心血管系统疾病动 脉 粥 样 硬 化 （Atherosclerosis, AS）病理学系 周洁P120P120Case Report朱某，男，57岁。半年前，提水时突感胸 骨后疼痛，同时伴左肩、左上臂疼痛，并有气 急、肢体冷、面色苍白，出冷汗，经休息后缓 解。以后，每当劳累后，上述症状时有发生并 有加重。在医院检查时发现，血总胆固醇、脂 蛋白。数周前上楼后，胸骨后剧痛，出现呼吸困 难、咳粉红泡沫痰，今晨解大便时，突然昏倒 ，经抢救无效死亡。n尸检(autopsy)n左冠状A前降支动脉粥 样硬化,血栓形成，管 腔闭塞。前壁心肌梗 死nCoronary atherosclerosis with thrombosis and infarctionCoronary atherosclerosis with thrombosis and infarctionn血脂过多沉积于动 脉内膜并形成坏死 粥糜样物质的动脉 硬化性疾病n血脂异常及血管壁 成分改变有关的动 脉性疾病Whats atherosclerosis?How to understand atherosclerosis?nCause: lipid deposition脂质代谢障碍/内皮损伤 nFeature: gruel plaques坏死粥糜样物nSite: large & middle vessels大中A, 弹力肌型AnOutcomes: ischemia管壁增厚变硬,管腔阻塞, 器官缺血(心、脑)Definition: 动脉硬化 ( (Arteriosclerosis)Arteriosclerosis) (Hardening of Arteries)(Hardening of Arteries)动脉粥样硬化(AtherosclerosisAtherosclerosis ) )大、中 A, 粥样硬化斑块 动脉中膜钙化(Medial Calcification Sclerosis)Medial Calcification Sclerosis)颞A、四肢A,临床意义不大 细动脉硬化(Arteriolosclerosis)Arteriolosclerosis)Hyaline degenerationHyaline degeneration 高血压病(1)脂斑脂纹（fatty spot & streak)n黄色斑点或条纹1.基本病变(basic pathology)fatty patchfatty spot & plaqueBasic pathology: atherosclerosis(2)纤维斑块（ fibrous plaque）n纤维增生,内膜表面突出 灰白色斑块n纤维帽(玻璃样变纤维 ,SMC) FC,SMC,基质,脂 质,炎Cfibrous plaque(3)粥样斑块 (atheromatous plaque) “粥瘤”（atheroma）斑块内坏死黄色粥糜 样物质Basic pathology: atherosclerosisBasic pathology: atherosclerosisBasic pathology: atherosclerosisBasic pathology: atherosclerosisBasic pathology: atherosclerosis表层 纤维帽,大量胶原玻变,基质,SMC深部 大量无定形坏死物,胆固醇结晶,钙化底周 肉芽组织，少许FC、淋巴C中膜 SMC萎缩变薄,弹力纤维破坏Summary: morphology of AS复合病变(Complicated lesion) 斑块内出血斑块破溃 血栓形成；钙化；动脉瘤形成动脉粥样硬化出血(Hemorrhage)Hemorrhage)动脉粥样硬化溃疡(Ulceration)Ulceration)动脉粥样硬化血栓形成(Thrombosis)Thrombosis)动脉粥样硬化钙盐沉积(Calcification)Calcification)动脉粥样硬化 动脉瘤 (aneurysm)aneurysm夹层动脉瘤形成(Aorta Dissecting Aneurisms)Summary: 复合病变(complicated lesion)斑块内出血(Hemorrhage): Hemorrhage): 斑块突大,阻塞 斑块破裂(Rupture):Rupture): 溃疡形成( (Ulceration)Ulceration) 血栓形成( (Thrombosis):Thrombosis): 附壁血栓,栓塞,梗死 钙化( (Calcification): Calcification): A壁硬脆 A瘤形成( (Aneurysm):Aneurysm): 局限性扩张或壁内大血腔 2.主要动脉病变(1)主动脉粥样硬化 (Aorta ASAorta AS )n部位 腹主A, 后壁,分支开口，n病变 主动脉瘤形成Rupture Rupture 大出血致命(2)冠状动脉粥样硬化(Coronary AS) )n左冠状A前降支右冠状A干左冠状A旋支nOutcomes 心肌急剧暂时缺血心绞痛（Angina pectoris)严重持久缺血心肌梗死(Myocardial infarction)慢性供血不足心肌硬化(Myocardial fibrosis )突然停搏,心室颤动心源性猝死 (140, Diastolic 90 mmHgCauses of hypertension(HT)n原发性(primary HT) 95% 特发性(Idiopathic HTIdiopathic HT) 高血压病n继发性(secondary HT) 5% 症状性(symptomatic HT)Types of primary hypertension(分型) 良性(benign) 缓进型(Chronic)95-98%恶性(malignant)急进型(Accelerated) 2-5%，进展迅速, 病变严重,1-2y死亡1. 良性高血压benign (Chronic) hypertension(1)机能紊乱期(functional phase) 细小A痉挛(spasm)血压波动n无器质性变化(without organ damage)ndizziness, headache, and visual difficultiesStages of Chronic hypertension(2)动脉系统病变期(arteries change phase)n细A(1mm)玻璃变细A硬化 (Arteriolosclerosis)n肌型A内膜胶原弹力纤维增生,内弹力膜分裂 中膜增厚,管腔狭窄nBP持续增高, 舒张压100mmHgn左心室轻度肥大ArteriolosclerosisStages of Chronic hypertension(3)内脏病变期 （visceral change phase）a. 心(heart)n外周阻力左室代偿肥大(厚1.5-2.0cm)n向心性肥大(concentric):心腔不扩张n离心性肥大(eccentric): 肌原性扩张n高血压性心脏病(hypertensive heart disease)正常心脏与高血压心脏(Hypertensive heart disease)Left Ventricular HypertrophyLeft Ventricular HypertrophyLeft Ventricular Hypertrophyb.肾(kidney)n原发性颗粒性固缩 肾(essential granular atrophic kidney)nGross morphology弥漫性对称性缩小 ，变硬,表面细颗粒 状,皮质变薄2mm （3-5mm)Leathery Granularity Leathery Granularity due to minute scarringdue to minute scarring颗粒性固缩肾和正常肾比较Essential granular atrophic kidneyn入球小A玻璃样变n肌型小A纤维化n肾小球纤维化玻璃样变n肾小管萎缩n肾小球代偿性增生 、肥大Microscopic:essential granular atrophic kidneyHyaline Arteriolosclerosis（3）脑(brain)高血压脑病（hypertensive encephalopathy）n中枢N功能障碍征候群: 颅内高压,头痛,呕 吐,视力障碍及意识模糊n病变 脑水肿，点状出血脑软化(Cerebral Infarction)（softening of the brain） n微梗死灶( microinfarct）/梗死灶n液化性坏死: 淡染、疏松网状n周围胶质细胞胶质疤痕Cerebral Infarction脑出血(cerebral hemorrhage)n部位 基底节,内囊,大脑白质，脑干n原因细小A痉挛,脑组织缺血性坏死形成微A瘤破裂出血豆纹A大脑中A直角分出,高压冲击脑出血(Cerebral hemorrhage)n破入脑室突然昏迷，肢体驰缓，反射 消失，二便失禁, 死亡n内囊偏瘫 n左脑出血失语n桥脑出血面瘫,对侧上下肢瘫n血肿占位颅内高压,脑疝Subarachnoid Haemorrhage: Cerebral Blood vessels Special features: Thin walled* End arteries* Micro- aneurisms高血压危象（hypertensive crisis）n短期内血压急剧升高，舒张压超过120 或130mmHg并伴一系列严重症状， 危及生命的临床现象高血压脑病 颅内出血蛛网膜下腔出血 急性脑梗死急性左心衰竭 不稳定型心绞痛急性心肌梗死 急性肾衰竭级 视网膜动脉变 细级 视网膜动脉狭窄，动脉交叉压迫；级 眼底出血或棉絮状渗出；级 出血或渗出物伴有视神经乳头水肿(4)眼(eyes)Normal Retina Hypertensive RetinopathyFundoscopy2.恶性高血压Malignant(Accelerated) hypertensionn中青年(Middle & young ages)nBP,舒张压130 mmHgn快速进展(Rapidly progressive)n较早出现肾衰(Early renal failure)n高血压脑病(Hypertensive encephalopathy) n死于尿毒症(Uraemia)、脑出血、心 衰Pathology: Accelerated hypertensionn增生性小动脉硬化 hyperplastic arteriolosclerosis同心性排列,葱皮样n坏死性细动脉炎 necrotizing arteriolitis纤维素样坏死,小出血n微血栓,微梗死 Intravascular thrombosis& infarctionHyperplastic ArteriolosclerosisOnion Skin ThickeningOnion Skin Thickening Of arterioles.Of arterioles.Narrow LumenNarrow LumenNecrotizing arteriolitisFibrinoidFibrinoid NecrosisNecrosisThrombosisThromb