脑动脉狭窄的分布及影像学评估研究进展

我国10%～20%的缺血性卒中患者是由脑动脉狭窄所致,究其病因主要是动脉粥样硬化。 我国缺血性卒中患者颅内动脉粥样硬化性狭窄发生率高于颅外动脉。因此,颅内外动脉粥样硬化性 狭窄的早期诊断对预防卒中的发生具有重要临床意义。目前,磁共振血管成像（magnetic resonance angiography,MRA）、高分辨率磁共振成像（high-resolution magnetic resonance imaging,HRMRI）、计算 机断层扫描血管造影（computed tomography angiography,CTA）、数字减影血管造影（digital subtraction angiography,DSA）等影像学检查已广泛应用于颅内外动脉狭窄的评估。通过血管影像学显示狭窄分 布差异,从而探索卒中的发病机制已成为近些年研究的热点,本文就缺血性卒中患者的脑动脉狭窄 分布规律及影像学评估的研究进展情况做一综述。     

专题综述:颅内血管性疾病的诊断与介入治疗

正编者按颅内动脉粥样硬化性狭窄是亚洲人群缺血性卒中的常见病因,中国颅内动脉粥样硬化研究(Chinese IntraCranial Athero Sclerosis Study,CICAS)显示中国人群的卒中发生率高达46.6%。介入治疗作为颅内动脉狭窄的治疗手段,其安全性、有效性仍存在诸多争议。比较支架术和积极药物治疗颅内动脉狭窄预防卒中复发的     

颅内动脉粥样硬化性狭窄支架成形术相关并发症

颅内动脉粥样硬化性狭窄为急性缺血性卒中的重要病因之一。血管内支架成形术是目前治疗颅内动脉粥样硬化性狭窄的主要手段,可用于缺血性卒中急性期或亚急性期病例的治疗,尤其是可预防严重颅内动脉狭窄患者脑卒中的发生。其围手术期和远期并发症包括支架植入失败、颅内出血、刺破血管、栓塞,以及支架内再狭窄,而围手术期的抗凝药物治疗可减少并发症的发生。     

缺血性卒中患者颅内外血管狭窄率研究

目的:研究缺血性卒中患者颅内外血管狭窄或闭塞的发生率,并对其相关病因进行分析。方法:对经CT/MRI/DWI诊断的缺血性卒中患者的人口构成情况进行登记,了解其相关危险因素。并经TCD和/或MRA了解其颅内外血管狭窄或闭塞的情况。结果:579例缺血性卒中患者中,颅内外血管狭窄的发生率为70.98%(411/579例);411例大动脉狭窄或闭塞患者中,以大脑中动脉狭窄或闭塞最常见(64.48%),其次为颈内动脉(50.36%)。大动脉狭窄或闭塞的主要原因为动脉粥样硬化,引起动脉粥样硬化的危险因素的发病率依次为:高血压病(77.24%),吸烟(63.68%)。通过Logistic回归分析发现,糖尿病、高血压、吸烟是血管狭窄的主要相关危险因素(P值均<0.05)。结论:国内缺血性卒中患者颅内外血管狭窄或闭塞的发生率高,其主要病因为动脉粥样硬化,糖尿病是大动脉狭窄或闭塞的最主要危险因素。     

症状性颅内动脉狭窄的治疗现状

症状性颅内动脉狭窄(IAS)是当前临床关注的热点,颅内动脉狭窄是亚洲人,尤其是中国人缺血性卒中重要的病因.颅内动脉狭窄在所有缺血性卒中病因中占8%～10%[1].颅内动脉狭窄的患者每年卒中的复发率为10%～50%[2].尽管进行药物治疗,症状性颅内动脉狭窄患者每年卒中风险仍为10%～24%[3].当前开展的血管内治疗给症状性颅内动脉粥样硬化性狭窄的患者带来了希望.本文就症状性颅内动脉狭窄的治疗综述如下.     

HR-MRI血管壁成像在缺血性卒中病因诊断中的应用价值研究

目的 研究高分辨磁共振（high-resolution magnetic resonance imaging,HR-MRI）血管壁成像在缺血性 卒中病因诊断中的价值。 方法 选择2015年1月-2017年5月于南京鼓楼医院就诊的缺血性卒中患者,头颅数字减影血管造影 （digital subtraction angiography,DSA）未能明确病因,而HR-MRI血管壁成像确诊的典型性病例8例进行 研究分析。 结果 8例缺血性卒中患者,计算机断层扫描血管造影（computed tomography angiography,CTA）/磁 共振血管造影（magnetic resonance angiography,MRA）及DSA均未明确病因,HR-MRI血管壁成像发现 2例颅内动脉夹层（cerebral artery dissection,CAD）,2例烟雾病（Moyamoya disease,MMD）,2例动脉 粥样硬化烟雾综合征（atherosclerotic Moyamoya syndrome,AS-MMS）及2例原发性中枢神经系统血管炎 （primary angiitis of central nervous system,PACNS）。 结论 HR-MRI血管壁成像在缺血性卒中病因诊断（如CAD、MMD与AS-MMS的鉴别、PACNS等）中具有重 要价值,是CTA/MRA及DSA诊断技术的重要补充。     

高分辨磁共振管壁成像在颅内动脉疾病诊断中的应用

<正>颅内动脉粥样硬化性疾病(Intracranial Atherosclerotic Disease,ICAD)是缺血性卒中的重要病因之一。既往认为动脉粥样硬化导致管腔狭窄闭塞,进而脑组织灌注不足、缺血坏死,而越来越多的研究表明仅关注狭窄程度不够全面,需结合管壁及斑块稳定性评估卒中风险。高分辨磁共振     

急性缺血性卒中患者颅内动脉粥样硬化性狭窄与不同血糖水平代谢综合征的相关性分析

目的 探讨急性缺血性卒中患者颅内动脉粥样硬化性狭窄与不同血糖水平代谢综合征的相关性。 方法 选取2013年6月-2016年6月入住本院神经内科的急性缺血性卒中患者352例为研究对象,根 据颅内血管狭窄情况分为狭窄组227例和非狭窄组125例;选取同期非颅内动脉粥样硬化性狭窄体检 者310例为对照组。研究对象中合并代谢综合征的患者分为3个亚组：糖耐量正常组、伴糖尿病组、伴 高血糖组（包括空腹血糖受损、糖耐量降低）。同时测定代谢综合征患者血脂水平,分析不同血糖 水平代谢综合征与颅内动脉粥样硬化性狭窄的相关性。 结果 352例急性缺血性卒中患者共确诊代谢综合征195例（55.39%）,其中狭窄组和非狭窄组代谢 综合征的发生率均明显高于对照组,比较差异有显著性（P <0.05）;狭窄组代谢综合征的发生率明显 高于非狭窄组,比较差异有显著性（P <0.05）。狭窄组中伴糖尿病的代谢综合征患者比例明显高于非 狭窄组和对照组,比较差异有显著性（P <0.05）;狭窄组中伴高血糖和糖耐量正常的代谢综合征患 者比例与非狭窄组比较,差异均无显著性（P＞0.05）。Logistic回归分析显示：代谢综合征与颅内动脉 粥样硬化性狭窄存在明显相关性;代谢综合征伴糖尿病、伴低高密度脂蛋白（high density lipoprotein, HDL）、高甘油三酯（triglyceride,TG）与颅内动脉粥样硬化性狭窄发生风险呈明显正相关。 结论 在急性缺血性卒中患者中,代谢综合征尤其是糖尿病、高TG血症及低HDL血症和颅内动脉粥 样硬化性狭窄密切相关。     

颈动脉狭窄的血管成形和支架置入术

颈动脉狭窄的病因包括动脉粥样硬化、动脉夹层分离、纤维肌性发育不良、大动脉炎和放射性损伤等，是缺血性脑血管病的重要病理学基础。业已证实，颈动脉内膜切除术（carotid endarterectomy,CEA）能够显著降低中到重度有症状颈动脉狭窄患者的缺血性卒中风险，对于无症状重度狭窄患者，CEA也有一定益处。近年来，随着血管内介入治疗技术的不断成熟和发展，血管成形和支架置入术（carotid angioplasty and stenting,CAS）在颈动脉狭窄中的应用越来越广泛，成为CEA的一种替代治疗手段。     

HR-MRI血管壁成像对很可能的烟雾病与动脉粥样硬化烟雾综合征的鉴别诊断

目的探讨利用高分辨磁共振(high-resolution magnetic resonance imaging,HR-MRI)血管壁成像对很可能的烟雾病(Probable Moyamoya dissection,P-MMD)与动脉粥样硬化烟雾综合征(atherosclerotic Moyamoya syndrome,AS-MMS)患者鉴别诊断的价值。方法回顾性分析2019年1月～2019年12月于本院就诊的11例缺血性卒中患者的HR-MRI血管壁成像,其均为单侧大脑中动脉(middle cerebral atery,MCA)狭窄或闭塞且伴烟雾状血管生成。结果 11例缺血性卒中患者,计算机断层扫描血管造影(computed tomography angiography,CTA)、磁共振血管造影(magnetic resonance angiography,MRA)及(digital subtraction angiography,DSA)均发现单侧大脑中动脉狭窄伴烟雾状血管生成,但未明确病因,HR-MRI血管壁成像发现6例为P-MMD,5例为AS-MMS。结论 HR-MRI血管壁成像在鉴别可能烟雾病与动脉粥样硬化烟雾综合征缺血性卒中的病因诊断中具有重要价值,可作为CTA、MRA及DSA诊断技术的重要补充。     

Six-month follow-up study in patients with symptomatic intracranial arterial stenosis.

Ischaemic stroke due to intracranial atherosclerosis is estimated to comprise 8-12% of all ischaemic strokes. It is known that the risk of recurrence is extremely high in patients with ischaemic stroke caused by intracranial stenosis. In the present study we aimed to evaluate the clinical and radiological findings over a 6-month follow-up period in patients with intracranial atherosclerosis. Prospective data for the ischaemic stroke patients admitted to our clinic between 2001 and 2004 were collected. The localization of stenosis/occlusion detected by magnetic resonance angiography (MRA) was recorded and patients were divided into two groups according to the presence of one or more arterial stenoses on MRA. The patients were followed up for 6 months at regular intervals and stroke recurrence and deaths were noted. Of the 47 patients, 11 had posterior circulation stenosis and 36 had anterior circulation stenosis. Thirty-three patients had only one intracranial artery stenosis, whereas 14 had more than one intracranial artery stenosis. Of the 38 patients who completed the 6-month follow-up period, 13 had recurrent stroke, and 10 died. The rate of stroke recurrence in patients with intracranial artery stenosis may be higher than in patients with stroke due to other aetiologies, and stenosis of multiple intracranial arteries increases the rate of recurrence.     

缺血性脑卒中患者动脉粥样硬化分布的临床研究

目的探讨急性缺血性脑卒中不同亚型与颈动脉粥样硬化分布的相关性。方法通过经颅多普勒超声(TCD)和颈动脉彩色多普勒血流成像(CDFI)方法检测颅内、外动脉粥样硬化程度,并结合病史、生化指标及影像学提示的病变部位进行综合分析。结果411例急性缺血性脑卒中患者,颅内动脉狭窄率为38.93%(160/411),颈动脉颅外段狭窄率24.09%(99/411)。颈动脉颅外段狭窄者年龄大、吸烟比例高,与无狭窄者比较差异有统计学意义(P=0.020,0.013);而颅内动脉狭窄者糖尿病发病率明显高于无狭窄者(P=0.005)。411例中皮质梗死49例、皮质下梗死108例、腔隙性梗死72例和短暂性脑缺血发作30例,颈动脉颅外段狭窄者以皮质梗死为主(P=0.001),并且动脉内-中膜层厚度明显增加(P=0.020);而颅内动脉狭窄者以腔隙性梗死更多见(P=0.016)。颅内、外动脉狭窄者的年龄、性别、血糖及血脂之间差异无统计学意义(均P>0.05)。结论临床和影像学检查所确定的急性缺血性脑卒中亚型与颅内、外动脉粥样硬化的病变部位相关,提示发病的原因可能不同。糖尿病与吸烟是引起颅内、外动脉病变的重要原因。     

颅内动脉粥样硬化的自然病程

动脉粥样硬化是全身性疾病,颅内动脉也是动脉粥样硬化的好发部位。在所有的缺血性卒中患者中,8%～10%是由于颅内动脉粥样硬化性狭窄所致。颅内动脉粥样硬化性狭窄是一个炎症反应过程,近来认为氧化型低密度脂蛋白在动脉粥样硬化过程中的作用最强。颅内动脉粥样硬化的好发部位包括颈动脉海绵窦虹吸段、大脑中动脉主干、椎动脉邻近融合部和基底动脉。颅内动脉粥样硬化在流行病学、自然病程、病理生理及药物治疗、介入治疗等方面均有显著进展。本文对颅内动脉粥样硬化的自然病程做一综述。     

颈动脉超声对冠状动脉粥样硬化性心脏病合并缺血性脑血管疾病患者颅内动脉狭窄性病变的预测价值

目的探讨颈动脉超声评价冠状动脉粥样硬化性心脏病(CAD)合并缺血性脑血管(ICVD)患者颅内动脉狭窄性病变的预测价值。方法对209例经血管造影证实冠状动脉狭窄(≥70%)同时合并缺血性脑血管疾病的患者采用彩色多谱勒超声(CDFI)和经颅多普勒超声(TCD)分别检查颈动脉和颅内动脉,并将患者分为脑动脉狭窄组与非狭窄组,分别比较两组患者颈动脉超声检查结果中差异有统计学意义的指标。结果颈动脉球部内-中膜(IMT)增厚、不均质回声斑块、多发斑块、颈动脉狭窄与CAD患者合并颅内动脉狭窄性病变之间具有良好的相关关系,(P<0.05)。结论颈动脉内膜增厚、不均质回声斑块,多发斑块、颈动脉狭窄与CAD合并ICVD患者颅内动脉狭窄性病变之间有明显的相关性。采用CDFI对冠状动脉狭窄的患者进行颈动脉检测,在心脑血管事件高危人群中进行筛选,对临床诊断与治疗具有重要的指导意义。     

Evolving atherosclerosis at carotid and intracranial arteries in Japanese patients with ischemic heart disease: a 5-year longitudinal study with MR angiography

Progression of atherosclerosis at extracranial carotid and intracranial arteries in patients with ischemic heart disease (IHD) is not well defined. We carried out a 5-year longitudinal study with magnetic resonance angiography (MRA) of patients with IHD to assess the incidence of progression of atherosclerosis at extracranial carotid and intracranial arteries and to determine predictors of the progression. We previously performed carotid and intracranial MRA on 67 patients who had received selective coronary angiography for the clinical diagnosis of IHD. Of these 67 subjects, 41 patients gave informed consent to undergo MRA reexaminations to evaluate changes of extra- and intracranial arteries over a 5-year period. The degree of stenosis was divided into five grades depending on the narrowness of the arteries, i.e. normal, mild, moderate, severe and occluded. The average of follow-up period with MRA examination was 58.8 months. The progression of atherosclerosis, as defined as an increase of one grade of the stenosis rating, including both the exacerbation of pre-existing stenosis and the appearance of new stenotic lesions, were found in five patients (12.2%) for the cervical carotid artery and in only one patient (2.4%) for the intracranial artery. A multiple logistic regression analysis revealed that baseline carotid artery stenosis ( P  = 0.008), age ( P  = 0.047), and coronary events during the follow-up period ( P  = 0.048) were significant and independent predictors of progression of carotid atherosclerosis. In conclusion, our findings suggest that follow-up evaluation of the carotid artery is indicated for patients with IHD in whom carotid artery stenosis was detected on an initial examination. Further study is needed with larger numbers of patients to confirm these findings.     

单纯颅内动脉狭窄性缺血性脑血管病预后评估

目的 探讨单纯颅内动脉狭窄性缺血性脑血管病1年卒中复发的影响因素。 方法 筛选经数字减影血管造影（digital subtraction angiography,DSA）证实存在单纯颅内动脉粥样硬 化性狭窄的缺血性脑血管病患者86例,随访1年,将卒中事件作为终点事件。分析颅内动脉狭窄的分 布特征,Cox回归模型分析年龄、性别、高血压、高血脂、糖尿病、吸烟、饮酒、超敏C反应蛋白（high sensitive C reactive protein,hsCRP）、动脉狭窄数目、动脉狭窄程度、前后循环狭窄、缺血类型、冠状动 脉粥样硬化性心脏病史、缺血性脑血管病史等对终点事件的影响。 结果 结果显示颅内动脉狭窄好发于大脑中动脉（35.51%）,80例符合入组标准的患者完成1年随访。 多因素Cox回归分析显示：年龄≥60岁[危险比（risk ratio,RR）2.628,95%可信区间（confidence interval, CI）1.066～6.478,P =0.036] 、女性（RR 2.645,95%CI 1.133～6.178,P =0.025）、美国国立卫生研究院 卒中量表（National Institutes of Health Stroke Scale,NIHSS）评分＞1（RR 3.644,95%CI 1.280～10.369, P =0.015）和多发性颅内动脉狭窄（RR 2.712,95%CI 1.048～7.019,P =0.040）是终点事件的危险因素。 结论 年龄、性别、NIHSS评分和颅内动脉狭窄数目可能是颅内动脉狭窄性缺血性脑血管病患者1年 内再发卒中事件的独立危险因素。     

The clinical value of head-neck joint high-resolution vessel wall imaging in ischemic stroke

Background and PurposeTo study the feasibility and clinical utility of head-neck joint high-resolution vessel wall imaging (HNJ-VWI) in the assessment of ischemic stroke.MethodsWe reviewed our institutional HNJ-VWI database. Patients with transient ischemic attack (TIA) or ischemic stroke were included. Abnormal findings of intracranial and/or extracranial artery were assessed on three-dimensional time-of-flight magnetic resonance angiography (3D TOF MRA) and HNJ-VWI modified from high-resolution 3D T1 sequence and classified into three groups including intracranial, extracranial and coexisting based on the locations. Etiologies of stroke were recorded according to Trial of Org 10172 in Acute Stroke Treatment criteria.ResultsOne hundred and ten consecutive patients were studied. 3D TOF MRA displayed 71.8% (79/110, based on patients) abnormal arteries (stenosis or occlusion) , while HNJ-VWI displayed 96.3% (106/110) abnormal arteries (plaque,wall thickness and occlusion) including four isolated extracranial lesions and ten coexisting lesions. The etiologies of TIA/ischemic stroke included large artery atherosclerosis (80 cases), cerebral small vessel disease (6 cases), cardiogenic (2 cases), dissection (6 cases), vasculitis (4 cases), moyamoya disease (6 cases), others (2 cases) and undetermined (4 cases). For patients with atherosclerosis stroke, re-infarctions were more common in coexisting group than intracranial group (extracranial vs. intracranial vs coexisting: 0% vs. 9.1% vs. 43.7%, p = 0.001).ConclusionsHNJ-VWI is a feasible and valuable technique in assessment of ischemic stroke by detecting extracranial and intracranial artery abnormalities with one-step scan.     

Comparison of spontaneous intracranial vertebral artery dissection with large artery disease

OBJECTIVE: To compare clinical and angiographic characteristics and stroke patterns between spontaneous intracranial vertebral artery dissection (VAD) and vertebral large artery disease (LAD) (atherosclerosis). DESIGN: Retrospective study. SETTING: Tertiary referral center for cerebrovascular diseases. Patients Twenty-two patients with spontaneous VAD and 25 with LAD in the intracranial portion of the vertebral artery. MAIN OUTCOME MEASURES: We compared (1) clinical characteristics, including epidemiologic data, vascular risk factors including inflammatory markers, the presence of headache, and stroke syndromes and severity; (2) stroke pattern on diffusion-weighted imaging, which was classified as vertebral perforator infarct, basilar perforator infarct, small scattered infarct, large scattered infarct, and territorial infarct; and (3) angiographic findings, ie, the distribution of involved arteries, degree of stenosis, and the involvement on the anterior circulation and calcification of vertebral artery. RESULTS: Although patients with VAD were younger, and more often had headaches and fewer vascular risk factors than those with LAD (P<.01 in all cases), these clinical features were also observed in some LAD patients. Diffusion-weighted imaging data showed that vertebral perforator infarct and small scattered infarct were most common in the VAD group, while territorial infarct and large scattered infarct were most common in the LAD group (P = .02). On angiography, LAD more frequently had anterior circulation arterial involvement (P = .002), higher degree of stenosis (P = .002), and calcifications (P = .008). CONCLUSION: Our findings indicate that results of diffusion-weighted imaging and noninvasive vascular studies might provide clues to the clinical characteristics in differential diagnosis between VAD and LAD.     

不同年龄组TIA患者颅内/外动脉粥样硬化性狭窄的分布特征比较

目的 探讨不同年龄组短暂性脑缺血发作（TIA）患者颅内、外动脉粥样硬化性狭窄的分布特征。方法 对64例TIA患者的全脑血管数字减影血管造影术（DSA）资料进行分析，计算颅内、外动脉狭窄的发生率，并对不同年龄患者颅内、外动脉狭窄或闭塞情况进行统计学比较。结果 64例患者中，54例（84%）存在脑动脉粥样硬化性狭窄，颅内动脉狭窄发生率略高于颅外动脉（68.5% vs 64.8%）。在<50岁组中，单纯颅内动脉狭窄或闭塞的发生率为54.5%，高于单纯颅外动脉（27.3%）及颅内-颅外动脉多发性狭窄或闭塞（18.2%）；而≥50岁组中，单纯颅内动脉狭窄或闭塞的发生率（21.9%）低于颅内-颅外狭窄或闭塞（43.8%）及单纯颅外动脉狭窄或闭塞(34.4%)，差异具有统计学差意义（P <0.05）。结论 TIA患者颅内、外动脉粥样硬化性狭窄随年龄变化而呈特征性分布。