: 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!

相关主题
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谁来给科普一下这个RVU【参加活动】Paget-Schroetter disease
进入Medicalpractice版参与讨论
s********p
发帖数: 1319
11
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——患者的侧枝循环、代偿程度如何?
目前大脑的血液供应情况如何?患者的年龄多大?全身情况如何?手术的得益有多大?
这些因素都综合考虑以后,才能在风险和得益之间,找到一个最佳的平衡点........
“现在病情相对稳定,饮食起居有什么注意事项?”,看签名档下我回答过其它网友的
问题。
s********p
发帖数: 1319
12
"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。

【在 y**q 的大作中提到】
: 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!

A*******s
发帖数: 9638
13
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。

【在 s********p 的大作中提到】
: "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。

s********p
发帖数: 1319
14
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!



【在 A*******s 的大作中提到】
: 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。

A*******s
发帖数: 9638
15
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。

【在 y**q 的大作中提到】
: 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!

s********p
发帖数: 1319
16
Totally Agree On and With.....!!

呵呵

【在 A*******s 的大作中提到】
: 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。

L****n
发帖数: 12932
17
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 AHA:
Three recent trials of carotid endarterectomy showed that when acceptably
low surgical morbidity and mortality are achieved, carotid endarterectomy
improves outcome in symptomatic patients with severe carotid stenosis(>60%).
L****n
发帖数: 12932
18
----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
.
c**********m
发帖数: 2088
19
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

【在 L****n 的大作中提到】
: 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 AHA:
: Three recent trials of carotid endarterectomy showed that when acceptably

L****n
发帖数: 12932
20
risk of surgery mainly comes from perioperative event - 找一个手术技术过硬的
地方是王道。
相关主题
请问车祸后颈椎骨质增生的手术治疗和热凝靶点术未名医疗实践好文章大家读-012012
请问 眼睛 黄斑局灶色素上皮损害 的英文怎么说?Summary: 医学文献阅读-Jan, 2012
Let this new year bring happiness to every ones li求老师们评点以下这一治疗方案
进入Medicalpractice版参与讨论
L****n
发帖数: 12932
21
huh? what? where do u get that?

【在 c**********m 的大作中提到】
: 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

c**********m
发帖数: 2088
22
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.

【在 L****n 的大作中提到】
: huh? what? where do u get that?
L****n
发帖数: 12932
23
that is not true, period.

【在 c**********m 的大作中提到】
: 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.

A*******s
发帖数: 9638
24
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 the
CEA is not going to prevent syncope in this case.

year
for
during
patients

【在 L****n 的大作中提到】
: ----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
: .

L****n
发帖数: 12932
25
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

【在 A*******s 的大作中提到】
: 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 the
: CEA is not going to prevent syncope in this case.
:
: year

A*******s
发帖数: 9638
26
TIA even stroke in the left carotid artery territory does not cause loss of
consicousness.
In Banzhu you can trust. :)

-

【在 L****n 的大作中提到】
: 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

L****n
发帖数: 12932
27
? 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, including touch, pain, temperature, pressure,
hearing, and taste
Confusion or loss of memory
Difficulty swallowing
Difficulty writing or reading
Inability to recognize objects or people
Lack of control over the bladder or bowels
Lack of coordination and balance, clumsiness, or trouble walking
Muscle weakness of the face, arm, or leg (usually only on one side of
the body)
Numbness or tingling on one side of the body
Personality, mood, or emotional changes
Problems with eyesight (double vision, loss of all or part of vision)
Trouble speaking or understanding others who are speaking

of

【在 A*******s 的大作中提到】
: TIA even stroke in the left carotid artery territory does not cause loss of
: consicousness.
: In Banzhu you can trust. :)
:
: -

A*******s
发帖数: 9638
28
That is why web MD can not replace physicians. :)

2
unconscious*

【在 L****n 的大作中提到】
: ? 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, including touch, pain, temperature, pressure,

L****n
发帖数: 12932
29
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 could be having some trouble.

【在 A*******s 的大作中提到】
: That is why web MD can not replace physicians. :)
:
: 2
: unconscious*

A*******s
发帖数: 9638
30
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 have said above, and if she choose to have surgery, I do not oppose.
Tell you a story about this CEA. Our group used to be liberal to have
surgeons to do CEA for asymptomatic stenosis since the surgeon was very
skillful with a great reputation and he was aggressive on CEA. Since I
arrived, I kinda opposed his approach and had some deep discussion. He had
two bad cases since then. All of them are my patients. Everything has
changed. Now not only him , all other PCPs stop referring asymptomatic
patients to him. In my opinions, Getting a 2nd opinion is one thing, going
for surgery is another thing.
How justified if a patient was totolly asymptomatic, found a carotid
stenosis at a healthfare(free screen), went for CEA and had a big stroke?

directly
symptomatic
carotid
stroke

【在 L****n 的大作中提到】
: 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 could be having some trouble.

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肾脏不好的患者用那种降压药比较好?【医读-2】subclavian steal syndrome(SSS)
求助:动脉硬化闭塞症,装支架是否有效?放了支架还可以再做血管内膜剥离吗?
进入Medicalpractice版参与讨论
L****n
发帖数: 12932
31
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 also published by study i mentioned
earlier. severe stenosis (>70%) has a better long term outcome with CEA,
even including the risk of perioperative event. If you only consider the
successful surgeries, the difference is even wider.

without

【在 A*******s 的大作中提到】
: 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 have said above, and if she choose to have surgery, I do not oppose.

A*******s
发帖数: 9638
32
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

【在 L****n 的大作中提到】
: 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 also published by study i mentioned
: earlier. severe stenosis (>70%) has a better long term outcome with CEA,
: even including the risk of perioperative event. If you only consider the

m********4
发帖数: 607
33
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。

【在 y**q 的大作中提到】
: 请教各位医学专家,看看此病人--我姨妈的病情及超声诊断结果,推荐下一步治疗方案
: ,保守还是手术。如果手术,在国内哪家医院比较好。多谢了!
: 病人:女,66岁,20年高血压,15年心脏病史。两年前行心脏搭桥手术。一月前,晨起
: 锻炼时,突然晕倒在地,昏迷,经医院超声检查:脑动脉硬化;动脉硬化,多发附壁斑
: 块,右椎动脉血管闭塞 (详见附件超声报告),经保守治疗,目前暂时清醒。
: 身体一般情况差,严重颈椎病,腰椎间盘突出,行走不稳。

L****n
发帖数: 12932
34
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.

【在 A*******s 的大作中提到】
: 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

s********p
发帖数: 1319
35
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?
L****n
发帖数: 12932
36
你吃药的目的是什么?

【在 s********p 的大作中提到】
: 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?

s********p
发帖数: 1319
37
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?!

【在 L****n 的大作中提到】
: 你吃药的目的是什么?
L****n
发帖数: 12932
38
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。

【在 s********p 的大作中提到】
: 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?!

L****n
发帖数: 12932
39
if you were my doctor, i'm pretty sure i would get a stroke on the spot.

厥。

【在 m********4 的大作中提到】
: 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。

A*******s
发帖数: 9638
40
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
消除远端血管的thrombosis, 毕竟血供可以依靠colateral circulation。 什么可以
降低thrombosis, springstep的铁血降脂加上抗血小板可以有效。
实际上手术的benefit相对于药物只有1%/year, 实在是微不足道, 如果遇上一个一般
的surgeon, 或者这个surgeon has a bad day, then what?

is

【在 L****n 的大作中提到】
: 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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【参加活动】难忘的一个病例。【征文活动】 有趣的临床综合症。
进入Medicalpractice版参与讨论
L****n
发帖数: 12932
41
什么样的症状?wait till patient actually had a stroke? and survive the
stroke?

【在 A*******s 的大作中提到】
: 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

r********n
发帖数: 48
42
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

【在 L****n 的大作中提到】
: 什么样的症状?wait till patient actually had a stroke? and survive the
: stroke?

L****n
发帖数: 12932
43
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.

【在 r********n 的大作中提到】
: 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

A*******s
发帖数: 9638
44
Yes. You are absolutely right on that. TIA is another indication.

【在 L****n 的大作中提到】
: 什么样的症状?wait till patient actually had a stroke? and survive the
: stroke?

L****n
发帖数: 12932
45
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?

【在 A*******s 的大作中提到】
: Yes. You are absolutely right on that. TIA is another indication.
A*******s
发帖数: 9638
46
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。

【在 L****n 的大作中提到】
: 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?

s********p
发帖数: 1319
47
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!!

【在 L****n 的大作中提到】
: 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。

A*******s
发帖数: 9638
48
Stop it, please

【在 s********p 的大作中提到】
: 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!!

s********p
发帖数: 1319
49
我要吃大龙虾!

【在 A*******s 的大作中提到】
: Stop it, please
c**********m
发帖数: 2088
50
我吃大龙虾吃腻过,一次吃了5只,一年之内不想吃它。

【在 s********p 的大作中提到】
: 我要吃大龙虾!
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s********p
发帖数: 1319
51
小弟,被鞋子挂啦?!
为什么?!
我帮你修理他!!

【在 c**********m 的大作中提到】
: 我吃大龙虾吃腻过,一次吃了5只,一年之内不想吃它。
L****n
发帖数: 12932
52
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。

【在 s********p 的大作中提到】
: 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!!

A*******s
发帖数: 9638
53
没问题, 你请还是我请?

【在 s********p 的大作中提到】
: 我要吃大龙虾!
s********p
发帖数: 1319
54
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!!!

【在 L****n 的大作中提到】
: 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。

c**********m
发帖数: 2088
55
你是心内科的?

啦。

【在 s********p 的大作中提到】
: 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!!!

L****n
发帖数: 12932
56
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 actually has both side disease, just one side more
severe than the other, read the report.
2) conservative treatment is superior to surgery in severe stenosis?
no more judgement from personal experience, favorites, provide objective
data please.
L****n
发帖数: 12932
57
easy easy, i think you need some versed to calm down first.

啦。

【在 s********p 的大作中提到】
: 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!!!

A*******s
发帖数: 9638
58
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 consideration of life
expectancy, age, sex, and comorbidities. The benefit of surgery may now be
less than anticipated on
the basis of earlier randomized trials, and the cited 3% complication rate
should be interpreted in the context of interim advances in medical therapy.
Even when the data from ACAS and ACST are combined to increase the
statistical power of the estimate of benefit, it remains unclear whether
women benefit as much as men from CEA.
The reference you had is for symptomatic patients, which has no
controversial.

the
that

【在 L****n 的大作中提到】
: 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 actually has both side disease, just one side more
: severe than the other, read the report.
: 2) conservative treatment is superior to surgery in severe stenosis?

L****n
发帖数: 12932
59
要晕倒了。 您的这个study和我们讨论的这个病人无关啊。
She did have a NEUROLOGY symptom one month ago, and you want to call her
ASYMPTOMATIC, I want to know your reason. Why? and any reference to your
point?
A*******s
发帖数: 9638
60
给你做个carotid u/s吧, 不过不管address你的stenosis。 lol
得撤了, 晚安

【在 L****n 的大作中提到】
: 要晕倒了。 您的这个study和我们讨论的这个病人无关啊。
: She did have a NEUROLOGY symptom one month ago, and you want to call her
: ASYMPTOMATIC, I want to know your reason. Why? and any reference to your
: point?

相关主题
Summary: 医学文献阅读-Jan, 2012肾脏不好的患者用那种降压药比较好?
求老师们评点以下这一治疗方案求助:动脉硬化闭塞症,装支架是否有效?
【attending 日记】有没有开车年龄的限制(Too old to drive)【case discussion】 Syncope
进入Medicalpractice版参与讨论
y**q
发帖数: 570
61
谢谢各位!有国内手术的专家推荐吗?可站内发短信。
稍作放松,看看youtube,回来在讨论。
A*******s
发帖数: 9638
62
Stand by me, stand by Banzhu. lol

【在 y**q 的大作中提到】
: 谢谢各位!有国内手术的专家推荐吗?可站内发短信。
: 稍作放松,看看youtube,回来在讨论。

s********p
发帖数: 1319
63
如果患者的主管医生认为一定需要血管外科的手术、瑞金这样的医院都没有把握的话,
可以找汪忠镐院士的Group。
汪忠镐院士——国际血管外科学会副主席。
我出国的时候,他在首都医科大学血管外科研究所和北京邮电医院供职。
首都医科大学血管外科研究所是从宣武医院分出来的,而且神经外科特别强的天坛医院
,也是宣武医院的一班人分出去的,宣武医院本身的神经内科也很强——这些,都适合
这患者。
个人的一点建议而已。
患者下一步究竟怎么办,听患者主管医生的。因为他最清楚患者的情况。
谢谢你提供了一个很好的病例——在仁者见仁、智者见智的探讨、争论过程中,对我
大家都是一个复习和进步的过程。

【在 y**q 的大作中提到】
: 谢谢各位!有国内手术的专家推荐吗?可站内发短信。
: 稍作放松,看看youtube,回来在讨论。

s********p
发帖数: 1319
64
版大,豪饮李太白的时候,没你的事;雅酌陶渊明的些候,我难得摸钱包。
还有,我坦白从宽:有女童鞋在场的细候,不管细小奥黑、克林顿还是胡靠、金三大将
军,谁和我争着买单,我当场揍谁——很强烈的堂•吉诃德的绅细风度、情节……
哎,来生再做女人——出门不用带钱包!

【在 A*******s 的大作中提到】
: 没问题, 你请还是我请?
L****n
发帖数: 12932
65
let me kindly remind you: regarding patient communication, don't speak on
other's behalf without prior consent. I don't care how good you think you
are, you really shouldn't post as a physician here unless you are dully
trained and licensed. Even after that, speak ONLY on your own behalf unless
you are explicitly consented to present others, ie, use "I" not "we".
I don't post on each and every case, but if i do, i do it seriously, as if
this is a patient in front of me. I feel comfortable to direct this patient
to a neurosurgeon's office base on the avaialbe history, test result.

里探讨、争论,是我们的错误,我向你致歉。

【在 s********p 的大作中提到】
: 版大,豪饮李太白的时候,没你的事;雅酌陶渊明的些候,我难得摸钱包。
: 还有,我坦白从宽:有女童鞋在场的细候,不管细小奥黑、克林顿还是胡靠、金三大将
: 军,谁和我争着买单,我当场揍谁——很强烈的堂•吉诃德的绅细风度、情节……
: 哎,来生再做女人——出门不用带钱包!

s********p
发帖数: 1319
66
You are right, changed.
As for you concerned about my qulification, frankly tell you, I have been accepted well trained and licensed, but not from UAS for the time being. I am talking to Banzhu about this and I'd like to obey the bylaw of Mediparctice.

unless
patient

【在 L****n 的大作中提到】
: let me kindly remind you: regarding patient communication, don't speak on
: other's behalf without prior consent. I don't care how good you think you
: are, you really shouldn't post as a physician here unless you are dully
: trained and licensed. Even after that, speak ONLY on your own behalf unless
: you are explicitly consented to present others, ie, use "I" not "we".
: I don't post on each and every case, but if i do, i do it seriously, as if
: this is a patient in front of me. I feel comfortable to direct this patient
: to a neurosurgeon's office base on the avaialbe history, test result.
:
: 里探讨、争论,是我们的错误,我向你致歉。

r********n
发帖数: 48
67
" TIA can NEVER present as loss of consciousness/coma?" -- I never said
this, please read my post carefully.
Well, you just have too much book smart.

NEVER

【在 L****n 的大作中提到】
: 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.

L****n
发帖数: 12932
68
hmm, i thought i was ok before you show up. Now i realize i'm plain dumb - i
didn't understand at all what you were trying to say? yes i have read your
post carefully - i can recite it - dear dr. lexian ...., but i don't
understand it. would you mind just lay out what you want to say in plain
English? or Chinese if you prefer?
i do sense this is getting to be a little personal, however, and i'd
appreciate it if you can handle a professional discussion between, errh,
professionals, like a professional?

【在 r********n 的大作中提到】
: " TIA can NEVER present as loss of consciousness/coma?" -- I never said
: this, please read my post carefully.
: Well, you just have too much book smart.
:
: NEVER

r********n
发帖数: 48
69
我觉得我就是写一篇长篇大论大概也没有办法说服你改变想法。就好比我喜欢的电影偏
偏是你觉得很烂的,我没有办法说服你。还是算了,我这人又懒又不喜欢和人争论。
Just ignore me, nothing is serious online.

i
your

【在 L****n 的大作中提到】
: hmm, i thought i was ok before you show up. Now i realize i'm plain dumb - i
: didn't understand at all what you were trying to say? yes i have read your
: post carefully - i can recite it - dear dr. lexian ...., but i don't
: understand it. would you mind just lay out what you want to say in plain
: English? or Chinese if you prefer?
: i do sense this is getting to be a little personal, however, and i'd
: appreciate it if you can handle a professional discussion between, errh,
: professionals, like a professional?

L****n
发帖数: 12932
70
its unfortunately that you have to resort to personal issue again. trying to
paint your opponent as stubborn or augmentative don't speak very highly of
you...i have ask for simple objective reference such as published paper or
even textbook, for numerous times, and this is what you can come up with?
hehe, nothing i can do but ignore you for sure.

【在 r********n 的大作中提到】
: 我觉得我就是写一篇长篇大论大概也没有办法说服你改变想法。就好比我喜欢的电影偏
: 偏是你觉得很烂的,我没有办法说服你。还是算了,我这人又懒又不喜欢和人争论。
: Just ignore me, nothing is serious online.
:
: i
: your

相关主题
【case discussion】 Syncope【征文活动】2013的最后一天
【医读-2】subclavian steal syndrome(SSS)【参加活动】难忘的一个病例。
放了支架还可以再做血管内膜剥离吗?一个失败的CASE(Not a presenation)
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h**s
发帖数: 1757
71
好久没看到外科内科"打架"撩。
小萝莉们看得很兴奋!口水,鼻涕一块流, 好看,欧耶!学习鸟。zzz
A*******s
发帖数: 9638
72
嗨嗨, 大过年的, 打什么架啊? 这叫学术探讨, 一句骂人的话都没有, hoho

【在 h**s 的大作中提到】
: 好久没看到外科内科"打架"撩。
: 小萝莉们看得很兴奋!口水,鼻涕一块流, 好看,欧耶!学习鸟。zzz

h*******l
发帖数: 1542
73
老刀要是加入混战,就好看了。呵呵

【在 h**s 的大作中提到】
: 好久没看到外科内科"打架"撩。
: 小萝莉们看得很兴奋!口水,鼻涕一块流, 好看,欧耶!学习鸟。zzz

h**s
发帖数: 1757
74
欧,对!学术讨论,俗称" "...哈哈哈哈,介是我最喜欢的拉
上学的时候,作journal club, 最喜欢的就是看老头们学术讨论,说的可激烈呢。。。
还有原来在医院,请外科会诊,也这样,好玩极了。好久没看到了,激动ING。。。

【在 A*******s 的大作中提到】
: 嗨嗨, 大过年的, 打什么架啊? 这叫学术探讨, 一句骂人的话都没有, hoho
1 (共1页)
进入Medicalpractice版参与讨论
相关主题
Summary: 医学文献阅读-Jan, 2012【征文活动】2013的最后一天
求老师们评点以下这一治疗方案【参加活动】难忘的一个病例。
【attending 日记】有没有开车年龄的限制(Too old to drive)一个失败的CASE(Not a presenation)
肾脏不好的患者用那种降压药比较好?谁来给科普一下这个RVU
求助:动脉硬化闭塞症,装支架是否有效?【征文活动】 有趣的临床综合症。
【case discussion】 SyncopeLLE weakness, numbness and tightness
【医读-2】subclavian steal syndrome(SSS)【参加活动】Paget-Schroetter disease
放了支架还可以再做血管内膜剥离吗?请问车祸后颈椎骨质增生的手术治疗和热凝靶点术
相关话题的讨论汇总
话题: carotid话题: stenosis话题: cea话题: syncope