计算机辅助三维CT重建椎动脉横突段的走行及解剖变异

背景：目前不同影像学方法对椎动脉的检查仍然存在差异和争论,计算机断层扫描血管造影技术的发展,为血管及骨关节结构的解剖观察及疾病诊断提供了新的手段。 目的：评价三维CT血管造影显示椎动脉横突段的效果,明确其走行及变异。 方法：从2009-12-01/2010-05-31头颈部联合CT血管造影检查的三维影像资料中,去除椎动脉不显影或显影不清楚的资料,选出无明显异常病变者250例,在三维图像上观察椎动脉在横突段的走行及血管管径的变异。获得原始断层图像后,通过容积重建、多层面重建、表面遮盖成像来显示椎动脉。 结果与结论：椎动脉经C6横突孔进入占所有样本的92.6%,经异常横突孔进入占所有样本的7.4%(37条),经C4,C5,C7横突孔进入的发生率分别为2.2%(n=11,占不正常的29.7%),4.6%(n=23,占不正常的62.2%),0.6%(n=3,占不正常的8.1%)。20例为右侧异常(54.1%),17例为左侧异常(45.9%)。所有患者中27例为单侧异常(10.8%),5例为双侧异常(2%)。比较椎动脉管腔直径,左侧直径明显大于右侧53例,右侧直径明显大于左侧30例,左右侧差异具有显著性意义(P < 0.01)。提示椎动脉在横突段的解剖变异发生率较高,三维CT血管造影能客观地反映椎动脉的病理改变,并清晰显示椎动脉与骨性结构的关系。     

以头晕起病的迷走锁骨下动脉大动脉炎1例

大动脉炎是中国及其他亚洲国家青年女性好发于大中血管的慢性肉芽肿性炎症性疾病，病变多见于主动脉弓及其分
支，临床超声检查中见到受累动脉内中膜广泛均匀增厚的“通心粉”征等特征性图像时不难诊断，病变常呈节段性。本例
独特之处在于所累及的是单支迷走锁骨下动脉，且近段管腔闭塞，给探查和诊断带来难度，单从超声图像很难诊断大
动脉炎，需通过结合其他实验室指标最终确诊。对于锁骨下动脉迷走，扫查过程中要重点关注椎动脉的起源和走行，本
例中右侧椎动脉即起源于同侧颈总动脉，因起源的变异，不出现锁骨下动脉盗血，也在一定程度上掩盖了右侧锁骨下动
脉起始段病变。此外，锁骨下动脉迷走时还需关注颈总动脉的走行和位置、血管与气管的相对位置。该病例还提示，对
于不典型超声表现的患者，要结合性别、年龄、病史、实验室检查等多方面因素综合考虑，避免漏诊、误诊。     

永存颈内-基底动脉吻合的血管病变特点

目的探讨CTA诊断永存颈内-基底动脉吻合的血管病变特点。方法回顾性分析6例永存颈内-基底动脉吻合患者的CTA检查及MRI检查资料。结果 6例患者中,4例为永存三叉动脉(PTA),1例为永存舌下动脉(PHA),1例为永存寰前节间动脉(PIA)。4例PTA中2例位于右侧,2例位于左侧,其中2例伴有近心端基底动脉和两侧椎动脉发育不良,1例伴有胚胎型左侧大脑后动脉。1例PHA起始于右侧颈内动脉颈段,合并右侧大脑中动脉动脉瘤,双侧椎动脉缺如。1例PIA起始于右侧颈外动脉,合并右位主动脉弓、双侧颈内动脉闭塞、右侧后交通动脉多发动脉瘤。结论永存颈内-基底动脉吻合属于罕见的先天性头颈部血管变异。PTA起源于颈内动脉海绵窦段,穿过鞍背中线或绕过鞍背连于基底动脉。PHA起源于颈内动脉C1段,经扩大的舌下神经管入颅后与基底动脉吻合。PIA起源于颈内动脉C1段或颈外动脉,向上与椎动脉汇合后,经枕骨大孔入颅。     

右椎动脉起源于右颈总动脉二例报道及文献复习

椎动脉通常起源于锁骨下动脉,少数人可出现各种解剖变异.常见的变异起源部位包括主动脉弓、颈总动脉、颈内动脉等.本文报道2例少见的右椎动脉起源于右颈总动脉的变异,现就其影像学特点、发育机制及临床意义进行讨论.病例1:女,78岁,突发意识不清伴呕吐1.5 h入院.入院时处昏迷状态,头颅CT示蛛网膜下腔出血.行DSA示双侧颈内动脉起始部狭窄,左侧大脑中动脉水平段狭窄,右椎动脉起自右侧颈总动脉.患者行保守治疗,意识一度好转,后因哮喘反复发作,出现呼吸功能衰竭,家人放弃治疗.     

椎动脉横突孔段受压的手术治疗二例

例1 女,45岁。4年前感肩背部酸沉麻木,2年来常感头痛,头晕、转颈过度时头晕加重伴恶心呕吐、视物旋转,偶然出现猝倒。1986年3月入院检查,颈椎正及双斜位X线平片示颈4、5、6双侧钩椎关节骨质增生,左侧为著.椎动脉造影示:左椎动脉于颈4、5、6横突孔之间有受压现象。手术于全麻插管下颈前入路,以颈5为中点沿胸锁乳突肌前缘皮肤切口,将胸锁乳突肌、颈动、静脉牵向外侧,气管、食道牵向对侧,将颈长肌切断分离横突。发现上下横突孔之间椎动脉周围纤维组织增生变硬无弹性,椎动脉内侧壁受钩突关节外侧增生骨质压     

颈动脉和推动脉自发性夹层动脉瘤二例报告

一侧颈内动脉或椎动脉自发性夹层动脉瘤,几年前是较少见的,而双侧颈内动脉或椎动脉夹层动脉瘤尤为罕见。本文报告至少三条大的动脉自发性急性夹层动脉瘤二例。例一:女40岁,服避孕丸6年,两周来出现急性头痛、颈痛与呕吐,左耳可听到杂音,入院次日头痛及杂音逐渐加重。症状发生10天后有短暂的意识丧失,4天后突发视力模糊,持续15分钟,继后视力下降。血压190/120mmHg。查体:除有Horner氏征及左侧头颈部可听到粗大的杂音外,神经系无其它异常。脑CT正常,未用强化对比剂。全脑血管造影:右侧颈内动脉起始部广泛严重的狭窄,并延及虹吸部及经眼动脉逆行至颈外动脉。左侧末梢血管明显狭窄,在C_1水平示扩张的动脉瘤。左侧椎动脉从起始至末梢血管不规则狭窄扩延至C_3水平,并发现二个扩张动脉瘤。右侧椎动脉除发育不良外,在C_1段显示严重的狭窄。左侧椎动脉被双侧大脑中动脉所充盈。经用大剂量肝素治疗2周后,血管杂音和头痛消失,但左侧Horner氏征无变化,8月后造影示完全建立侧支循环,多普勒超声检查正常。例二:女,42岁,亦有服避孕丸史10     

血管内治疗双侧创伤性椎动脉夹层一例报告并文献复习

病例报告 患者男,46岁.因车祸伤及头、颈部1d入院.颅脑及颈椎CT示蛛网膜下腔出血,左侧第5颈椎椎板骨折;颅脑CTA示左侧椎动脉Cs水平局限狭窄,远端呈双腔;右侧椎动脉硬膜内段不规则囊状膨出.DSA示左侧颅外段椎动脉C5水平内膜撕脱,远端呈双腔,诊断为椎动脉夹层(图1a,b);右侧颅内段椎动脉小脑后下动脉(PICA)近端可见囊袋状膨出,诊断为夹层动脉瘤(图2a).结合临床症状及影像学检查充分评估后,决定分次行左侧椎动脉支架成型术并右侧夹层段椎动脉栓塞术.     

椎-基底动脉供血不足的全脑血管造影诊断及支架治疗

目的探讨全脑血管造影对椎-基底动脉供血不足(VBI)的诊断作用及支架治疗效果。方法对182例临床诊断为椎-基底动脉供血不足的患者行数字减影血管造影(DSA)检查,并对其中48例适合介入治疗的VBI患者实施脑血管成形及支架治疗(CAS)。结果131例VBI患者存在不同类型的椎-基底动脉病变,包括动脉粥样硬化斑块形成所致狭窄76例、椎动脉起始部扭曲34例、颈椎横突孔骨性狭窄所致椎动脉狭窄2例、先天性椎动脉发育不良18例。动脉粥样硬化斑块所致病变中,包括锁骨下动脉狭窄9例、基底动脉狭窄8例、椎动脉起始部狭窄59例、锁骨下动脉完全闭塞4例。在DSA诊断基础上对适合血管内治疗的48例患者实施了CAS治疗,手术成功率为100%,术后6～12个月随访,48例患者均未见椎-基底动脉系统短暂性脑缺血发作(TIA)及新发后循环供血系统脑梗死。结论DSA对VBI患者的病因诊断有重要的临床指导意义,因为椎-基底动脉狭窄所致的VBI行血管成形及支架治疗可能是今后治疗本病的方法之一。     

多层螺旋CT血管造影术在迷走右锁骨下动脉诊断中的应用价值

目的探讨多层螺旋CT血管造影术(CTA)诊断迷走右锁骨下动脉的临床应用价值。方法对5800例接受头颈部联合CTA检查患者的临床资料进行回顾分析,结合原始数据、最大密度投影、曲面重组及容积再现三维技术,观察迷走右锁骨下动脉及其伴发的其他主动脉弓分支变异。结果共检出迷走右锁骨下动脉伴左位主动脉弓患者52例,其中单纯性21例(40.38%),合并双侧颈总动脉共干19例(36.54%),合并一侧椎动脉起源异常9例(17.31%),迷走右锁骨下动脉、颈总动脉共干合并左侧椎动脉起自主动脉弓3例(5.77%);Kommerell憩室10例(19.23%),无一例Kommerell憩室发生动脉瘤样改变。结论多层螺旋CTA能够很好地评价迷走右锁骨下动脉及其伴发的其他主动脉弓分支变异,对临床有重要意义。     

枕下远外侧经髁手术入路的显微解剖研究

目的为远外侧经髁手术入路提供基本的解剖标志和重要的解剖参数,以利于术中保护重要结构。方法选用颅骨干性标本15例及福尔马林固定的成人头颅湿标本20例(40侧)进行显微解剖测量。结果枕骨髁为术中重要的解剖标志,枕骨髁长径,左侧24.47±3.32(18.19~30.30)mm,右侧25.16±2.39(20.66~29.02)mm。枕骨大孔后缘中点至枕骨髁后缘距离,左侧27.66±2.45(23.00~31.48)mm,右侧26.27±1.83(23.68~29.64)mm。枕骨下三角为显露椎动脉的重要标志,枕骨下三角由三条肌肉形成,即头后大直肌、头上斜肌和头下斜肌。枕骨下三角内有椎动脉及肌支、椎静脉丛和第一颈神经。测量寰椎横突孔外缘至椎动脉入颅处距离,左侧16.87±2.08(12.64~20.1)mm,右侧16.79±1.90(12.44~20.22)mm。结论以上测量指标为远外侧经髁手术入路的顺利进行提供了重要的解剖学参考。     

Anomalous Variations of the Origin and Course of Vertebral Arteries in Patients with Retroesophageal Right Subclavian Artery

We present two rare cases of anomalous vertebral artery (VA) with retroesophageal right subclavian artery. One patient had a right VA arising from the right common carotid artery (CCA), and a left VA originating from the third branch off the aorta. Both VAs ascended anteriorly to the transverse foramen of C5 to C6 vertebra and entered the transverse foramen of C4. The other patient had a right VA arising from the right CCA and entering the transverse foramen of C5. The presence of anomalous variations of the origin and course of vertebral artery might have serious implications in angiographic and surgical procedures, and it is of great importance to be aware of such a possibility.     

单肢肌萎缩/平山病:41例患者临床、电生理和颈椎MRI特征分析

目的 探讨单肢肌萎缩(MMA)/平山病患者的临床、肌电图及颈椎MRI特征。方法 2009年5月至2014年5月就诊本科,符合诊断标准的患者,连续登记并详细记录及分析人口学资料、临床、电生理和颈椎自然位和屈曲位MRI资料。结果(1)共41例,男39例、女2例,发病年龄14～24岁、平均年龄(16.87±2.62)岁。病程1～121月、平均病程(22.13±26.25)月。双上肢均有临床症状者6例(14.6%),症状局限单侧者35例(85.4%); 单侧者左12例(29.3%)、右23例(56.1%)。冷麻痹22例,指震颤9例,手麻木4例; 41例均有手固有肌萎缩,均无感觉障碍;(2)症状侧尺和正中神经运动潜伏期延长,小指展肌、拇短展肌运动波幅减低,小指展肌/拇短展肌波幅比值减小;(3)症状侧针肌电图显示异常自发活动者的出现率,在第一骨间肌和小指展肌为100%、拇短伸肌90.1%、拇短展肌86.3%、肱桡肌16.8%、肱二头肌13.8%; 在仅限于单侧症状的35例患者中,无症状侧手固有肌也显示异常自发活动者占51.4%;(4)32例患者完成颈椎MRI检查。自然位时32例均显示颈2-颈7椎体后方下缘连线与椎体相交; 均显示下段颈髓萎缩变扁平,其中位于C5-C7节段14例,C5-C6节段6例,C6-C7节段7例,C5-T1节段5例; 屈颈位时15例显示硬膜腔后壁前移,移位的硬膜后方可见硬膜外占位,内有流空信号,恢复自然位后占位消失。9例显示髓内可疑T₂异常高信号。结论 MMA/平山病主要见于青少年男性; 电生理表现为低位颈髓前角细胞病变,且无症状侧可显示临床下神经源性损害; 小指展肌/拇短展肌波幅比值减小,是有鉴别意义的电生理指标; 屈颈位颈椎MRI对于诊断很重要。结合临床、神经电生理及影像表现,有助于更全面认识本病。     

The V2 segment of the vertebral artery in anterior and anterolateral cervical spinal surgery: a cadaver angiographic study

OBJECTIVE: The second segment of the vertebral artery is under the risk of injury during anterior and anterolateral cervical spine procedures. To avoid such a risk, one needs to be familiar with the regional anatomy. The aim of this study was to measure the distance between the vertebral artery and the uncinate process, midline, and the medial side of the longus colli muscle using vertebral artery angiograms at the level of C6, C5, C4, and C3 vertebrae. MATERIALS AND METHODS: In 12 human cadavers, the vertebral arteries were first irrigated with water. Then the arteries were filled with silicon and barium, and finally their angiographic images were obtained. RESULTS: The transverse diameter of the vertebral artery was measured at C6, C5, C4, C3, and C2 level. The values on the left were bigger than the values on the right (p>0.05). The distance between the vertebral artery and the midline decreased from C6 (17.2+/-5.6mm on the right, 17.2+/-2.3mm on the left) to C3 (15.8+/-5.3mm on the right, 13.8+/-2.1mm on the left) (p>0.05). The distance between the apex of the uncinate process and the medial side of the vertebral artery was found to be longer at C4 (2.7+/-1.0 mm on the right, 2.2+/-1.0mm on the left) and C5 (2.5+/-1.1mm on the right, 2.5+/-1.0mm on the left) vertebra levels on the right side (p=0.339 at C4, p=0.862 at C5). The distance between the medial side of the longus colli muscle and the medial side of the vertebral artery was measured as 9.7+/-2.7 mm (9.5+/-2.9 mm on the right, 9.8+/-2.6mm on the left) at C6 level, 9.2+/-2.6mm (8.6+/-2.4mm on the right, 9.8+/-3.1mm on the left) at C5, 9.4+/-1.9 mm (9.2+/-2.1mm on the right, 9.5+/-2.0mm on the left) at C4, and 10.4+/-2.7 mm (10.5+/-3.0mm on the right, 10.1+/-2.6mm on the left) at C3 vertebra level. No significant difference was found between the right and the left (p>0.05). The angle between the vertebral artery and the midline was measured as 4.0+/-1.9 degrees on the right and 2.2+/-1.4 degrees on the left side (p=0.030). CONCLUSION: It was considered that the values obtained could be useful in anterolateral and anterior cervical approaches in terms of evaluating the position of the vertebral artery and its relation to vertebral structures. It is also concluded that the risk of injury in upper subaxial cervical spine is higher than in the lower part of the subaxial cervical spine.     

Microsurgical anatomy of the intracranial part of the vertebral artery

Abstract

We studied the intracranial portion of the vertebral artery and its branches in 11 cadaveric specimens. We evaluated the course of vessels and their dimensions (external diameter and length), as well as relationships between each of them. The vertebral artery was larger on the ? left side in two cases, on the right in five cases, and equal on both sides in four cases. The right and left vertebral arteries joined each other forming the basilar artery at the level of the pontomedullary junction in four cases, 2 mm below it in one case, and 1 to 7 mm above it in six cases. We divided all branches of the intracranial vertebral artery into two groups: the medial branches and the lateral branches. Two major types of medial branches were observed: the anterior spinal artery and the branches of the foramen caecum. The origin of the anterior spinal artery was located 6.5 mm (5-11 mm) proximal to vertebrobasilar junction on the right and 8.5 mm (6-17 mm) on the left. The anterior spinal artery was absent on the right in two cases and on the left in one. Branches arising from the vertebral artery to the foremen caecum were found in four brains. Lateral branches originated from the posterolateral or lateral aspect of vertebral artery. The posterior inferior cerebellar artery, the largest branch of the vertebral artery, was included in this group. Other branches were mostly located between the origin of the posterior inferior cerebellar artery and the vertebrobasilar junction. Forty-six lateral branches originating from the vertebral artery were found in 11 brains (26 on the right and 20 on the left). Lateral branches widely anastomosed with perforators from the basilar arteryposterior inferior cerebral artery; and the anterior inferior cerebellar artery. [Neurol Res 1994; 16:171–180]     

Comparison of methods eliciting cerebral ischaemic pressor response in the cat

Three methods of intercepting the blood supply to the brain were tested by means of X-ray angiography and by monitoring the pressor response following cerebral ischaemia. The methods were: (1) occlusion of carotid and basilar artery; (2) occlusion of carotids and vertebral arteries in the cervical canal of the third vertebra; (3) occlusion of carotid and subclavian arteries. The X-ray angiographs showed that in most cases we could close the accessory sources of the cerebral circulation and drastically reduce the blood supply to the brain of the cat. With all three methods the cerebral ischaemia evoked strong blood pressor elevation, which was weaker however when the carotid and basilar artery were clamped, in comparison with the other two methods. This may be explained by the existence of small arteries supplying the lower brain stem and originating intracranially from the vertebral artery near to the junction of the vertebral and anterior spinal artery.     

Tethering of the vertebral artery in the congenital arcuate foramen of the atlas vertebra: a possible cause of vertebral artery dissection in children

Twelve children with vertebrobasilar artery stroke are reported (seven males, five females; aged 6 months to 15 years). Patient 1 showed an arcuate foramen in the posterior arch of the atlas, an anatomical variant occurring in 3 to 15% of the population. It was hypothesized that the presence of the arcuate foramen might cause tethering of the vertebral artery and lead to its dissection by repetitive trauma. Lateral plain films of the cervical spine in cases of posterior circulation stroke were taken. Eight of 11 patients showed aberrant arcuate foramina. Of the remaining three patients, one had normal cervical spine X-rays, one had an absent right posterior arch of the atlas following previous surgery for a cervical meningocele, and one patient had incomplete ossification of the vertebrae. Seven of the nine patients with arcuate foramina had vertebral angiograms. In all cases this showed the vertebral artery passing through the arcuate foramen before entering the brain and an appearance consistent with arterial dissection and occlusion at the same site below the foramen. Most documented cases of posterior circulation stroke in children follow trauma, which may be minimal or repetitive, with thrombotic occlusion of the artery at C1-C2 level. The association with an arcuate foramen and its possible causative role in the genesis of posterior circulation stroke in children has not been previously recognized. There may be a causal association between the presence of an arcuate foramen, tethering of the vertebral artery in the foramen, and dissection from repetitive trauma with movement of the neck.     

Duplex scanning of normal vertebral arteries

Vertebral arteries were studied by Duplex scanning in 50 normal subjects. Pretransverse and C6-C5, C5-C4 intertransverse segments were visualized in all cases on both sides; segment C4-C3 was visualized in 100% of the cases on the right side and in 90% on the left; ostium was obtained in 94% of the cases on the right and in 60% on the left. The left vertebral artery was dominant in 48% of the cases while the right vertebral artery was dominant in 14%. Three vertebral arteries were hypoplasic. Duplex scanning was thus found to be an easily performed noninvasive method to study morphological and hemodynamic characteristics of vertebral arteries from their origin to the C4-C3 level.     

支架置入治疗颈动脉、椎动脉狭窄的疗效及其安全性

目的 探讨血管内介入治疗颈、椎动脉狭窄的临床疗效.方法 回顾性分析行血管内介入治疗的34例颈动脉和椎动脉狭窄(狭窄≥70%)患者的临床表现、颈部血管超声、全脑血管造影等相关资料.结果 (1)颈部血管听诊发现血管杂音28例(82.4%).脑血管疾病危险因素排序依次为高脂血症22例(64.7%)、高血压18例(52.9%)、糖尿病15例(44.1%)、吸烟11例(32.4%)、高同型半胱氨酸血症2例(5.9%);(2)DSA检查发现符合入组条件并行支架治疗单纯颈动脉狭窄22例,单纯椎动脉起始部狭窄6例,颈动脉和椎动脉狭窄合并存在6例,共置入支架40枚;(3)血管内支架置入术成功率100%,治疗后残余狭窄率均低于30%.血管狭窄由术前的平均(80.8±8.8)%降至术后的(3.7±8.2)%(P<0.01).所有患者未发生手术期死亡及严重神经系统并发症,支架治疗1周后症状、体征消失.术后随访6～48个月未发生短暂性脑缺血发作及新发脑梗死.结论 血管内介入诊疗技术在症状性颈、椎动脉狭窄的临床诊治中具有重要价值,是一种安全有效的方法.     

A case of transient blindness due to severe stenosis of the internal carotid artery with persistent primitive hypoglossal artery (PPHA)]

We report a patient having transient blindness due to severe stenosis of the internal carotid artery (ICA) with persistent primitive hypoglossal artery (PPHA). This 73 year-old man was admitted because of the transient visual impairment. At first, he had bilateral blindness for a several minutes and after that the right amaurosis continued for an hour. MRI showed an old lacunar infarction of the right caudate nucleus. Carotid duplex ultrasonography and conventional angiography demonstrated severe stenosis of the origin of the right ICA, and PPHA was arising from the right ICA at the level of 2nd cervical spine. The left ICA was normal. Because of the aplasia of the right vertebral artery and hypoplasia of the left vertebral artery, almost all blood flow of the basilar artery was supplied from the right ICA via PPHA. We considered that transient ischemia of both the bilateral posterior cerebral arteries and the right ocular artery occurred due to stenosis of the right ICA which branching PPHA. When ischemic neurological symptoms of multiple vascular territories occurr at the same time, we often think that ischemic mechanism was cardiogenic embolism. But we should recognize that stenosis of the ICA with PPHA cause the complex neurological deficits.