螺旋CT三维血管成像对重型颅脑损伤术前评估的临床研究

目的探讨螺旋CT三维血管成像(CTA)对重型颅脑创伤的术前评估。方法对34例重型颅脑损伤患者术前及术后动态行螺旋CTA检查。结果重型颅脑损伤后CTA显示脑血管主要发生以下变化:血管移位、动脉痉挛或闭塞、动脉穿支减少、大脑浅静脉狭窄或闭塞及脑深静脉狭窄或闭塞。CTA显示以血管移位或狭窄为主者,手术疗效良好;大动脉痉挛或闭塞者手术疗效预后差;大脑深静脉闭塞者,手术疗效极差。大脑浅静脉的狭窄或闭塞反映了颅内压的变化。结论 CTA可用于重型颅脑损伤的术前评估,为判定手术疗效及预后提供影像学依据。     

CT血管造影对重型颅脑创伤的早期监测及预后判定

目的 探讨CT血管造影(CTA)对重型颅脑创伤早期监测及预后判定的作用.方法 对58例重型颅脑创伤患者术前及术后使用128层螺旋CT行头颅CTA动态检查.结果 重型颅脑创伤后CTA显示脑血管主要发生五种变化:血管移位、动脉痉挛或闭塞、动脉穿支减少、脑深静脉狭窄或闭塞、大脑浅静脉狭窄或闭塞.大动脉痉挛或闭塞者预后差,大脑深静脉如大脑内静脉和基底静脉同时闭塞者预后极差,大脑浅静脉的狭窄或闭塞反映了颅内压的变化.结论 CTA可用于重型颅脑创伤的早期监测及预后判定.     

重视腔隙性脑卒中的诊断

腔隙性脑卒中(lacunarstroke)系指大脑半球深部和脑干等中线部位,由血管直径100～400μm的穿支动脉梗死所引起的,梗死病灶为0.5～15.0mm3的脑梗死。大多由大脑前、大脑中、大脑后、前脉络膜动脉和基底动脉的穿支动脉梗死所引起。高血压和糖尿病是其主要原因,特别是高血压尤为重     

症状性椎-基底动脉重度狭窄或闭塞致后循环缺血性卒中的血管重建治疗

目的探讨慢性椎-基底动脉重度狭窄或闭塞致后循环缺血性卒中血管重建治疗的有效性和安全性。方法纳入2018年1月至2021年1月天津市环湖医院诊断与治疗的11例慢性椎-基底动脉重度狭窄或闭塞致后循环缺血性卒中患者,采用MRI定位梗死部位,CTA确定血管狭窄或闭塞部位以及狭窄率,DSA明确侧支代偿情况,分别行枕动脉-椎动脉(OA-VA)搭桥术、颈外动脉-桡动脉-椎动脉(ECA-RA-VA)搭桥术、枕动脉-小脑后下动脉/小脑前下动脉(OA-PICA/AICA)搭桥术、颞浅动脉-大脑后动脉/小脑上动脉(STA-PCA/SCA)搭桥术等后循环血管重建治疗,采用改良Rankin量表(mRS)评价预后。结果 11例患者经CTA确定血管狭窄或闭塞部位,分别位于基底动脉占2/11,双侧椎动脉V4段-基底动脉串联病变占1/11,双侧椎动脉颅内段占2/11、颅外段占1/11,一侧椎动脉颅内段合并对侧颅外段占4/11,一侧椎动脉起始部闭塞合并另一侧椎动脉纤细占1/11。DSA明确侧支代偿情况,代偿血管分别为后交通动脉占7/11,小脑软膜吻合(包括小脑后下动脉、小脑前下动脉和小脑上动脉)占5/11,颈升动脉占4/11,大脑软膜吻合(大脑中动脉-大脑后动脉)占3/11,脊髓前动脉占1/11。11例患者顺利完成血管搭桥术,影像学检查(吲哚菁绿荧光血管造影术、DSA和CTA)均提示桥血管通畅。2例术后并发肺部感染,1例可疑颅内感染,均经抗生素治疗后好转。11例患者出院时mRS量表中位评分为1;术后平均随访8个月,9例预后良好(mRS评分为0～1)、2例预后中等(mRS评分为2～3)。结论血管重建治疗慢性椎-基底动脉重度狭窄或闭塞致后循环缺血性卒中有效性和安全性均较好,具备临床可行性。     

大脑中动脉狭窄程度与不同急性脑梗死模式的相关性研究

目的探讨大脑中动脉(MCA)狭窄程度与不同急性脑梗死病变模式的关系。方法回顾性分析324例急性脑梗死患者,根据头颅磁共振弥散加权成像(DWI)和磁共振血管成像(MRA),MCA狭窄程度分为轻、中、重度,患者梗死模式分为:单发性梗死(包括小的穿支动脉供血区梗死、大的穿支动脉供血区梗死、皮质分支动脉供血区梗死和大面积梗死)、分水岭梗死(CWI)和多发性梗死。比较不同模式的急性脑梗死患者的MCA病变情况。结果 324例急性脑梗死患者中,MCA狭窄致穿支动脉(PAI)梗死最为多见,占137例(42.28%);PAI患者MCA重度狭窄率与其他单发性梗死、多发性梗死和内分水岭梗死(IWI)患者相比较,差异具有统计学意义(P0.01)。内分水岭梗死、多发性梗死和大面积梗死的MCA重度狭窄率高于小穿支动脉梗死、大穿支动脉梗死、皮质穿支动脉梗死和外分水岭梗死(P0.05),而内分水岭梗死、多发性梗死和大面积梗死之间的MCA重度狭窄率相比差异无统计学意义(P0.05)。结论 MCA狭窄致PAI最为多见,但是MCA重度狭窄并非是PAI的重要原因;MCA重度狭窄易导致CWI(尤其是IWI)和多发性梗死;MCA重度狭窄也是导致LTI重要原因之一。     

脑分水岭梗死的影像诊断

目的探讨脑分水岭梗死的影像诊断价值。方法选择临床资料完整的36例脑分水岭梗死患者进行回顾性分析。结果单侧25例,双侧11例。CT平扫呈白质内低密度影,MRI上为长T1长T2信号。CT分型：皮质前型10例,皮质后型11例,皮质下型12例,小脑型3例。DSA显示单侧颈内动脉狭窄2例,闭塞1例,双侧颈内动脉狭窄1例,单侧大脑中动脉狭窄3例,闭塞1例,单侧大脑前动脉狭窄2例,双侧大脑中动脉狭窄1例,双侧大脑前动脉狭窄1例。结论脑分水岭梗死的CT和MRI表现有其特征性,MRI对准确判断梗死的位置与形状优于CT、DSA为判断颈内动脉狭窄或闭塞提供可靠依据。     

多层螺旋CT诊断大面积脑梗死的应用价值

目的探讨螺旋CT对大面积脑梗死的诊断效果及应用价值。方法对在我院住院治疗的40例大面积脑梗死患者行多层螺旋CT平扫及CT血管造影(CTA),观察其诊断效果。结果 CT平扫初步诊断阳性率为55%,二次CT平扫复查阳性率为100%。CT表现为:22例为血管阻塞引起的大面积梗死,表现为片状低密度影,或表现浮云征、脑回征或假肿瘤征;12例为血栓脱落引起的大面积脑梗死,表现为大片状,低密度影,密度较均匀,边界较清楚,并且阴影沿血管走行;6例为外伤所致脑梗死,表现为在损伤基础上的大片状低密度影,且往往累及灰白质。CT血管造影示大脑前动脉严重狭窄或者闭塞患者7例,大脑中动脉严重狭窄或者闭塞患者18例,两动脉同时闭塞患者5例,颈内动脉末端闭塞2例,病变血管支配的脑实质范围比CT平扫所见梗死范围明显增大。结论多层螺旋CT平扫对大面积脑梗死诊断准确、省时,联合CT血管造影能够清楚显示病变血管狭窄程度及病变位置,为临床治疗提供有利依据,值得推广应用。     

脑穿支动脉病变梗死类型和神经影像学研究进展

大脑前动脉、大脑中动脉及后循环血管的穿支动脉,如豆纹动脉、脉络膜前动脉（anterior choroidal artery,AChA）和髓质动脉等,阻塞会导致脑深部缺血性病变。不同穿支动脉梗死类型不 同：豆纹动脉供血区域的梗死类型为腔隙性梗死、穿支动脉粥样硬化病型梗死和纹状体内囊梗死; AChA病变可导致AChA综合征;髓质分支梗死会导致半卵圆中心、放射冠部位的边界区梗死。7T二维 相位对比MRI、三维时间飞跃法MRA和三维快速自旋回波T1WI序列等神经影像学新技术有助于确定穿 支动脉早期病变,并可早期发现疾病的发生发展。     

脑分水岭梗死的影像诊断

目的 探讨脑分水岭梗死的影像诊断价值.方法 选择临床资料完整的36例脑分水岭梗死患者进行回顾性分析.结果 单侧25例,双侧11例.CT平扫呈白质内低密度影,MRI上为长T1长T2信号.CT分型:皮质前型10例,皮质后型11例,皮质下型12例,小脑型3例.DSA显示单侧颈内动脉狭窄2例,闭塞1例,双侧颈内动脉狭窄1例,单侧大脑中动脉狭窄3例,闭塞1例,单侧大脑前动脉狭窄2例,双侧大脑中动脉狭窄1例,双侧大脑前动脉狭窄1例.结论 脑分水岭梗死的CT和MRI表现有其特征性,MRI对准确判断梗死的位置与形状优于CT、DSA为判断颈内动脉狭窄或闭塞提供可靠依据.     

基底动脉动脉瘤合并胚胎型大脑后动脉自发性闭塞的诊治分析(附1例报道并文献复习)

目的 总结基底动脉动脉瘤合并胚胎型大脑后动脉（FPCA）自发性闭塞致枕叶梗死的诊治经验,以提高此类疾病的认识,避免将FPCA残端误诊为动脉瘤。方法 回顾性分析1例基底动脉动脉瘤合并FPCA自发性闭塞致枕叶梗死的临床资料。结果 病人以突发右上肢麻木及视物模糊起病,外院DWI显示左侧枕叶内侧面梗死伴左侧丘脑灶样梗死,外院头颈部CTA示左侧颈内动脉后交通动脉动脉瘤（呈梭形）、基底动脉动脉瘤以及颅内多发血管硬化狭窄。我院左侧颈内动脉造影见左侧后交通动脉闭塞残端,残端远端可见中断后又部分显影,左侧大脑后动脉P1、P2均闭塞,椎动脉造影未见P1段发育,基底动脉中段动脉瘤。结合病人DWI梗死部位及术前灌注成像所示灌注失代偿区,考虑为左侧FPCA急性闭塞引起同侧枕叶梗死,CTA所谓的“梭样动脉瘤”其实为闭塞后的残端。采用双支架套叠辅助弹簧圈栓塞治疗基底动脉中段动脉瘤,出院时改良Rankin量表评分1分。结论 FPCA自发性闭塞临床极其罕见,急性闭塞后是否行血管内治疗依然存在争议;应加强对其影像学特征的认识和了解,以避免将其闭塞后残端误当做动脉瘤。     

颅内后循环动脉瘤的临床特征及显微外科治疗

目的 探讨颅内后循环动脉瘤的临床特征、显微外科治疗的方法及其效果.方法 对2000年1月至2008年10月手术治疗的10例颅内后循环动脉瘤的临床资料进行回顾分析.结果 动脉瘤位于基底动脉分叉部4例,大脑后动脉P1-P2交界处2例,小脑后下动脉3例,小脑前下动脉1例.以蛛网膜下腔出血为临床表现者8例,以脑神经麻痹等占位效应为表现者2例;8例行单纯动脉瘤夹闭术,2例行动脉瘤夹闭及残颈包裹术.术后随访6个月至8年,恢复良好6例,中度伤残2例,重度残疾1例,死亡1例.结论 后循环动脉瘤手术较为困难,应选择合适的入路,充分显露动脉瘤和载瘤动脉,术中尽可能保护脑干、脑干穿支动脉及脑神经,以减少手术后致死致残率.     

Correlation with superior cervical sympathetic ganglion and sympathetic nerve innervation of intracranial artery-electron microscopical studies

When the superior cervical ganglion was resected in dogs, nerve degeneration in arterial walls began after about 28 h and marked degenerative substance was shown after 40–48 h; after 4 days the small cored vesicles of adrenergic axons disappeared. The same condition was seen after 3 months, but after 6 months the small cored vesicles were again visible. When the middle cerebral artery was examined by separating it into the perforating artery near to the internal carotid artery and the peripheral portion of the middle cerebral artery, degeneration of the nerve fibers of the arterial walls occurred earlier in the more proximal portion.The distribution of adrenergic nerve fibers from the superior cervical ganglion is bilateral in the anterior cerebral artery from the anterior communicating artery to the peripheral region, basilar artery, and vertebral artery, but ipsilateral only in the anterior cerebral artery as far as the anterior communicating artery, middle cerebral artery, posterior communicating artery, posterior cerebral artery and superior cerebellar artery.Degeneration of nerve fibers of the walls of these cerebral arteries was not seen ever after stellate ganglionectomy in both sides.     

单侧扩大翼点人路显微手术治疗颅内多发动脉瘤

目的探讨单侧扩大翼点入路显微手术治疗颅内多发动脉瘤的适应症、手术时机及手术入路。方法对本院经单侧扩大翼点人人路一期手术治疗的颅内多发动脉瘤患者进行回顾性研究,总结显微手术治疗方法。结果13例患者共28个动脉瘤均一期手术夹闭,其中后交通动脉瘤14个,前交通动脉瘤6个,大脑中动脉瘤5个,脉络膜前动脉瘤2个,颈内动脉分又部1个,术后CTA复查示多发动脉瘤消失,载瘤动脉通畅,无死亡病人。结论单侧扩大翼点人路显微手术可治疗部分颅内多发动脉瘤,根据多发动脉瘤的特征设计个体化治疗方案可达到良好效果。     

Early operation of ruptured basilar artery aneurysm associated with bilateral carotid occlusion (moyamoya disease)

A 34-year-old Caucasian man presented with subarachnoid hemorrhage. Angiography revealed bilateral carotid occlusion at the cavernous sinus and an aneurysm at the basilar artery bifurcation. The whole brain was supplied with blood from the basilar artery and posterior cerebral arteries through a large number of collateral vessels to the internal carotid artery bifurcation, middle cerebral and anterior cerebral arteries: the moyamoya phenomenon. The aneurysm was clipped within hours of the subarachnoid hemorrhage. The relation between moyamoya disease and basilar artery aneurysms is discussed and some surgical and management considerations are given.     

The arterial patterns associated with internal carotid disease and cerebral infarcts

In 20 necropsies with 15 stenosed and 17 thrombotic occluded internal carotid arteries there were 46 cerebral infarcts larger than 1 cm diameter. Using portmortem arteriographic and pathological techniques the patterns of the neck and brain artery systems were correlated with the situation and extent of the brain infarcts. Massive infarcts involving two major cerebral artery territories were associated with distal internal carotid artery occlusion and grossly ineffective cervical and circle of Willis anastomoses. Isolated middle cerebral artery territory infarcts were associated with internal carotid occlusion or stenosis and impairment of the circle of Willis anastomoses, perhaps with middle cerebral artery stenosis. The pattern of adequate size arteries determined if these infarcts were total, deep central, anterior, medium or posterior partial territory infarcts. Boundary zone infarcts were associated with internal carotid artery disease and limitation of anterior or posterior circle of Willis anastomoses. These limitations determined which boundary zones were affected. Isolated anterior cerebral artery territory infarcts were associated with bilateral internal carotid disease and an anterior cerebral artery stenosis or small caliber anterior communicating artery. Isolated posterior cerebral artery territory infarcts were associated with internal carotid disease and a direct impairment of the ipsilateral posterior cerebral artery capability.     

夹闭术治疗栓塞后复发的颅内动脉瘤的疗效分析

目的探讨栓塞后复发的颅内动脉瘤的手术治疗方法及其疗效。方法回顾性分析夹闭术治疗的10例栓塞后复发的颅内动脉瘤的临床资料,其中后交通动脉动脉瘤4个,前交通动脉动脉瘤3个,大脑中动脉动脉瘤2,基底动脉顶端动脉瘤1个。结果 10例动脉瘤夹闭完全,其中5个动脉瘤内弹簧圈术中全部或部分去除,5个动脉瘤内弹簧圈予以保留。术后CTA或DSA显示动脉瘤夹闭完全,载瘤动脉通畅。10例出院时GOS评分5分8例,4分1例,3分1例。术后平均随访20个月,GOS评分5分9例,4分1例(术后发生脑血管痉挛造成脑梗死);随访期间无动脉瘤复发。结论栓塞后复发的颅内动脉瘤具有较高的手术难度,夹闭术仍然是一种安全有效的治疗方法。     

Detection of cerebral artery fenestrations by computed tomography angiography

Background and purposeCerebral artery fenestrations (CAF) are rare congenital variations usually diagnosed by digital subtraction angiography (DSA). The aim of this study was to examine the frequency of occurrence of fenestrations in cerebral arteries and their coexistence with cerebral aneurysms in computed tomography angiography (CTA).Material and methodsAll reports of cerebral CTA (1140) performed in one institution from March 2005 to December 2007 were analysed. We found 40 patients with single fenestrations of the intracranial arteries. All 40 examinations were retrospectively reviewed for location of vascular malformations and presence of aneurysms or subarachnoid haemorrhage (SAH). Medical histories of those patients were then analysed for evidence of SAH and referral reasons for CTA.ResultsForty fenestrated arteries were found in CTA: 18 basilar arteries (45%), 16 anterior cerebral arteries (40%), 4 anterior communicating arteries (10%) and one middle cerebral artery (2.5%). Only one vertebral artery fenestration was found due to the technique of the examination. Six patients (15%) with fenestrated arteries had a total of 8 aneurysms, although only one aneurysm was ipsilateral to the fenestration. In 8 cases of SAH, two were with no evidence of vascular malformation. The coexistence of CAF and aneurysms in CTA amounted to 15% (6/40), but the incidence of ipsilateral aneurysm was only 2.5% (1/40) and it affected the anterior cerebral artery.ConclusionsBasilar artery fenestration is the most frequent observed fenestration in CTA, followed by anterior cerebral artery and anterior communicating artery fenestrations. Coexistence of fenestration and aneurysm is uncommon in CTA examination.     

颅内动脉瘤破裂合并颅脑损伤5例分析

目的探讨颅内动脉瘤破裂合并颅脑损伤的临床特征,以此鉴别创伤性蛛网膜下腔出血。方法对我院近三年来收治的5例颅内动脉瘤破裂合并颅脑损伤患者的临床资料进行回顾性研究,总结其临床特征。结果 4例患者入院后急诊经CTA检查证实为颅内动脉瘤破裂出血,其中前交通动脉瘤2例,大脑中动脉瘤1例,颈内动脉-后交通动脉瘤l例;1例患者为动脉瘤再次破裂后行CTA检查示颈内动脉-后交通动脉瘤。急诊开颅血肿清除及动脉瘤夹闭术2例,动脉瘤夹闭术1例,血管内介入栓塞治疗术1例,药物保守治疗1例。恢复良好3例,重残1例,死亡l例。结论对伴有颅脑外伤史的蛛网膜下腔出血应注意考虑颅内动脉瘤破裂的可能,以便采取积极合理的治疗方案。     

Intraaneurysmal embolization of an unruptured basilar tip aneurysm associated with moyamoya disease.

We describe a patient with moyamoya disease associated with an unruptured basilar tip aneurysm which was treated by endovascular embolization using Guglielmi detachable coils (GDCs). A 53-year-old man presented with left hemiparesis persisting for 3 mon ths before admission. Cerebral angiography revealed occlusion of the bilateral middle cerebral arteries and the left anterior cerebral artery, stenosis of the right anterior cerebral artery, and basal moyamoya vessels. In addition, a saccular small aneurysm was seen at the top of the basilar artery. The aneurysm was completely embolized by intraaneurysmal GDCs. Direct surgical clipping is often selected for the treatment of posterior fossa aneurysms in moyamoya disease. However, complete clipping is usually difficult due to the difficulties in operative technique associated with moyamoya disease. We suggest that the endovascular treatment using GDCs is comparatively safe and effective for the treatment of surgically difficult aneurysms in patients with moyamoya disease.     

显微外科手术治疗颅内后循环动脉瘤（附21例分析）

目的总结颅内后循环动脉瘤的临床特点、手术时机、手术入路选择及手术注意要点。方法我院2005年以来收治的颅内后循环动脉瘤21例（共26个动脉瘤）,其中基底动脉分叉部动脉瘤4例（1例同时伴有前交通动脉瘤）,大脑后动脉瘤5例（1例P2和P3段各有1动脉瘤）,小脑上动脉瘤2例,小脑后下动脉瘤7例（同时伴左侧眼动脉瘤、大脑中动脉瘤、颈内动脉C5段动脉瘤各1例）,椎动脉瘤3例。手术治疗18例,栓塞治疗2例,1例手术麻醉过程中死亡。结果按GOS评分评定预后,18例预后好,2例差（轻残）。结论后循环动脉瘤大多瘤体较大,瘤内多有血栓形成。手术治疗需要选择合适的手术入路,以便充分显露动脉瘤和载瘤动脉。应根据病人的术前Hunt-Hess分级以及动脉瘤的部位、大小、形态和医院的设备条件,选择个体化的治疗方法,方可取得较为满意的治疗效果。