颈内动脉狭窄或闭塞后侧支循环与脑缺血的关系研究

目的 探讨颈内动脉狭窄或闭塞后侧支循环与脑缺血的关系。资料与方法 颈内动脉狭窄或闭塞患者40例．分析MRA、MRI表现及临床资料。结果 40例患者59侧有颈内动脉分叉以上狭窄或闭塞，MRI上大面积脑梗死10例．腔隙性梗死15例．介于二者之间者4例．严重半球脑萎缩3例，轻度脑萎缩4例．无异常表现者4例。MRA上大面积梗死及严重脑萎缩者侧支循环很差或缺乏。腔隙性梗死、轻度脑萎缩及表现正常者均有较丰富的侧支循环。结论 颈内动脉狭窄或闭塞后脑缺血程度与侧支循环有密切关系。侧支循环差或缺乏，会引起大面积梗死．侧支循环丰富，不出现梗死或只引起小的梗死。     

单侧颈内动脉狭窄或闭塞后侧支循环与脑缺血关系的研究

目的 探讨单侧颈内动脉狭窄或闭塞后侧支循环与脑缺血的关系.方法 对比分析68例单侧颈内动脉狭窄或闭塞患者(实验组)及20例脑血管DSA检查正常者(对照组)的临床资料及数字减影血管造影(DSA)表现.结果 (1)实验组68例中,狭窄或闭塞发生于颈内动脉41例、大脑中动脉17例、大脑前动脉A1段4例、大脑前动脉A1段以远6例.发现侧支循环开放代偿共109例次,其中前交通动脉32例次、后交通动脉22例次、后软脑膜吻合27例次、前软脑膜吻合19例次、眼动脉4例次、穿支动脉2例次、其他3例次.重度狭窄组与闭塞组侧支循环开放率较高,分别为72.7％、86.7％,与正常对照组差异有显著性(x2=14.029、25.301,P均＜0.001);轻、中度狭窄组侧支循环开放率较低,分别为为16.7％、20.0％,与正常对照组差异无显著性(P=0.676、P=0.551).(2)初级侧支循环开放的比例:症状组小于无症状组,差异有显著性(P=0.042);次级侧支循环开放的比例:症状组大于无症状组,差异有显著性(P =0.022).前交通动脉开放的比例:症状组小于无症状组,差异有显著性(P=0.038);后交通动脉开放的比例:症状组与无症状组无显著性差异(P=0.382).(3)Willis前环变异:症状组最高,其次为正常对照组,而无症状组变异率最低,三组间差异有显著性(P =0.032);Willis后环变异比例:三组间差异无显著性(P=0.110).(4)颈内动脉闭塞的26例,侧支血流评分:梗死组得分最低为(2.4286±0.17271)分,其次为TIA组(3.2500 ±0.2500)分,最高的为无症状组(3.7500±0.16366)分,三组间差异有显著性(F=13.903,P＜0.001).结论 DSA对侧支循环状况的分析、评估具有非常重要的价值,能为颈内动脉狭窄或闭塞的诊断、治疗、预后提供较全面的评价.     

远隔缺血预适应治疗患者侧枝循环与脑缺血关系的探讨

目的:探讨远隔缺血预适应治疗患者侧枝循环与脑缺血关系。方法:选择我院门诊患者30例,所有患者均行远隔缺血预适应治疗。根据有无侧枝代偿将患者分为两组,有侧枝代偿组12例,无侧枝代偿组18例。经颅多普勒超声(transcranial Doppler,TCD)检查证实患单侧颅内动脉中、重度狭窄或闭塞。磁共振成像(magnetic resonance imaging,MRI)检查除外脑占位病变及脑出血性病变。分别对两组患者的脑血流灌注显像结果进行对比分析。结果:无侧枝代偿组患者额、颞、顶、枕叶的血流灌注治疗前后无显著性差异(P>0.05),基底节、丘脑的血流灌注治疗前后有显著差异(t=-2.223,P=0.04;t=-3.164,P=0.006)。有侧枝代偿组患者治疗前后仅基底节区血流灌注有显著差异(t=-2.92,P=0.014),余额、颞、顶、枕叶及丘脑治疗前后血流灌注无显著差异(P>0.05)。结论:行远隔缺血预适应治疗的患者,治疗前后基底节血流灌注明显改善,与侧枝循环的存在与否无关;丘脑血流灌注变化与侧枝代偿有关,无侧枝代偿患者治疗后丘脑对缺血产生显著耐受性,有侧枝代偿者则变化不明显。     

单侧颈内动脉狭窄或闭塞患者脑血管储备力的评估

脑动脉狭窄会导致脑血流动力学发生改变,进而造成脑血管储备力（eerebrovaseular reserve,CVR）下降,CVR受损是卒中的独立危险因素,测定CVR可以预测卒中的发生。笔者用SPECT显像结合CO2吸入试验测定单侧颈内动脉（internal carotid artery,ICA）严重狭窄或闭塞患者CVR的变化。     

64层螺旋CT脑灌注联合CT血管造影对颈内动脉狭窄或闭塞的应用

目的探讨64层螺旋CT脑灌注(CTP)联合CT血管造影(CTA)对颈内动脉狭窄或闭塞的应用价值。方法根据病史或临床症状及体征诊断为颈内动脉及其分支的狭窄或闭塞50例患者分别行CTP和CTA扫描,评价CTP参数平均通过时间(MTT)、对比剂峰值时间(TTP)、脑血流量(CBF)、脑血容量(CBV)以及造影后颈内动脉狭窄程度。结果36例TIA患者患侧MTT延长较健侧具有显著性意义,rCBF侧较健侧无显著性意义,rCBV患侧较健侧无显著性意义。34例梗死组患者患侧MTT延长较健侧有显著性意义,rCBF患侧较健侧无显著性意义,rCBV患侧较健侧无显著性意义。结论 CTP联合CTA可以同时判断颈内动脉狭窄和脑组织局部血流灌注情况。     

应用多层螺旋CT评价脑缺血症状与颈动脉狭窄关系的研究

目的探讨基于多层螺旋CT血管造影(MDCTA)测量的颈动脉直径和脑血管症状之间的关系,寻找与症状相关的颈动脉狭窄的阈值。方法以接受MDCTA检查的230例可疑颈动脉狭窄患者为研究对象,记录患者有无大脑前循环障碍症状。所有患者均行MDCTA检查测量狭窄颈动脉直径,同时观测动脉粥样硬化斑块类型。利用ROC曲线对症状和狭窄颈动脉直径进行分析确定诊断阈值,利用Logistic多元回归探讨症状与狭窄颈动脉直径、粥样硬化斑块类型和其他变量之间的关系。结果症状组颈动脉直径明显较无症状组小,ROC曲线分析发现曲线下面积为0.720,出现脑缺血症状的最佳预测值为1.6mm,灵敏度为0.734,特异度为0.638。Logistic回归分析证实颈动脉狭窄和软斑块是脑血管症状的独立危险因素。结论利用MDCTA测量颈动脉直径能够较为可靠地预测脑缺血症状,脑缺血症状与颈动脉狭窄和软斑块密切相关,这对于MDCTA在脑卒中防治领域进一步应用具有重要意义。     

全脑CTP及动态CTA评估单侧大脑中动脉狭窄或闭塞患者侧支循环状态及预后的价值

目的探讨全脑CT灌注(CTP)及动态CT血管成像(CTA)在大脑中动脉(MCA)狭窄或闭塞患者侧支循环评估中的应用。方法选取我院收治的102例MCA狭窄或闭塞患者的临床资料,均行CTP结合动态CTA检查。统计CTA图像下MCA狭窄程度及MCA狭窄或闭塞侧与对侧脑灌注参数及侧支循环良好一端与侧支循环差一端的灌注参数相对值。结果102例单侧MCA狭窄或闭塞患者均得到了良好的CTA图像,其中46例完全闭塞患者,占45.1%,40例重度狭窄患者,占39.2%,16例中度狭窄患者,占15.7%;动态CTA图像显示MCA狭窄或闭塞一侧侧支循环良好的患者65例,占63.7%,随访3个月患者临床预后良好;侧支循环差的患者37例,占36.3%,随访患者临床预后差,生活质量差;相较于对侧,MCA狭窄或闭塞患者闭塞侧TTP、MTT明显更高,而CBF、CBV明显更低,差异均有统计学意义(均P<0.05);相较于侧支循环良好,MCA狭窄或闭塞一侧侧支循环差者rCBF、rCBV明显更低(均P<0.05),两者rTTP、rMTT差异无统计学意义(P>0.05)。结论全脑CTP及动态CTA可很好地评估一侧MCA闭塞或狭窄情况及侧支循环情况。     

Proton magnetic resonance spectroscopy in patients with symptomatic unilateral internal carotid artery / middle cerebral artery stenosis or occlusion

Purpose:

To explore the value of proton magnetic resonance spectroscopy imaging (¹H‐MRSI) in patients with stenosis or occlusion of the internal carotid artery (ICA) / middle cerebral artery (MCA).

Materials and Methods:

Fifty noninfarcted patients with stenosis or occlusion of unilateral ICA/MCA were included in our study. In the meantime, 25 patients with cerebral infarction and 25 healthy control subjects were enrolled. All patients and healthy control subjects underwent ¹H‐MRSI. Cerebral metabolic changes were studied in the noninfarcted patients and compared with the infarcted patients as well as healthy control subjects.

Results:

In 50 noninfarcted patients N‐acetylaspartate (NAA) decreased and choline increased in the ischemic hemisphere compared with the contralateral side and control subjects. Lactate peaks were observed in 12 patients. The metabolic changes were relatively slight but were associated with metabolic disruption in infarcted patients. There were relationships between metabolic abnormalities and neurological status of the noninfarcted patients.

Conclusion:

¹H‐MRSI can demonstrate abnormal metabolic changes in cerebral tissues with no infarction, while with ICA/MCA may show stenosis or occlusion at an early stage, which may help guide treatment decisions and preoperative evaluation. J. Magn. Reson. Imaging 2011;. © 2011 Wiley‐Liss, Inc.     

一站式CT灌注成像评估单侧颈内动脉重度狭窄或闭塞患者颅内血流动力学改变及Willis环侧支循环情况

【摘要】目的：通过对单侧颈内动脉重度狭窄或闭塞患者行脑CT灌注成像联合CTA一站式扫描,对其脑血流动力学改变及Willis环侧支循环代偿作用进行评价,为临床血管再通治疗提供血流动力学依据。方法：对40例经颈部血管超声或头颈CTA检查确定为单侧颈内动脉重度狭窄或闭塞患者（狭窄率>70%）行320排CTPI检查,重建灌注参数图及4D-CTA图。在基底节层面选取大脑前动脉供血区、大脑中动脉供血区及前、后分水岭区作为感兴趣区行灌注参数测量,包括脑血容量（CBV）、脑血流量（CBF）、平均通过时间（MTT）和达峰时间（TTP）,对患侧与健侧的各项灌注参数进行对比分析。根据CTA图将Willis环分为开放组及未开放组,对两组的dTTP（患侧TTP-健侧TTP）、dMTT、rCBF（患侧CBF/健侧CBF）及rCBV进行比较,采用χ2检验对比分析两组间各个兴趣区的缺血程度（rCBF＜80%为重度,＞80%为轻度）,评价Willis的代偿能力。结果：与健侧比较,患侧脑区MTT、TTP延长,CBV增大,CBF略下降,其中在大脑中动脉供血区和前、后分水岭区CBV、MTT、TTP差异有统计学意义（P＜0.05),大脑前动脉供血区MTT、TTP差异有统计学意义（P＜0.05）。Willis环未开放组各兴趣区dTTP、dMTT、rCBV和rCBF均高于开放组。仅前分水岭区的脑缺血程度与Willis环是否开放有相关关系（P=0.001）。结论：单侧颈内动脉重度狭窄及闭塞患者的患侧脑组织MTT、TTP延长,部分脑区CBF下降,处于低灌注状态;Willis环对患侧有一定的代偿作用,在前分水岭区代偿作用明显;CTPI可以为颈内动脉重度狭窄或闭塞患者提供血管再通依据。     

Differentiation of gray matter and white matter perfusion in patients with unilateral internal carotid artery occlusion

In this study, we investigated differences between gray matter and white matter perfusion in patients with a unilateral occlusion of the internal carotid artery (ICA) with dynamic susceptibility contrast. Seventeen patients and 17 control subjects were studied, using T2*-weighted gradient echo acquisition. Gray and white matter regions were obtained by segmentation of inversion recovery MRI. Lesions were excluded by segmentation of T2-weighted MRI. In the symptomatic hemisphere, cerebral blood volume was increased in white matter (P < .05) but not in gray matter. No cerebral blood flow changes were found. All timing parameters (mean transit time [MTT], time of appearance, and time to peak) showed a significant delay for both white and gray matter (P < .05), but the MTT increase of white matter was significantly larger than for gray matter (P < .05). These findings indicate that differentiation between gray and white matter is essential to determine the hemodynamic effects of an ICA occlusion.     

Transcranial Doppler ultrasound in the evaluation of collateral blood flow in patients with internal carotid artery occlusion: correlation with cerebral angiography.

PURPOSETo determine the accuracy of transcranial Doppler (TCD) ultrasound for evaluation of collateral supply through the circle of Willis in patients with internal carotid artery (ICA) occlusion.METHODSThe evaluation of the collateral pathways through the circle of Willis with TCD ultrasound and with cerebral angiography was compared in 40 patients (30 men, 10 women; mean age, 55 +/- 9 years) in a total of 44 ICA occlusions of which 43 had a suitable ipsilateral temporal bone window for TCD examination.RESULTSBy TCD, a patent anterior communicating artery is indicated by a reversal blood flow in the A1-segment of the anterior cerebral artery or by a prompt fall of blood velocity in the middle cerebral artery after compression of the nonoccluded contralateral carotid artery. In 42 of 43 instances of ICA occlusion, TCD and angiography agreed in the evaluation of a present or absent anterior communicating artery collateral supply. TCD''s sensitivity was 95%, its specificity 100%. A collateral supply through the basilar artery was assumed with TCD when there was: (a) a basilar artery blood velocity of more than 70 cm/s; (b) a marked increase of basilar artery blood velocity after compression of the nonoccluded carotid artery; (c) an evident side-to-side asymmetry of the blood velocity of the posterior cerebral arteries with high blood velocity ipsilateral to the ICA occlusion. For evaluating the collateralization via the basilar artery, TCD and angiography agreed in 37 of 40 ICA occlusions. TCD''s sensitivity was 87%, its specificity 95%.CONCLUSIONSTCD is a reliable tool for the evaluation of the collateral supply in patients with ICA occlusions.     

颈内动脉狭窄或闭塞侧支循环途径的DSA和MR血管成像研究

目的　研究DSA、MR血管成像 (MRA)对颈内动脉狭窄或闭塞后侧支循环途径评价的意义。方法　颈内动脉狭窄或闭塞者 74例 ,DSA和MRA上脑血管正常表现者各 6 0例为对照组 ,分析其DSA和MRA表现。结果　 74例患者均有颈内动脉分叉以上狭窄或闭塞。病变同侧后交通动脉在DSA上的出现率 ,疾病组低于对照组 (P =0 0 2 5 ) ;在时间飞跃 (TOF)法MRA上的出现率 ,疾病组明显高于对照组 (P =0 0 0 0 )。后交通动脉DSA、MRA测量值均较对照组增大 (P =0 0 0 0 )。眼动脉直径DSA测量值较对照组增大 (P =0 0 0 3)。疾病组后交通动脉出现率在DSA上高于MRA (P <0 0 5 )。结论　DSA对本病侧支途径评价有重要意义 ,为术前必要检查。MRA安全 ,可从形态和功能上评价侧支循环 ,可做为首选方法     

Reproducibility of quantitative CT brain perfusion measurements in patients with symptomatic unilateral carotid artery stenosis

BACKGROUND AND PURPOSE: To establish intraobserver and interobserver variability for regional measurement of CT brain perfusion (CTP) and to determine whether reproducibility can be improved by calculating perfusion ratios. MATERIALS AND METHODS: CTP images were acquired in 20 patients with unilateral symptomatic carotid artery stenosis (CAS). We manually drew regions of interest (ROIs) in the cortical flow territories of the anterior (ACA), middle (MCA), and posterior (PCA) cerebral arteries and the basal ganglia in each hemisphere; recorded cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT); and calculated ratios of perfusion values between symptomatic and asymptomatic hemisphere. We assessed intraobserver and interobserver variability by performing a Bland-Altman analysis of the relative differences between 2 observations and calculated SDs of relative differences (SDD(rel)) as a measure of reproducibility. We used an F test to assess significance of differences between SDD(rel) of absolute CTP values and CTP ratios, and the Levine test to compare the 4 perfusion territories. RESULTS: MTT was the most reproducible parameter (SDD(rel) 相似文献   

血管内支架置入治疗高危颈动脉狭窄

目的　评价伴对侧颈内动脉闭塞的高危颈内动脉狭窄病人血管内支架治疗的疗效和安全性。方法　 8例不适合颈动脉内膜剥脱的高危颈内动脉狭窄病人接受了血管内支架置入治疗。术前颈内动脉平均狭窄程度为 (85 2± 9 4) % (70 %～ 98% )。术前和术后 2 4h采用NIHSS评分 ,术前和术后 3个月采用改良Rakin评分标准对这些病人进行神经功能评分。术后随访 6～ 1 4个月。结果　术中造影证实 8枚支架均放置成功 ,残余狭窄程度 (5 3± 2 2 ) % (5 %～ 9% ) ,管腔狭窄程度较术前明显改善 (t=4 79,P <0 0 0 1 )。术中没有发生与手术相关的并发症 ,术后 2 4h病人的NIHSS神经功能评分保持在术前水平 [(2 5± 2 4)分 ] ;术后 3个月 ,改良Rakin神经功能评分为 (1 1 3± 0 99)分 ,同术前 (1 2 5± 1 2 8)分比较差异无显著性意义 (T =1 89,P >0 0 5)。术后随访 6～ 1 4个月 ,除 1例偶发一过性脑缺血发作 (TIA)外 ,其他病人未再出现TIA和新的中风。结论　血管内支架置入术是治疗高危颈内动脉狭窄安全、有效的治疗手段     

Endovascular recanalization of internal carotid artery occlusion in acute ischemic stroke

BACKGROUND: Endovascular therapy (ET) of internal carotid artery (ICA) stenosis is equivalent to carotid endarterectomy for stroke prevention; however, patients with ICA occlusion and acute symptoms are traditionally not candidates for ET. We report our experience in endovascular recanalization of acute stroke patients with ICA occlusion. PATIENTS AND TECHNIQUES: We reviewed our registry for acute stroke patients treated with ET who had (1) ICA occlusion by digital subtraction angiography (thrombolysis in myocardial ischemia=0) with location of type II (above ophthalmic artery involving M1 or A1 but not both) or type III (proximal to the ophthalmic artery but distal to the bifurcation); (2) acute stroke symptoms from the index lesion presenting 3 hours after onset of symptoms; (3) minimal ischemic changes on brain CT scan (less than one third of the MCA territory); (4) attempted ET. Neuroradiologists reviewed angiograms for thrombolysis in cerebral infarction. A blinded vascular neurologist reviewed post-procedural brain imaging for Alberta Stroke Program Early CT (ASPECT) scoring. Outcome scales were assessed. RESULTS: We identified 14 patients, 10 of whom were men (mean age, 58 +/- 14 years; median age, 54 years; age range, 40-74 years). There were 8 left ICA occlusions, 3 type II; and 6 right ICA occlusions, one type II. Median baseline National Institutes of Health Stroke Scale score was 17 (range, 11-25; mean, 18 +/- 4.9). Mean time to ET was 389 +/- 103 minutes (median, 306 minutes; range, 197-1290 minutes). Immediate recanalization occurred in 64%. Decrease in expected stroke volume by brain imaging occurred in 50% with mean ASPECT score of 4 +/- 2.9 (median, 3; range, 0-8; 21% > or = 8). Two hemorrhages occurred, one symptomatic; 3 patients died. Good outcome was achieved in 64% of cases. CONCLUSION: Endovascular therapy of carotid occlusion in hyperacute stroke patients is feasible and may help to reduce stroke volume and increase good outcome in some patients.     

颈动脉狭窄或闭塞患者数字记忆的功能磁共振成像研究

目的:探讨左侧颈内动脉/大脑中动脉狭窄和闭塞患者与正常人数字工作记忆的激活脑区差异及其记忆障碍的脑加工机制。方法:对12例左侧颈动脉狭窄/闭塞患者(其中左侧颈内动脉狭窄4例,左侧颈内动脉闭塞2例,左侧大脑中动脉狭窄5例,左侧大脑中动脉闭塞1例,24例正常对照组进行数字记忆任务的功能磁共振成像,采用AFNI软件进行数据分析和脑功能区活动图像。结果:左侧颈内动脉/大脑中动脉狭窄和闭塞患者的反应时间较对照组显著延长(P0.05),正确率较对照组明显降低(P0.05)。脑激活图显示数字工作记忆的编码期、保持期、提取期患者组的脑激活明显少于正常对照组,而且脑激活的左侧半球优势减弱,右侧半球出现代偿性激活,其中提取期最为明显。结论:左侧颈动脉狭窄/闭塞患者数字记忆任务的脑激活区存在损害,功能磁共振成像研究能为早期诊断认知障碍提供影像学依据。