颈动脉疾病与认知功能障碍

颈动脉疾病对认知功能的影响尚存有争议 ,颈动脉狭窄、颈动脉闭塞和颈动脉斑块均与认知障碍有关。颈动脉内膜切除术可改善认知功能。颈动脉疾病导致认知障碍可能与低灌注、白质病变、无症状梗死、腔隙性梗死和神经元变性有关。     

血管回声跟踪技术对颈动脉斑块者颈动脉弹性功能的定量检测

目的探讨颈动脉斑块患者颈动脉弹性功能的改变及其与斑块的关系。方法应用血管回声跟踪技术检测31例颈动脉斑块患者及138例正常人颈动脉僵硬度参数β、压力应变弹性系数、动脉顺应性、脉搏波放大指数及单点脉搏波传递速度;其中单侧斑块者21例,双侧斑块者10例;无基础疾病者15例,合并其他疾病者16例。比较单侧斑块患者双侧颈动脉弹性差异;比较颈动脉斑块合并及不合并其他疾病者与正常人颈动脉弹性的差异。结果单侧颈动脉斑块者左右两侧颈动脉弹性差异无统计学意义;颈动脉斑块不合并其他疾病组仅僵硬度参数β和压力应变弹性系数有改变;合并其他疾病组的僵硬度参数β、压力应变弹性系数、动脉顺应性和单点脉搏波传递速度均有改变。结论颈动脉斑块对颈动脉弹性的影响是复杂的:就整体而言,颈动脉斑块会影响颈动脉弹性功能,单纯颈动脉斑块者弹性降低,合并其他疾病者弹性下降更明显;但就局部而言,颈动脉斑块并不明显影响局部颈动脉弹性。血管回声跟踪技术能够定量检测颈动脉斑块者颈动脉弹性功能的改变。     

高血压伴颈动脉粥样硬化患者的动态血压

目的了解高血压伴颈动脉粥样硬化患者的动态血压变化。方法对186例高血压患者行超声检查双侧颈动脉,分成颈动脉正常组;颈动脉内膜增厚但无颈动脉斑块组和颈动脉内膜增厚有颈动脉斑块形成组。监测24h动态血压。结果颈动脉内膜增厚病人,无颈动脉斑块组和有颈动脉斑块组的最大收缩压、最小收缩压、平均收缩压、日间平均收缩压、夜间平均收缩压均高于颈动脉正常组,差异有统计学意义(P<0.05);无颈动脉斑块形成组和有颈动脉斑块形成组之间差异无统计学意义(P>0.05);最大舒张压、最小舒张压、平均舒张压、日间平均舒张压、夜间平均舒张压和全天平均动脉压在3组之间差异无统计学意义(P>0.05)。颈动脉内膜增厚病人组的异常昼夜节律的检出率和动态血压负荷值等于或超出40%的检出率高于颈动脉正常组。结论高血压患者动脉粥样硬化和有斑块患者的动态血压负荷值增大和昼夜节律异常。     

颈动脉疾病与认知功能障碍

颈动脉疾病对认知功能的影响尚存有争议，颈动脉狭窄、颈动脉闭塞和颈动脉斑块均与认知障碍有关。颈动脉内膜切除术可改善认知功能。颈动脉疾病导致认知障碍可能与低灌注、白质病变、无症状梗死、腔隙性梗死和神经元变性有关。     

超声评价东营地区45岁及以上人群颈动脉粥样硬化现状

目的通过超声检查了解东营地区≥45岁城乡居民的颈动脉粥样硬化病变发生现状。方法以整群随机抽样方法,从东营5个县区各选出一个居委会和自然村,共选取10 182位≥45岁的居民进行颈动脉血管超声检查,检测颈动脉内膜-中膜(IMT)厚度、斑块形成、管腔狭窄程度等情况,并进行统计学分析。结果颈动脉粥样硬化病变的检出率为74.8%。其中单纯IMT增厚、斑块形成、存在单发斑块、存在多发斑块、单条颈动脉受累、多条颈动脉受累、颈动脉支架植入术(CAS)及术后再狭窄的检出率分别为20.3%、55.9%、20.8%、33.5%、21.6%、53.1%、0.12%和0.03%。东营地区居民颈动脉轻度狭窄、中度狭窄、重度狭窄或闭塞的检出率分别为73.6%、1.0%、0.2%。城市居民在颈动脉粥样硬化病变、斑块形成、多发斑块、多条颈动脉受累检出率均高于乡村居民(P0.05)。城市和乡村居民颈动脉狭窄程度的总体构成比有差别(P0.05)。颈动脉粥样硬化病变、单纯IMT增厚、斑块形成、存在多发斑块、多条颈动脉受累、颈动脉支架植入术后的男性检出率明显高于女性(P0.05)。结论东营地区居民颈动脉粥样硬化的患病率较高,城市较乡村居民颈动脉粥样硬化的患病率和病变程度更高。     

超声在老年颈动脉粥样硬化狭窄诊断中的应用

目的探讨彩色多普勒超声在颈动脉粥样硬化狭窄诊断及治疗中的意义。方法选择382例缺血性脑血管病患者,有脑卒中史1 71例,无脑卒中史41例,头晕170例。彩色多普勒超声检查斑块大小、斑块回声、是否合并溃疡;测量并记录颈动脉狭窄近端、狭窄处收缩期峰值流速(PSV),舒张末期流速(EDV)。计算颈动脉狭窄率,用颈动脉狭窄率与颈动脉狭窄处PSV、EDV、颈动脉狭窄处与狭窄近端PSV/PSV行直线回归分析,推算颈动脉狭窄的彩色多普勒血流参数分级标准。结果有脑卒中史患者在低回声斑块、等回声斑块、强回声斑块、不均匀回声斑块分别为39、10、41、81例,无脑卒中史患者分别为6、6、27、2例。血管造影和超声检查对斑块溃疡诊断分别为87、94例。颈动脉狭窄处PSV≥1 45 cm/s、EDV≥45 cm/s、颈动脉狭窄处与狭窄近端PSv/PSV≥2.0和颈动脉狭窄处PSV≥260 cm/s、E)V≥88 cm/s、颈动脉狭窄处与狭窄近端PSV/PSV≥3.6可以分别作为颈动脉狭窄≥50%和颈动脉狭窄≥70%的血流参数临界点。结论超声可以作为颈动脉狭窄的第一筛选手段,PSV、EDV、颈动脉狭窄处与狭窄近端PSV/PSV是评估颈动脉狭窄程度准确的多普勒血流动力学参数。     

辛伐他汀对代谢综合征患者颈动脉结构和功能的影响

目的:通过超声检测颈动脉的结构和功能,观察辛伐他汀对代谢综合征患者颈动脉结构和功能的作用.方法:选择85例代谢综合征患者,检测体质指数(BMI)、腰围、血脂、空腹血糖、血浆超敏C反应蛋白(hs-CRP)和颈动脉超声测量颈动脉内膜-中层厚度(IMT),计算斑块指数、颈动脉顺应性、颈动脉扩张性及颈动脉僵硬度.比较辛伐他汀治疗4周、24周及48周后各指标及颈动脉超声参数的改变.结果:治疗4周后,代谢综合征患者血浆LDL-C、hs-CRP水平下降;颈动脉顺应性、颈动脉扩张性及颈动脉僵硬度已有明显改善,但颈总动脉IMT、斑块指数无明显变化.治疗24周后,颈动脉顺应性、颈动脉扩张性及颈动脉僵硬度进一步改善;血浆LDL-C、hs-CRP水平进一步下降;颈总动脉IMT、斑块指数有明显改善.治疗48周后,血浆LDL-C、hs-CRP水平与治疗24周相比,无进一步下降,但颈总动脉IMT、斑块指数仍能进一步改善.结论:代谢综合征患者使用辛伐他汀短期能有效改善颈动脉的功能,长期治疗有消退颈动脉斑块的作用,其作用机制可能与其抗炎作用有关.     

颈动脉超声和CT血管成像及DSA在颈动脉夹层诊断中的应用价值

目的探讨颈动脉超声、CT血管成像(CTA)及DSA对颈动脉夹层的诊断价值。方法对24例颈动脉夹层患者的三种影像资料进行回顾性分析。结果 DSA检查24例,CTA检查16例,颈动脉超声检查21例。DSA、CTA、颈动脉超声检查颈动脉夹层的检出率分别为95.8%(23例)、75.0%(12例)、71.4%(15例)。其中DSA显示以线样征最多见,有12例(占50%),CTA检查和颈动脉超声检查均以双腔征多见,分别为37.5%(6例)和52.4%(11例)。颈动脉超声及CTA检出颈动脉夹层与DSA相比,一致率分别为66.7%和81.3%,差异均无统计学意义(分别为Kappa=0.39,P=0.08;Kappa=0.43,P=0.22)。颈动脉超声联合CTA检查与DSA的一致率为87.5%(15例),(Kappa=0.67,P=0.047),差异有统计学意义。结论 DSA是诊断颈动脉夹层的金标准,不可替代。颈动脉超声联合CTA能提高诊断率,颈动脉超声可作为颈动脉夹层的筛查方法。     

老年高血压患者颈动脉病变与脉压及内皮素、醛固酮相关性探讨

目的:探讨老年高血压患者脉压及内皮素、醛固酮与颈动脉病变的关系。方法:将108例老年原发性高血压患者按照颈动脉超声结果分成颈动脉正常组与颈动脉斑块组,分别测定脉压、内皮素、醛固酮指标。结果:颈动脉斑块组脉压、内皮素、醛固酮指标均较颈动脉正常组增高(P<0.05)。结论:脉压、内皮素、醛固酮是致颈动脉壁硬化的危险因素,而醛固酮的变化是受内皮素影响的,脉压是老年高血压患者血管重塑发生和发展的重要因素。     

老年无症状颈动脉粥样硬化性狭窄的治疗

正颈动脉粥样硬化性狭窄是脑卒中的重要危险因素。药物治疗、颈动脉内膜剥脱术及颈动脉支架成形术是主要的治疗手段。不过,相对于症状颈动脉狭窄,无症状颈动脉狭窄尤其是老年无症状颈动脉狭窄治疗的临床研究和证据,相对较少。如何指导老年无症状颈动脉狭窄患者的治疗,值得探讨。1无症状颈动脉粥样硬化性狭窄治疗原则无症状颈动脉粥样硬化性狭窄是指既往无脑卒中或短暂性脑缺血发作史或在180d内没有脑卒中     

Cerebral hyperperfusion after angioplasty and stenting of a totally occluded left subclavian artery: a case report

Cerebral hyperperfusion syndrome is documented after angioplasty of carotid and vertebral artery lesions. The authors report the first instance of cerebral hyperperfusion syndrome in the posterior cerebral circulation after angioplasty and stenting of a totally occluded left subclavian artery.     

颈动脉内膜切除术后高灌注综合征的诊断与治疗

目的探讨颈动脉内膜切除术后高灌注综合征的机制、临床表现和治疗方法。方法回顾性分析3例颈动脉内膜切除术后高灌注综合征患者的临床资料，特别是术中和术后的血压管理、经颅多普勒超声（TCD）监测脑血流速度和最终的治疗及转归。结果2例患者经严格控制血压1～3d后，脑血流速度恢复正常，脑高灌注状态得以缓解。1例患者因血压控制不佳，导致脑高灌注状态，诱发脑出血而死亡。结论颈动脉内膜切除术后高灌注综合征有潜在的危险，经严格控制血压后，多于术后1～3d缓解。     

Early recognition of cerebral hyperperfusion syndrome after carotid stenting--a case report

The hyperperfusion syndrome is a recognized complication of carotid endarterectomy. Reports of cerebral hyperperfusion injury following internal carotid artery angioplasty and stenting are few We report a case of 76-year-old hypertensive man who was admitted to our hospital for assessment 2 years after experiencing an ischemic stroke of right hemisphere. Angiography confirmed 60% stenosis of left internal carotid artery (ICA). Percutaneous transluminal stenting of left internal carotid artery was performed without any immediate complications. Two hours after the procedure, the patient suddenly deteriorated. Computed tomography (CT) of the brain revealed extensive intracerebral hemorrhage and he died 5 days later. There was precipitating migranous headache, and his blood pressure was moderately elevated at the time of deterioration. Sentinel headache could solely indicate the early sign of hyperperfusion injury after carotid stenting, especially in the presence of arterial hypertension. Patients with sentinel headache after angioplasty should be recognized early and they deserve intensive study for other features of cerebral hyperperfusion injury and prompt early management.     

Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: risk factors, prevention, and treatment

OBJECTIVES: The study defined the incidence of cerebral hyperperfusion syndrome and intracranial hemorrhage (ICH) and the risk factors for their development following carotid artery stenting (CAS). BACKGROUND: Hyperperfusion syndrome and ICH can complicate carotid revascularization, be it endarterectomy or CAS. Although extensive effort has been devoted to reducing the incidence of ischemic stroke complicating CAS, little is known about the incidence, etiology, and prevention strategies for hyperperfusion and ICH following CAS. METHODS: We retrospectively reviewed the prospective database of 450 consecutive patients who were treated with CAS in our department to identify patients who developed hyperperfusion syndrome and/or ICH. RESULTS: The mean age of the patients was 72.7 +/- 10.9 years, and the mean diameter narrowing was 84 +/- 12.8%. Five (1.1% [95% confidence interval 0.4% to 2.6%]) patients developed hyperperfusion. Three (0.67%) of the five developed ICH. Two of these patients died (0.44%). Symptoms developed within a median of 10 h (range, 6 h to 4 days) following stenting. All five patients had correction of a severe internal carotid stenosis (mean 95.6 +/- 3.7%) with a concurrent contralateral stenosis >80% or contralateral occlusion and peri-procedural hypertension. These same risk factors are involved in cerebral hyperperfusion following carotid endarterectomy. The use of platelet glycoprotein IIb/IIIa receptor blockers did not appear to increase the risk ICH. CONCLUSIONS: The hyperperfusion syndrome occurs infrequently following CAS, and ICH occurs in 0.67% of patients. Patients with severe bilateral carotid stenoses may be predisposed to ICH, particularly if there is concurrent arterial hypertension. Patients with these factors may require more intensive hemodynamic monitoring after CAS, including prolongation of hospitalization in some cases.     

Ipsilateral intracerebral hemorrhage following carotid stent-assisted angioplasty: a manifestation of hyperperfusion syndrome--a case report

A case of hyperperfusion syndrome manifested as intracerebral hemorrhage following carotid stent-assisted angioplasty while using intravenous abciximab is described. Review of literature regarding hyperperfusion syndrome in patients undergoing carotid artery revascularization is presented. Possible mechanisms of hyperperfusion and the role of arterial hypertension, anticoagulation, and antiplatelet treatment in the genesis of hyperperfusion syndrome are discussed. Widening use of percutaneous carotid revascularization necessitates physicians' awareness of early recognition of this complication.     

颈动脉血管成形和支架置入术的并发症及其处理

颈动脉狭窄是导致脑梗死的重要原因之一。颈动脉血管成形和支架置入术(CAS)已被证实能够预防卒中发生,临床应用越来越广。尽管CAS是一种微创治疗方法,但仍然有许多潜在的并发症,如血流动力学异常、过度灌注综合征、脑梗死和再狭窄等。文章对CAS的并发症及其处理方法进行了综述。     

颈动脉支架置入术围手术期血压调控的探讨

目的探讨粥样硬化性颈动脉狭窄患者,经皮血管内支架置入血管成形术(PTAS)围手术期血压调控的必要性及初步经验。方法回顾性分析293例粥样硬化性颈动脉狭窄患者经全脑数字减影血管造影术诊断后,采用自膨式支架经股动脉入路行PTAS,围手术期对血压严密监控,并根据血压的高低采取综合措施及时进行调整,以避免发生高灌注性脑病或心、脑缺血。结果 293例患者中支架置入成功292例(99.7%)。术前狭窄率70%～95%平均(82.0±13.1)%,术后残余狭窄率为0～20%,平均(9.2±6.8)%,术后患者脑缺血症状及体征均有明显改善。有1例患者在术中及术后血压控制不理想,发生了高灌注性脑出血而死亡。通过采取综合措施调节血压后未再发生高灌注性脑病,血压降至90～120/60～90 mm Hg(1 mm Hg=0.133 kPa)后,所有患者均未发生心、肾、脑等脏器缺血。结论 PTAS微创安全有效,但术中及术后调整血压非常必要,围手术期有效地调控血压是减少术后高灌注性综合征发生的重要手段之一。     

Cerebrovascular resistance and blood flow velocity changes after carotid endarterectomy

BACKGROUND: To study the pattern of cerebral blood flow velocity and cerebral resistance changes after carotid endarterectomy. PATIENTS AND METHODS: In 81 patients (mean age +/- SD, 64 +/- 8 years) with unilateral carotid endarterectomy (CEA) the systolic, diastolic and mean blood velocities, and the pulsatility index (PI) were recorded in both middle cerebral arteries preoperatively and repetitively postoperatively with the use of transcranial Doppler ultrasound (TCD). RESULTS: In the middle cerebral artery ipsilateral to CEA mean blood velocity was increased 6 hours (64 +/- 25 cm/sec; p < 0.005) and 7 days (54 +/- 15 cm/sec; p < 0.05) after CEA and had returned to the preoperative level (49 +/- 11 cm/sec) after 3 months. Compared to preoperatively (0.86 +/- 22), the PI was significantly increased at 6 hours examination (1.03 +/- 23, p < 0.005), and remained increased thereafter. A pathologically increased mean blood velocity (> 83 cm/sec) 6 hours after CEA occurred in 11 patients, two of them developed a slight hyperperfusion syndrome. In the contralateral middle cerebral artery, only the diastolic blood velocity showed significant changes (preoperatively, 35 +/- 12 cm/sec; 3 months after CEA, 33 +/- 8 cm/sec; p < 0.05). CONCLUSIONS: Using TCD, hemodynamic changes occur predominantly in the middle cerebral arteries ipsilateral to CEA. Early postoperative TCD studies may be of help to identify patients at risk to develop a hyperperfusion syndrome.     

颈动脉支架置入术后过度灌注综合征的危险因素分析

目的探讨颈动脉支架置入术(CAS)后发生过度灌注综合征(CHS)的危险因素。方法纳入419例患者的临床资料,其中48例同时行双侧CAS,共计行467次CAS。根据是否发生CHS分为CHS组15例和无CHS组404例。采用分层分析法分析术后发生CHS的危险因素。结果与无CHS组比较,CHS组糖尿病、术后高血压比例明显升高,差异有统计学意义(P<0.05,P<0.01)。单因素分析显示,术前糖尿病、术后高血压与CHS相关(P<0.05)。经分层分析显示,术前糖尿病(OR=3.168,95%CI:1.008～9.222,P=0.025)及术后高血压(OR=5.033,95%CI:1.733～14.646,P=0.001)为术后发生CHS的主要危险因素。结论 CAS术前糖尿病及术后伴高血压的患者更容易出现CHS。临床上对于术前有糖尿病史及术后出现高血压的CAS患者必须加以重视,尽早发现和处理CHS。     

Carotid artery reconstruction for Takayasu's arteritis the necessity of all-autogenous-vein graft policy and development of a new operation.

BACKGROUND: We have adopted an all-autogenous-vein-graft policy in carotid reconstruction for Takayasu arteritis, namely an ascendo-right carotid and right subclavian (axillary) arteries bypass using a pantaloon vein graft for patients all of whose arch branches are occluded, and an extra-anatomical bypass from the right subclavian artery for patients whose brachiocephalic artery is the only arch branch that remains patent. This report is to elaborate on these operations and to assess the long-term outcome. METHODS: Six patients were operated on according to this policy; (5 women, 1 man, age range: 14 to 59 years (mean: 30). The indications for surgery were severe cerebral ischaemia that significantly interfered with their daily lives. The pantaloon vein graft bypass was performed in four patients, and an extra-anatomical bypass in two. The specific management protocol to prevent the "postbypass hyperperfusion syndrome" and cerebral oedema included a shunt procedure to the internal carotid artery using one limb of the pantaloon vein graft, induced hypotension just before the completion of the carotid reconstruction and the administration of a glycerine-fructose solution. RESULTS: Cerebral ischaemic symptoms disappeared in all patients. All but one, who died of a ruptured thoraco-abdominal aneurysm on the 35th postoperative month, are living a normal life with a patent graft. No suture line complications have as yet been encountered (follow-up: 10 to 205 months, mean: 126 months). CONCLUSIONS: Carotid vein bypass for Takayasu arteritis, particularly, the pantaloon vein graft bypass is recommended for those of whom all aortic arch branches are occluded, resulting in severe brain ischaemia. Perioperative blood pressure control is important for prevention of the hyperperfusion syndrome.