颈部外伤致椎动脉夹层并Wallenberg综合征1例报告

<正>延髓背外侧综合征(lateral medullary syndrome,LMS)又称Wallenberg综合征,主要是供应延髓背外侧及小脑后下部的小脑后下动脉闭塞所致,临床表现较多。椎动脉夹层(vertebral artery dissection,VAD)临床少见且凶险,发病率为1.0/10万¹.5/10万,可以自发性或外伤形成,常以夹层破裂后导致蛛网膜下腔出血为首发症状,以Wallenberg综合征为首发症状者少见,而以颈部外伤致椎动脉夹层并Wallenberg综合征则更为罕见,现将我科收治的1例报道如下。1临床资料患者,男性,44岁,因"突起声音嘶哑,左侧肢体麻木5 h"     

Wallenberg综合征的磁共振成像

目的探讨MRI和MRA对wallenberg综合征的诊断价值.方法我们复习了经临床和影像学诊断的12例wallenberg综合征患者临床资料, 其中12例作了MRI检查, 有7例同时作了MRA检查.结果 MRI检查的12例中有2例正常, 10例可见延髓背外侧梗死, 其中8例为典型的延髓背外侧梗死病灶, 另2例病变超出延髓背外侧范围; 4例梗死病变仅限于延髓, 3例延髓合并小脑梗死, 3例延髓伴桥脑梗死.在MRA检查的7例中所有患者延髓梗死同侧的椎动脉显示流空消失, 5例患者的Willis环明显动脉粥样硬化, 1例基底动脉起始部明显狭窄.结论 MRI与MRA结合使用为wallenberg综合征的诊断提供了可靠的依据.     

弹簧圈闭塞基底动脉治疗巨大夹层动脉瘤一例并文献复习

目的 探讨弹簧圈闭塞基底动脉治疗巨大夹层动脉瘤的方法及可行性.方法 1例巨大的基底动脉夹层动脉瘤,行动脉瘤内的支架植入.术后DSA复查见夹层动脉瘤继续发展,并波及左侧椎动脉,且在椎基底动脉结合处呈球形扩张.采用弹簧圈将动脉瘤及基底动脉下端一并闭塞,闭塞后左侧椎动脉造影见基底动脉及动脉瘤不显影,右侧椎动脉造影仅见少量的血流缓慢通过.结果 术后患者恢复良好,无后遗症.随访至6个月时复查DSA,见基底动脉完全闭塞,动脉瘤不显影,侧枝循环代偿良好.结论 对于发生于基底动脉的夹层动脉瘤,可尝试采用弹簧圈闭塞基底动脉下端进行治疗,这为此类动脉瘤的治疗提供了新思路.

Abstract：

Objective The purpose of the current study was to evaluate the method and result of endovascular treatment for a giant unruptured dissection of the basilar artery ( BA ) .Method A 14-year- old boy underwent computed tomography (CT) scan following a minor head trauma was incidentally found a lesion located anterior to brain stem. Further imaging with magnetic resonance imaging ( MRI ) , computed tomography angiography ( CTA ) and digital subtraction angiography ( DSA )were consistent with a diagnosis of giant unruptured dissection of the BA.The patient was initially treated with BA stenting of the dissected lumen.The follow - up DSA obtained 15 days later showed thrombosis in dissected lumen and a reduction in diameter of the vessel wall.DSA obtained 3 months later revealed extension of the dissection inferiorly to involve the left vertebral artery ( VA ).The dissection expanded at the conjunction of VAs in the shape of ball.Therefore, coil embolization to partly occlude BA at the bottom of aneurysm was performed as a further treatment.Results The prognosis was good.Follow -up DSA 6 months later demonstrated complete obliteration of the dissection and good compensative perfusion from extensively established collateral circulation.Conclusions For young patients with isolated dissection of the BA, coil embolization to partly occlude BA at the bottom of aneurysm might be a tolerable and effective approach, which takes effect probably through resulting in the procedure of slow occlusion of BA.     

Wallenberg综合征临床与影像学分析

目的探讨Wallenberg综合征的临床及影像学特点。方法根据MRI表现将36例Wallen-berg综合征患者分为上、中、下3组,并结合临床特点进行回顾性分析。其中13例行DSA检查。结果上部组多伴有吞咽困难、构音障碍、软腭麻痹,下部组多伴有眩晕、共济失调、眼球震颤。上部组及中部组病变多为斜带状,病变大都临近延髓腹内侧,下部组病变多为小片状,多位于延髓背外侧表浅部分。DSA检查6例均存在不同程度椎动脉病变,2例示小脑后下动脉闭塞,1例示椎动脉闭塞伴同侧小脑后下动脉狭窄。结论Wallenberg综合征病变部位与临床症状有关。DSA检查可以进一步明确病因及病变程度。     

延髓背外侧综合征的康复护理

延髓背外侧综合征是由于小脑后下动脉闭塞或椎动脉血栓而形成的,既Wallenberg综合征.我科自2006-03～2008-12共收治19例,现将我们的护理体会报告如下.     

头MRI、全脑血管造影检查对Wallenberg综合征的诊断与预后评价

目的：探讨Wallenberg综合征病变血管部位及性质及MRI影像学特征,探讨二者与本病预后相关关系。方法：将12例临床确诊的Wallenberg综合征病人分别于发病1周及6周时头MRI检查并于1周内作全脑血管造影检查。结果：67％病例病变部位不仅累及延髓背外侧而且也累及同侧小脑半球及蚓部。50％病例并非是小脑后下动脉闭塞而是椎动脉狭窄。结论：血管病变部位及性质是决定本病预后的关键因素。     

椎动脉夹层致小脑、延髓和颈髓梗死1例报道并文献复习

目的报道1例椎动脉夹层(VAD)致小脑、延髓和颈髓梗死病例。方法回顾性分析1例VAD患者的临床资料,探讨椎动脉夹层致青年脑卒中的特点。结果患者为青年女性,右侧肢体无力。体检示右侧布朗-塞卡综合征(BSS)和交叉性偏身感觉障碍。影像学检查:头颅、颈部MRI示右侧小脑、延髓急性期梗死灶。全脑DSA示右椎动脉不规则变细。颈椎动脉MRA示右椎动脉双腔改变。结论对青年患者出现BSS、交叉性偏身感觉障碍要考虑VAD,影像学检查可明确诊断。     

延髓背外侧综合征22例临床分析

目的 分析延髓背外侧综合征的临床特征.方法 回顾性分析22例延髓背外侧综合征患者的临床资料.结果 本组均急性起病,以头晕、恶心、呕吐、同侧肢体共济失调、吞咽困难、饮水呛咳、构音障碍、Horner征、交叉性感觉障碍为常见临床表现.MRI检查22 例示延髓背外侧梗死;7例行血管检查,其中4例显示椎动脉狭窄或闭塞,2例显示小...     

延髓背外侧综合征22例临床分析

目的总结延髓背外侧综合征的临床表现与影像学改变。方法对22例延髓背外侧综合征的临床资料及影像学进行回顾性分析。结果延髓背外侧综合征的主要表现为眩晕、恶心、呕吐、构音障碍、饮水呛咳、吞咽困难、眼球震颤、Honer征、共济失调、交叉性感觉障碍等。头部CT检查未发现延髓病变,17例头部MRI示延髓背外侧梗死。结论延髓背外侧综合征的主要病因为动脉粥样硬化,诊断主要依据临床特征及MRI。     

椎动脉夹层六例临床诊断和预后

目的 探讨椎动脉夹层的临床特点、诊断、治疗和预后.方法 6例表现为急性后循环障碍导致脑缺血的患者,经询问病史、体检、常规检查及DSA、MRI、MRA及颈部血管超声等检查,总结临床上椎动脉夹层的诊疗过程.结果 起病时有突发颈、枕痛者4例,发病时全部伴有眩晕或头晕,临床上2例表现为Wallenberg综合征;3例有明确颈部外伤史;影像学特点:DSA示椎动脉闭塞或狭窄,MRI示壁内血肿,颈部血管超声示残端样血流信号或线样血流,未发现有血管内膜增厚及动脉粥样硬化斑块;6例椎动脉夹层中5例发生在颅外段;平均随诊26个月,经过抗凝治疗,改良的Rankin Scale评分分别由病初的4、4、4.2、2,2分提高到随诊时的4、3、2、1、0、1分,经配对秩和检验,差异有统计学意义(Z=-2.07,P=0.038).结论 椎动脉夹层动脉瘤有特殊的临床表现,诊断并不困难,经长期抗凝治疗,血管可以再通,临床预后较好.     

Spontaneous dissection of the extracranial vertebral arteries

Though the syndrome of carotid artery dissection is well known, "spontaneous" vertebral artery dissection is rarely recognized. We now report clinical and radiologic findings in five patients with presumed vertebral dissection, one pathologically confirmed. Mean age was 35.2 years (range 27-41). Two were men; three women. None had hypertension, vascular disease, or trauma. Headache and neck or occipital pain was prominent in all, often preceding other symptoms. Four of five patients had unilateral partial alteral medullary syndromes, in one accompanied by medial medullary signs. One patient had a cerebellar infarct. Angiography in four patients showed severe irregular stenosis of the distal extracranial vertebral artery (three bilaterally). A fifth patient with irregular stenosis above the vertebral origin had verified extensive dissection in the resected segment. No patient developed late ischemia. Repeat angiography in three showed healing. We conclude that spontaneous vertebral artery dissection, though rare, has recognizable clinical and radiologic features.     

Spontaneous dissections of the vertebral arteries

Clinical and angiographic features and outcome in 25 patients with spontaneous dissections of the vertebral arteries are described. Most patients were in their fourth or fifth decade of life, and women predominated. Forty-eight percent of the patients were hypertensive. Angiographic evidence of fibromuscular dysplasia was noted in one only. Brainstem ischemic symptoms (usually a lateral medullary syndrome) and ipsilateral occipital headache and neck pain (often preceding but sometimes associated with or following the brainstem ischemic event) were the most common clinical findings. The angiographic features in decreasing order of frequency were luminal stenosis (often irregular and tapered), aneurysm, occlusion, and intimal flap. On follow-up, most of the patients (88%) made complete or very good recoveries. Angiographic abnormalities either subsided or improved in 76%. Multivessel dissection (involvement of both vertebral arteries or one or both vertebral arteries and one or both internal carotid arteries) was noted in about two-thirds of the patients. This tendency of vertebral artery dissections to involve multiple cervicocephalic vessels concurrently, if not simultaneously, implies that four-vessel angiography should be attempted if a vertebral artery dissection is visualized. It also raises the possibility of an underlying arteriopathy that predisposes the vessel to dissection.     

70例脑动脉夹层患者临床特点分析

目的分析脑动脉夹层住院患者的临床特点,促进对脑动脉夹层的早期识别、早期诊断和治疗。方法回顾性分析首都医科大学附属北京天坛医院神经内科及神经介入科2014年12月~2015年4月经全脑血管造影或高分辨磁共振成像诊断的脑动脉夹层患者的临床特点、影像学特点及治疗措施的情况。结果共纳入70例脑动脉夹层患者。平均年龄(50.0±12.8)岁,男性52例(74%),女性18例(26%)。颈动脉颅外段夹层21例(30%),椎动脉段夹层30例(43%),基底动脉夹层15例(21%),大脑中动脉水平段夹层1例(1%),侧裂段夹层1例(1%)。大脑后动脉及锁骨下动脉夹层各1例(1%)。非蛛网膜下腔出血性头痛19例(27%),头晕3例(4%),颈痛11例(16%),缺血性卒中16例(23%),蛛网膜下腔出血5例(7%),短暂性脑缺血发作4例(6%),其中3例经检查后发现缺血性卒中,无症状者19例(27%)。1例同时存在头痛和颈痛。3例患者同时存在缺血性卒中和头痛,1例患者同时存在颈痛、短暂性脑缺血发作和缺血性卒中。动脉夹层的影像学特征主要表现为动脉局部瘤样扩张、内膜瓣、动脉壁内新月形高信号征等。接受抗栓治疗者9例(13%),单纯抗凝治疗2例(3%),支架辅助弹簧圈填塞17例(24%),单纯弹簧圈填塞5例(7%),单纯支架治疗11例(16%),抗凝结合支架治疗者1例(1%),没有治疗者23例(33%),死亡2例(3%)。结论脑动脉夹层的患者临床症状表现形式不同,轻症者可无症状,或单纯头颈痛,重症者可表现为短暂性脑缺血发作、缺血性卒中或蛛网膜下腔出血,正确诊断和相应的治疗十分重要。     

Headache and neck pain as only manifestations of spontaneous of the dissecting aneurysm vertebral artery--a case report]

A 57-year-old woman had noticed occipital headache and neck pain bilaterally 6 weeks before admission. The headache and neck pain persisted for 3 weeks, then disappeared. Cranial magnetic resonance (MR) image obtained 4 weeks after the onset demonstrated intramural hematoma adjacent to intracranial left vertebral artery. MR image did not show any abnormal lesions in the brain parenchyma. Although cranial MR angiography did not show any definite aneurysms, three-dimensional CT angiography (3D-CTA) obtained 6 weeks after the onset disclosed an aneurysm of the left vertebral artery. The vessel distal to the aneurysm was occluded. Because the left posterior inferior cerebellar artery originated from the aneurysm, we did not perform embolization using coils. Spontaneous dissecting aneurysm of the left vertebral artery was diagnosed based on the clinical, MR image, and 3D-CTA findings. The systolic blood pressure was maintained under 130 mmHg using antihypertensive agents. Thereafter, 3D-CTA obtained 6 months after the onset showed recanalization of the occluded vessel distal to the aneurysm. The size of the aneurysm was unchanged. During these 6 months, there were no ischemic or hemorrhagic stroke events. In the present patient, headache and neck pain were the only manifestations of spontaneous dissection of the vertebral artery.     

Vertebral artery dissection after neck extension in an adult patient with Klippel–Feil syndrome

The association between Klippel–Feil syndrome and vertebral artery dissection is quite rare. We report an adult patient with vertebral artery dissection and Klippel–Feil syndrome, to our knowledge only the third reported case of its kind. A 45-year-old woman with a known history of Klippel–Feil syndrome presented with occipital head and neck pain following forced neck extension. Diagnostic cerebral angiography revealed a high grade vertebral artery stenosis, consistent with vertebral artery dissection. Following 6 months of medical management, a repeat diagnostic angiogram revealed complete healing of the vessel. While cervical fusion, as seen in Klippel–Feil syndrome, has previously been shown to cause neurologic injury secondary to hypermobility, the association with vertebral artery dissection is incredibly rare. We hypothesize that this hypermobility places abnormal shear force on the vessel, causing intimal injury and dissection. Patients with seemingly spontaneous vertebral artery dissection may benefit from cervical spine radiography, and this predisposition to cerebrovascular injury strongly suggests further evaluation of vascular injury following trauma in patients with Klippel–Feil syndrome or other cervical fusion as clinically warranted.     

A case of spontaneous cervical vertebral artery dissection resulting in Wallenberg's syndrome--diagnostic value of the cervical axial MRI

Findings of the cervical axial MRI are discussed in a case of spontaneous cervical vertebral artery dissection resulting in Wallenberg's syndrome. A 42-year-old male was hospitalized because of sudden onset of severe occipital pain. Cerebral angiography performed on the day of admission revealed severe tapering stenosis of the right vertebral artery at the C-5 level of the vertebra. Angiography repeated 50 days later showed partial resolution of the narrowing. T-1 weighted axial MRI of the neck demonstrated significantly narrowing flow void of the right vertebral artery when compared with the contralateral side. A crescent-like high intensity area was also seen surrounding the lumen. These findings were consistent with hematoma within the dissected wall of the vertebral artery. MRI is considered useful in identifying such vascular lesions as cerebral artery dissection.     

Wallenberg's syndrome due to vertebral artery dissection following minimal neck injury--report of two cases]

We described two cases of the lateral medullary syndrome (Wallenberg's syndrome) due to vertebral artery dissection following minimal neck injuries. The first case was a 45-year-old man, who hit his head and often rotated his head because of posterior neck discomfort. Two years after the injury, he suffered from sudden sharp neck pain, nausea, and vertigo, which was followed by left hand numbness and difficulty in walking due to the right lateral medullary syndrome. Angiography showed right vertebral artery dissection at the fourth segment. The second case, a 48-year-old man, suffered from neck pain immediately after he hyperextended his neck for painting a wall. Within several hours, he experienced left hand numbness and difficulty in walking due to the lateral medullary syndrome. Angiography showed a saccular aneurysm and dissection of the right vertebral artery at the fourth segment. In both cases, minor traumas were thought to be the causes of vertebral artery dissection. We surveyed previously reported 84 cases (men: 50, women: 34) of the vertebral artery dissection due to minor traumas. Seventy per cent of patients were in their third or fourth decade of life. The main causes of trauma preceding the dissection were neck manipulation especially chiropractics (52%). The third segment was most vulnerable. Delay in onset following neck trauma could be more than a week, but in most cases the delay was less than 24 hours. Cervical rotation and extension were thought to precipitate dissection.     

Acute primary cerebral angiitis mimicking basilar artery dissection

Two patients presented with acute severe occipital headache, neck pain, nausea, vomiting and blurred vision. In both patients angiograms of the posterior circulation showed focal narrowing of the basilar artery, thus basilar artery dissection was considered. Urgent magnetic resonance imaging (MRI) was unavailable. On the basis of additional angiography of the anterior circulation and control angiograms after 4 and 6 weeks, primary cerebral angiitis was the most probable diagnosis. Treatment with corticosteroids resulted in rapid clinical and angiographic improvement. We conclude that, when MR techniques are unavailable or inconclusive, presumption of basilar dissection on the base of clinical features, Doppler studies, Duplex scanning and angiography of the vertebro-basilar system should be confirmed by additional carotid angiography in order to exclude diffuse cerebral angiitis.     

Prolonged headache six weeks before ischemic symptoms due to vertebral artery dissection--a case report]

A 43-year-old woman presented with weakness in her left arm and leg. She had noticed headache persisting for 2 weeks in her right occipital area 6 weeks prior to the onset of the weakness. Cranial diffusion-weighted MR image demonstrated acute infarction in the right medial part of medulla oblongata. Cerebral angiography revealed pearl and string sign in the right intracranial vertebral artery. Magnetic resonance T1-weighted image obtained when the patient complained of left-sided weakness showed a high intensity area in right vertebral artery corresponding to intramural hematoma. The diagnosis of spontaneous vertebral artery dissection was established based on clinical features, laboratory findings, MR images and angiographic findings. Generally, in patients with cervicocephalic artery dissection with ischemic onset, the occurrence of headache is either simultaneous with the ischemic symptoms, or several days prior to the ischemic symptoms. The present case showed that headache due to arterial dissection can occur several weeks prior the ischemic symptoms. Precise history of headache should be taken in patients with cervicocephalic artery dissection.