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慢性ARBD概述
结合病理表现与临床表现，慢性ARBD的临床分类主要分为以下10种综合征［1‑3，18‑19］：酒精相关性认知障碍（alcohol-related cognitive impairment，ARCI）、酒精相关性痴呆（alcohol-related dementia，ARD）、韦尼克脑病（Wernicke′s encephalopathy，WE）、柯萨可夫综合征（Korsakoff syndrome，KS）、酒精性小脑变性（alcoholic cerebellar degeneration，ACD）、Marchiafava-Bignami病（MBD）、脑桥中央髓鞘溶解（central pontine myelinolysis，CPM）、酒精性癫痫、酒精性震颤-谵妄（delirium tremens，DT）和酒精性精神行为障碍等。
慢性ARBD的病理和影像学表现
推荐意见1：MRI可检测到慢性ARBD特定临床综合征的特征性影像学改变，并一定程度反映了的病理变化特征和严重程度，可辅助诊断慢性ARBD和鉴别其他脑疾病。（1B）
推荐意见 2：fMRI或 PET‑CT 检查可一定程度反映慢性ARBD的病理生理变化特征，可辅助分析慢性ARBD的功能改变和严重程度。（1C）
慢性ARBD的筛查、评估和临床诊断
推荐意见 3：AUDIT量表用于评估慢性 ARBD患者的酒精使用障碍及其严重程度具有良好的信度和效度。（1B）
推荐意见4：OCDS用于评估慢性ARBD患者酒精渴求的程度，可用于临床评估和临床研究的随访，具有良好的信度和效度。（1B）
推荐意见 5：MoCA 用于评估慢性 ARBD 患者的认知功能和不同认知域的改变，并可较好地检测视空间和执行能力水平，未矫正的MoCA<26分作为酒精使用障碍合并认知障碍的分界值，具有良好的信度和效度。（1B）
慢性ARBD的治疗
（一）戒酒
慢性ARBD的首要治疗方法就是戒酒。治疗一般分为2个阶段：一是戒酒阶段，也称作解毒阶段；另一阶段是康复治疗阶段。戒酒阶段可使用的方法包括：药物治疗和非药物治疗。
1.药物治疗：积极的药物治疗能够帮助患者戒断对酒精的依赖，防止疾病复发。
推荐意见6：可选择纳曲酮作为戒酒治疗的一线治疗药物，但纳曲酮在我国病例人群中的有效性和安全性仍需进一步明确。（2A）
推荐意见7：可选择纳美芬作为戒酒治疗的一线治疗药物，但纳美芬在我国病例人群中的有效性和安全性仍需进一步明确。（1B）
推荐意见 8：戒酒治疗药物双硫仑、阿坎酸虽然有戒酒疗效，但由于药物的可及性、安全性问题，我国病例人群临床应用少。（2A）
推荐意见9：可选择苯二氮䓬类药物作为戒酒治疗的二线治疗药物，尽可能短期使用以减少出现药物成瘾和依赖。（2A）
推荐意见10：巴氯芬、托吡酯和三环类抗抑郁药作为戒酒治疗的二线治疗药物，需充分评估患者获益‑风险比并严密随访用药安全性的情况下慎重选择使用。（2B）
推荐意见 11：对左侧 DLPFC的高频重复经颅磁刺激治疗可有效改善临床预后，减少酒精渴求和复饮，以下参数具有良好的有效性和安全性［刺激部位：左侧 DLPFC 区；刺激强度：110% 运动阈值（MT）；刺激频率10 Hz；刺激时间：5 s/次（循环）；间歇时间：间隔20 s/次（循环）；每疗程刺激次数：每天30次（循环），共10 d］。（1A）
推荐意见 12：其他脑区的重复经颅磁刺激治疗也能减少酒精渴求和复饮，但其疗效是否优于对左侧DLPFC 的高频重复经颅磁刺激治疗仍不明确。（2B）
推荐意见 13：经颅直流电刺激治疗的疗效和安全性仍需要进一步明确。（2B）
推荐意见 14：根据患者病情采取个体化的行为、心理治疗和康复治疗可提高患者临床预后，减少酒精依赖的严重程度和复饮。（2B）
（二）病因治疗
推荐意见15：纠正硫胺素（维生素B1）缺乏可改善慢性ARBD的临床预后，防止ARBD进展和加重，优先选择非肠道补充高剂量维生素B1。（1A）
推荐意见16：维生素C、维生素E对ARBD有一定的保护作用。（1C）
推荐意见 17：其他抗氧化剂的有效性和安全性仍需要进一步验证。（2D）
（三）纠正营养失调
推荐意见 18：纠正ARBD的营养失调是缓解病情、早日恢复的基础，包括给予多种维生素、必要脂肪酸、植物蛋白和植物多糖等。（1D）
（四）脑保护治疗
推荐意见 19：依达拉奉的抗氧化治疗可减少慢性 ARBD 患者的酒精渴求，并改善认知执行功能、抑郁情绪和睡眠障碍；鼠神经生长因子的神经营养治疗可减少慢性ARBD患者的酒精渴求、抑郁情绪和睡眠障碍。（1A）
推荐意见20：其他抗氧化、神经营养治疗慢性ARBD 的 有 效 性 和 安 全 性 仍 需 要 进 一 步 验证。（2D）
（五）各型综合征的治疗
推荐意见 21：积极非肠道补充高剂量维生素B1是KS、WE的关键病因治疗（1B）。注射甲钴胺治疗有助于提高临床预后（1D）。
推荐意见 22：胆碱酯酶抑制剂多奈哌齐可用于临床治疗 ARD的认知功能下降（1C）；NMDA受体非竞争性拮抗剂美金刚可用于临床治疗ARD的认知功能下降（1D）。
推荐意见 23：短期使用苯二氮䓬类药物可稳定DT的症状（2A）。
推荐意见 24：首选苯二氮䓬类药物治疗戒断期或恢复期出现的酒精性癫痫（1C）。必要时联合丙戊酸或左乙拉西坦控制酒精性癫痫发作（2C）。
推荐意见25：可使用SSRI、SNRI或米氮平等药物减少酒精性精神和行为障碍（1B）。对于轻度焦虑、抑郁障碍，也可以联合使用中成药如舒肝解郁胶囊、乌灵胶囊等（2D）。
（六）康复治疗及其他治疗
推荐意见 26：积极的康复治疗可改善小脑性共济失调的临床症状，减少继发性运动障碍的发生和进展（1C）。
推荐意见27：针灸治疗能减轻戒断症状，有助于癫痫发作和复饮的预防（2C）。
推荐意见28：高压氧治疗能增加慢性ARBD患者脑组织的有氧代谢（2D）。
引用
向上滑动阅览
参 考 文 献
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