以双耳听力下降为首发症状的脑梗死临床观察

目的观察以双耳听力下降为首发症状的脑梗死患者,探讨其病灶分布特点及血管形态异常之间的关系。方法对3例以双耳听力下降为首发症状的脑梗死患者行头MR(包括T1WI、T2WI、DWI、MRA)、TCD、BAEP检查。结果 3例患者均为后循环多灶性梗死,最常累及的部位是小脑、脑桥,均有双侧椎动脉或基底动脉起始段严重狭窄或闭塞,双侧内听动脉均受累。结论以双耳听力下降为首发症状的脑梗死均符合多灶性后循环缺血的特点,血管形态异常是其重要病理基础和致病因素,预后差。     

老年人血管性眩晕患者脑主要供血动脉DSA形态特征

目的利用数字减影血管造影(DSA)技术观察老年中枢性眩晕患者脑血管的形态特征,为该病的病因诊断和临床治疗提供依据。方法对临床诊断为血管性眩晕的76例患者,全部进行全脑血管DSA检查,分析血管结构异常的类型及分布特点。结果全部患者中有72例存在不同类型及不同程度的血管结构异常共计116支,其中颈动脉系统病变12例(16支),椎-基底动脉系统病变65例(100支)。累及两条或两条以上血管的共25例,以椎动脉合并其它血管狭窄最为常见。椎-基底动脉系统病变中椎-基底动脉狭窄或闭塞47支(47/116);后循环先天性发育不良47支(47/116),其中椎动脉发育不良19支。结论后循环狭窄或闭塞以及先天性发育不良可能是老年人血管性眩晕的主要原因。     

后循环缺血患者的血管形态和代偿侧支循环的DSA研究

目的探讨DSA对后循环缺血患者的血管形态和代偿侧支循环评价价值。方法选取后循环缺血患者100例,均接受DSA检查,观察后循环动脉造影结果,分析血管狭窄的部位、程度及数量。并观察侧支循环形成情况。结果 100例患者中78例(78.0%)检查动脉狭窄,共检出狭窄220处。其中35例(70.0%)TIA患者存在动脉狭窄,共89处;43例(86.0%)后循环梗死患者存在动脉狭窄,共131处。2组动脉狭窄发生率间比较差异无统计学意义(P0.05)。动脉狭窄以椎动脉起始段最多,其次为椎动脉V5段、大脑后动脉及基底动脉。后交通动脉开放患者32例,甲状颈干增粗24例,脉络膜前动脉增粗15例,颈外动脉软脑膜吻合支15例,颈深动脉肌支增粗12例。结论 DSA可清晰显示后循环缺血动脉病变情况,并可对侧支循环情况进行评价。     

后循环梗死与椎基底动脉狭窄的相关性分析

目的 探讨MRI所示的后循环梗死灶与DSA发现的椎基底动脉狭窄的相关性.方法 回顾分析30例后循环梗死患者的临床资料,将每例后循环梗死患者头部MRI发现的梗死灶与DSA所见的椎基底动脉狭窄血管进行对照.结果 MRI示单发性梗死22例(其中脑干梗死10例,小脑梗死8例,丘脑梗死2例,枕叶梗死2例),多发性梗死8例.DSA...     

400例缺血性脑梗死患者数字减影全脑血管造影分析

目的 分析缺血性脑梗死患者的脑血管病因和病变血管的分布情况.方法 回顾性分析400例缺血性脑梗死数字减影全脑血管造影(DSA)结果,分析脑梗死的血管病因,并对动脉粥样硬化脑梗死者总结分析动脉病变的部位、分布及血管狭窄形态.结果 脑血管造影结果提示88.25％缺血性脑梗死患者为不同程度的动脉粥样硬化引起血管狭窄或闭塞(353例),此外11.75％缺血性脑梗死患者病因是由于动脉夹层、Moyamoya病、椎基底动脉扩张延长症、鼻咽癌放疗后脑动脉病变、血管迂曲、微血管病变等原因引起.353例动脉粥样硬化性脑梗死中单纯前循环血管受累(45.61％)明显多于单纯后循环血管受累(34.27％),P＜0.01;前循环脑梗死中以颈内动脉(56.6％)和大脑中动脉(26.4％)受累最常见;后循环脑梗死中以椎动脉病变(33.0％)最多见.结论 脑血管造影显示缺血性脑梗死患者有最常见病因是动脉粥样硬化脑血管狭窄或闭塞,占88.25％.前循环脑梗死患者血管病变以颈内动脉起始部病变和大脑中动脉病变多见,后循环脑梗死中以椎动脉动脉病变多见.颅外血管狭窄以颈内动脉颅起始部和椎动脉起始部多见,颅内血管狭窄以大脑中动脉和椎动脉颅内段多见.     

106例缺血性脑血管病患者全脑血管造影分析

目的分析缺血性脑血管病患者颅内外动脉狭窄的分布。方法对我院实施DSA检查的106例缺血性脑血管病的结果进行分析,均经头颅CT排除脑出血,TCD及颈动脉彩超检查后怀疑有动脉狭窄的缺血性脑血管病。所有患者均实施选择性全脑血管造影术,椎动脉和颈动脉均有正侧位血管造影像;根据患者的DSA检查结果,分析动脉狭窄的部位、受累血管数目及血管狭窄形态;重度狭窄的病例予以支架治疗和球囊成型术。结果血管造影结果提示89.6%患者有不同程度的血管狭窄或闭塞,其中75.5%为前循环受累,37.7%为后循环受累。前循环受累血管中以颈内动脉(56.6%)和大脑中动脉(26.4%)受累最常见,后循环受累血管中以椎动脉(33.0%)最多见。支架治疗和球囊成型术临床疗效显著。结论缺血性脑血管病造影显示大部分患者有肯定的脑血管狭窄和闭塞。脑梗死患者血管病变以颈内动脉病变为主,椎基底动脉供血不足亦以颈内动脉病变多见,支架治疗和球囊成型可作为重度狭窄的治疗方法。     

MRA基底动脉不显影是后循环缺血预后不良的影像学征象

目的探讨后循环缺血患者中磁共振血管造影(MRA)基底动脉不显影的临床特点和神经影像特点与预后的关系。方法回顾性分析MRA上基底动脉不显影的18例后循环缺血患者的临床资料、影像学所见以及临床结局。男11例,女7例,年龄43~80岁,平均64.8岁。结果 18例患者中,高血压病14例(77.8%),脑梗死13例(72.2%),心脏病9例(50.0%)。入院时:NIHSS评分(12.11±6.92)分,GCS评分(9.44±4.80)分,其中10例呈昏迷状态(GCS评分≤8分),梗死评分(3.75±1.38)分。18例患者MRA上基底动脉和双侧椎动脉颅内段几乎不显影。出院时:结局较好者2例(11.1%);结局不良者16例(88.9%),其中住院期间死亡6例(1/3患者死亡)。结论 MRA基底动脉不显影的后循环缺血患者,系后循环多个血管支配区梗死,预后很差。     

椎-基底动脉夹层的临床特点

目的 分析椎-基底动脉夹层所致后循环缺血的临床特点。方法 对7例经磁共振血管造影（MRA）或全脑数字减影血管造影（DSA）证实的椎-基底动脉夹层患者的临床资料进行分析。结果 7例患者均表现为后循环缺血症状。其中1例患者经MRA诊断为椎动脉夹层，1例患者为尸检后确诊为椎-基底动脉夹层，另5例患者经DSA诊断。1例患者进行尿激酶溶栓治疗，3例进行抗血小板聚集治疗，3例进行支架成形术合并抗血小板聚集治疗。除1例溶栓治疗的患者死亡外，其余6例患者随访3～24个月均未发生缺血性卒中。结论 椎-基底动脉夹层是引起后循环缺血的原因之一，正确识别椎-基底动脉夹层对于患者预后至关重要。抗血小板聚集治疗和血管内治疗可能为椎-基底动脉夹层的有效治疗方法。     

中青年与老年脑梗死患者脑动脉狭窄分布的DSA分析

目的应用数字减影血管造影对中青年与老年脑梗死患者脑动脉狭窄的分布特征进行分析。方法选择脑梗死患者86例,根据患者年龄分为中青年组（年龄〈60岁）48例,老年组（年龄≥60岁）患者38例,应用数字减影血管造影技术（DSA）对患者脑动脉病变血管狭窄程度及分布进行分析。结果 1老年组患者在颅外动脉病变以及前循环狭窄发生率明显高于中青年组（P〈0.05）,而颅内动脉病变以及后循环狭窄发生率却明显低于中青年组（P〈0.05或P〈0.01）,在脑血管病变及颅内外动脉同时受累发生率上,两组差异无统计学意义（P〉0.05）;2中青年组最常见为重度狭窄,发生率高于轻度及中度狭窄（P〈0.05）,好发部位为椎动脉开口处,发生率高于颈内动脉起始段及大脑中动脉MI段（P〈0.05）;老年组最常见为重度狭窄（P〈0.05）,好发部位为椎动脉开口处及颈内动脉起始段,发生率高于大脑中动脉MI段（P〈0.05）。结论中青年患者最常受累血管为颅内血管,病变发生部位多以椎动脉起始处居多;老年患者最常受累血管为颅外血管,最常受累血管为椎动脉起始处及颈内动脉。     

196例急性脑梗死DWI与MRA分析

目的探讨急性脑梗死的临床表现与DWI(磁共振扩散加权成像)、MRA(磁共振血管成像)之间的相关性。方法对196例急性脑梗死患者行DWI和MRA检查,对其影像学特征进行分析。结果196例患者在DWI病灶均显示为高信号。MRA显示:142例患者发现颅内大动脉狭窄或闭塞,狭窄的动脉分布为大脑中动脉、大脑后动脉、大脑前动脉、三级分支动脉、基底动脉、椎动脉、颈内动脉颅内段。48例腔隙性脑梗死发现血管狭窄或闭塞,且有16例发展成进展性脑梗死,34例腔隙性脑梗死在MRA上未见明显血管狭窄和闭塞,仅1例发生进展性脑梗死。结论急性脑梗死DWI检出阳性率100%,MRA检查最常受累的是大脑中动脉。腔隙性脑梗死病灶所处解剖区的供血大动脉易发生狭窄,且容易出现进展性卒中。     

Multiple acute infarcts in the posterior circulation.

OBJECTIVE--to evaluate clinical, radiological, and prognostic features of patients with multiple acute infarcts in remote arterial territories of the posterior circulation. DESIGN--Data analysis from a prospective acute stroke registry in a community based primary care centre using a standard protocol including MRI and MRA. RESULTS--In three and a half years, 27 of the 236 patients (11%) with posterior circulation stroke had multiple acute infarcts in the posterior circulation as shown by gadolinium enhancement on MRI. Eighteen patients had multiple infratentorial and supratentorial infarcts including the cerebellum and posterior cerebral artery territory, with coexisting brainstem involvement in seven patients. Fourteen patients had a rostral basilar artery syndrome and cerebellar signs; four patients had a visual field defect with cerebellar signs. Causes were vertebral (six) or basilar (four) artery atheromatosis, and cardioembolism (four). Seven patients had multiple acute infarcts in the posterior circulation of the cerebellum and lower brainstem. Brainstem and cerebellar signs were found in most patients (five); aetiologies were small vessel disease (four), cardioembolism (one), and vertebral artery dissection (one). Two patients with large artery atheromatosis had multiple acute infarcts in the posterior circulation in the brainstem and posterior cerebral artery territory. One month after stroke more than 25% of the patients were dependent or had died. There was no difference in the outcome between the three groups, and recovery was linked to the size of infarcts rather than to a high number of infarcts. CONCLUSIONS--multiple acute infarcts in the posterior circulation usually involve the cerebellum. Simultaneous brainstem and posterior cerebral artery territory infarcts sparing the cerebellum are uncommon. They can be suspected clinically before neuroimaging, mainly when supratentorial and infratentorial infarcts coexist. This may be important, because different patterns of infarction are associated with different causes of stroke.     

New England Medical Center Posterior Circulation Stroke Registry: I. Methods, Data Base, Distribution of Brain Lesions, Stroke Mechanisms, and Outcomes

Among 407 New England Medical Center Posterior Circulation Registry (NEMC-PCR) patients, 59% had strokes without transient ischemic attacks (TIAs), 24% had TIAs before strokes, and 16% had only posterior circulation TIAs. Embolism was the commonest stroke mechanism accounting for 40% of cases (24% cardiac origin, 14% arterial origin, 2% had potential cardiac and arterial sources). In 32%, large artery occlusive lesions caused hemodynamic brain infarction. Stroke mechanisms in the posterior and anterior circulation are very similar. Infarcts most often included the distal posterior circulation territory (rostral brainstem, superior cerebellum and occipital and temporal lobes), while the proximal (medulla and posterior inferior cerebellum) and middle (pons and anterior inferior cerebellum) territories were equally involved. Infarcts that included the distal territory were twice as common as those that included the proximal or middle territories. Most distal territory infarcts were attributable to embolism. Thirty day mortality was low (3.6%). Embolic stroke mechanism, distal territory location, and basilar artery occlusive disease conveyed the worst prognosis.     

Acute basilar artery occlusion: topographic study of infarcts

OBJECTIVE: To determine the ischemic lesions distribution and extension of patients with basilar artery thrombosis by the means of magnetic resonance imaging (MRI). METHODS: In 17 patients with thrombosis of the basilar artery, MRI was performed, including T2-weighted, magnetic resonance angiography (MRA) and diffusion-weighted imaging (DWI) sequences in the short-term phase (<48 hours). The shapes of ischemic lesions were obtained by graphic software and overlapped on a representative layer outline background. RESULTS: The MRA showed basilar artery occlusion in all cases and the DWI revealed different patterns of ischemic lesions. Most patients showed multiple lesions within the posterior circulation territory. Lesions more often occurred in pontes, cerebellums and mesencephalons than medullas, thalami and occipital lobes. Basilar pons, cerebral crus and cerebellum hemisphere were more susceptible than pontine tegmentum, vermis, midbrain tegmentum and tectum. CONCLUSIONS: When the basilar artery is occluded, basilar pons, cerebral crus and cerebellum hemisphere were most susceptible. The branches with smaller lumen of basilar artery, which are easier to be affected, are thought to be the cause of such a phenomenon.     

后循环脑梗死患者的血管影像学检查及一年预后分析

目的通过全脑血管造影(DSA)观察后循环脑梗死患者的供血动脉形态学特点,根据供血动脉异常情况制定治疗方案,评估其预后与供血动脉异常的关系。方法对128例经头颅MRI检查诊断为后循环脑梗死的患者行DSA检查,全面分析其供血动脉形态学特点,同时针对DSA结果制定治疗方案,选择单纯药物治疗103例(其中重度供血动脉狭窄放弃支架治疗7例),药物+支架成形术治疗25例,随访1年对其预后进行分析。结果 DSA示椎-基底动脉系统供血动脉异常者60.9%,46例患者病后1年预后不良(35.9%),其中死亡20例(15.6%),严重残障26例(20.3%)。对于重度供血动脉狭窄进行支架成形术治疗及DSA发现有明显代偿者预后良好;7例重度供血动脉狭窄(椎动脉3例、基底动脉4例)放弃支架治疗者复发后循环脑梗死6例,其中3例死亡,3例重度残疾。结论供血动脉形态学异常是后循环脑梗死的重要病理基础,与患者的预后明显相关,DSA是评价脑供血动脉异常的金标准,对于后循环脑梗死可以采取药物治疗,对于重度供血动脉狭窄积极采取药物+支架成形术治疗可以取得明显疗效,通过DSA检查发现脑供血动脉代偿良好者预后良好。     

New England Medical Center Posterior Circulation Stroke Registry II. Vascular Lesions

Among 407 New England Medical Center Posterior Circulation Registry (NEMC-PCR) patients, the extracranial (ECVA) and intracranial vertebral arteries (ICVA) were the commonest sites of severe occlusive disease followed by the basilar artery (BA). Severe occlusive lesions were found in >1 large artery in 148 patients; 134 had unilateral or bilateral severe disease at one arterial location. Single arterial site occlusive disease occurred most often in the ECVA (52 patients, 15 bilateral) followed by the ICVA (40 patients, 12 bilateral) and the BA (46 patients). Involvement of the ICVAs and the BA was very common and some patients also had ECVA lesions. Hypertension, smoking, and coronary and peripheral vascular disease were most prevalent in patients with extracranial disease while diabetes and hyperlipidemia were more common when occlusive lesions were only intracranial. Intra-arterial embolism was the most common mechanism of brain infarction in patients with ECVA and ICVA occlusive disease. ICVA occlusive lesions infrequently caused infarction limited to the proximal territory (medulla and posterior inferior cerebellum). BA lesions most often caused infarcts limited to the middle posterior circulation territory (pons and anterior inferior cerebellum). Posterior cerebral artery occlusive lesions were predominantly embolic. Penetrating artery disease caused mostly pontine and thalamic infarcts. Prognosis was poorest in patients with BA disease. The best prognosis surprisingly was in patients who had multiple arterial occlusive lesions; they often had position-sensitive transient ischemic attacks during months or years.     

Juvenile-onset multiple brain infarcts localized in the posterior circulation: a case report]

We report a 37-year-old male patient with multiple brain infarcts due to arterial lesions localized in the posterior circulation, who developed a paramedian pontine infarct on the left side. He had been treated as schizophrenia for 20 years. A cranial CT performed one year before showed old small infarcts in the territories of the bilateral thalamo-perforating and left thalamo-geniculate arteries and the right posterior inferior cerebellar artery. The vertebral and basilar arteries were small in diameter on MRI and MR angiography(MRA). Cerebral angiography revealed a narrow smooth basilar artery. In addition, the P2 segments of the bilateral posterior cerebral arteries were markedly narrow with irregular walls. Carotid arteriograms were normal and no atherosclerosis was found. The nature of these arterial lesions remains unknown in this case. Even if MRA shows vertebrobasilar artery hypoplasia, a known congenital risk factor of a posterior circulation infarct, we must rule out a possibility that some arterial pathology is going on.     

Vertebrobasilar infarcts in patients with dolichoectatic basilar artery

We reported 18 patients who had stroke in the posterior circulation with dolichoectatic basilar artery. TIAs preceded posterior circulation infarct in 5 patients. Strokes involved medulla oblongata (3), pons (4), cerebellum (4), mesencephalon (4), thalamus or occipital lobe (3). Dolichoectatic basilar artery also produced hydrocephalus in one patient. The mechanism of stroke may be due to penetrating artery occlusion, basilar artery thrombosis or an embolism from the abnormal basilar artery. Short-term prognosis was poor seeing that 4 patients died within 12 days of stroke.     

The intracranial vertebral artery: a neglected species. The Johann jacob wepfer award 2012

Among posterior circulation arteries, the intracranial vertebral artery (ICVA) has been given the least attention, especially concerning treatment of occlusive lesions. Early clinicopathological studies showed that the ICVA was often occluded in patients with lateral medullary and posterior inferior cerebellar infarcts. Severe stenosis or occlusion of the ICVA was the most common arterial lesion among the 408 patients in the New England Medical Center Posterior Circulation Registry (NEMC-PCR). In this registry, the distal portion of the artery was most often involved, sometimes with spread into the basilar artery. ICVA occlusive lesions were often bilateral and very often accompanied by basilar and cervical vertebral artery occlusive lesions. Patients with bilateral ICVA occlusions often had attacks of dizziness, blurred vision, and ataxia during months and years but rarely later developed disabling infarction. Most posterior circulation infarcts in patients with ICVA occlusive lesions were located in the middle and distal posterior circulation territories and were rostral to the medulla and inferior cerebellum. Although diagnostic techniques now image the ICVA and its lesions well, the optimal treatment of patients with various ICVA occlusive lesions has very rarely been analyzed or reported. The therapeutics of patients with ICVA disease is uncharted territory and begs for attention and clarification.     

Isolated pontine infarcts: etiopathogenic mechanisms

Although there are several clinico-topographical studies of pontine infarcts, few include vascular studies. To clarify the etiopathogenic mechanisms of pontine infarcts we analyzed the vascular findings and their association with MRI lesions. The clinical features and vascular findings on transcranial Doppler (TCD) or MR angiography (MRA) of 67 patients with acute infarcts involving the pons were studied. Functional outcome was assessed by modified Rankin Scale (mRS) scores on admission and 2 months later. Two groups of isolated pontine infarcts were found on the basis of lesion location on MRI, according to the extent or not to the anterior surface of the pons: paramedian pontine infarcts (PPI, n = 36) and lacunar pontine infarcts (LPI, n = 31). Hypertension was the most common vascular risk factor and pure motor syndrome was the most frequent clinical profile in both groups. Basilar artery stenosis found on TCD or MRA was significantly more frequent amongst the PPI group (P < 0.05). On admission and 2 months later, the mRS scores of the PPI group were significantly worse (P < 0.0001) than those of the LPI group. Patients with PPI have a significantly higher frequency of basilar artery stenosis and they have a worse prognosis than patients with LPI.     

New England Medical Center Posterior Circulation registry

Among 407 New England Medical Center Posterior Circulation registry patients, 59% had strokes without transient ischemic attacks (TIAs), 24% had TIAs then strokes, and 16% had only TIAs. Embolism was the commonest stroke mechanism (40% of patients including 24% cardiac origin, 14% intraarterial, 2% cardiac and arterial sources). In 32% large artery occlusive lesions caused hemodynamic brain ischemia. Infarcts most often included the distal posterior circulation territory (rostral brainstem, superior cerebellum and occipital and temporal lobes); the proximal (medulla and posterior inferior cerebellum) and middle (pons and anterior inferior cerebellum) territories were equally involved. Severe occlusive lesions (>50% stenosis) involved more than one large artery in 148 patients; 134 had one artery site involved unilaterally or bilaterally. The commonest occlusive sites were: extracranial vertebral artery (52 patients, 15 bilateral) intracranial vertebral artery (40 patients, 12 bilateral), basilar artery (46 patients). Intraarterial embolism was the commonest mechanism of brain infarction in patients with vertebral artery occlusive disease. Thirty-day mortality was 3.6%. Embolic mechanism, distal territory location, and basilar artery occlusive disease carried the poorest prognosis. The best outcome was in patients who had multiple arterial occlusive sites; they had position-sensitive TIAs during months to years.