急性院内基底动脉闭塞所致呼吸心跳骤停血管内治疗1例

正1病例介绍患者,男性,63岁,退休工人。主因"头晕3 d,加重伴呼吸心跳骤停20 min"于2017年3月8日中午12时入郑州大学附属洛阳中心医院急诊重症监护室(emergency intensive care unit,EICU)。患者3 d前无明显诱因出现头晕,呈阵发性,无双眼黑蒙、视物旋转、视物不清及视物成双,无恶心、呕吐及肢体活动障碍,自测右上臂血压150/100 mm Hg,自服硝苯地平缓     

椎基底动脉延长扩张综合征一例

<正> 1 病例简介患者,男,51岁,因"右上肢麻木,右下肢活动力弱2个月"于2009年7月17日就诊于我院门诊。患者2个月前无明显诱因出现右上肢麻木,伴右侧面部发热感,自觉右下肢活动力弱,但不影响行走。左侧肢体均无感觉及活动异常。既往史:高血压病史10余年,血压最高200/100 mm Hg,长期服用"硝苯地平"和"依那普利",平素血压控制在150/90 mm Hg左右;高脂血症2个月,曾间断服用"辛伐他汀";否认糖尿病;吸烟3～5支/d,饮酒250ml/d。查体:左上肢血压145/90 mm Hg,右上肢血压140/90 mm Hg,颅神经检查未见明显异常。四     

椎基底动脉延长扩张症一例

患者男性,31岁。因突发性晕厥伴双下肢无力3 h,于2013年11月4日入院。患者于运动中突发短暂性意识丧失伴双下肢抽搐,无头痛、恶心、呕吐,无视物不清,无语言理解、表达障碍。急诊行头部CT检查可疑脑血管畸形（图1）。既往无高血压病史、其他基础疾病病史和脑卒中家族史;4年前罹患“心肌梗死”,治疗后好转,未再发。入院后体格检查：血压170/110mmHg（1mmHg=0.133kPa）、呼吸20次/min、脉搏76次/min、心率70次/min。     

双侧延髓内侧梗死一例

<正>患者男性,49岁。主因突发头晕2 d,言语不清、四肢无力1 d,于2013年5月7日入院。患者于入院前2 d晨起无明显诱因突发头晕伴恶心、呕吐,无视物旋转、肢体无力,症状持续存在,未予处理。入院前1 d出现言语不清、饮水呛咳,四肢无力,以左侧显著,并逐渐出现嗜睡。发病后6 h至我院急诊就诊,头部MRI检查显示双侧延髓内侧梗死。既往高血压病史20余年,血压控制欠佳,波动于170/110 mm Hg(1 mm Hg=0.133 kPa)。患者10年前曾发生过短暂性左上肢麻木,具体经过不详,否认其他病史。     

动静脉联合溶栓治疗急性大脑中动脉完全闭塞患者一例

患者,女性,74岁,因“突发右侧肢体无力伴神志不清2 h”,于2006年6月13日收入我院。患者入院前2 h(上午8点30分)活动中无明显诱因突发右侧肢体无力,并摔倒在地,继之呼之不应,由急救中心送至我院。当时查体:T 35．5℃,脉搏60次/分,呼吸20次/分,血压110/60 mm Hg (1mmHg=0．133kpa),双肺呼吸音粗。心率60次/分,     

反常栓塞致双侧丘脑旁正中区域梗死一例

临床资料 患者,女,24岁,主因"7 d前突发视物模糊、头晕、意识丧失1次,视物成双6 d"于2009年5月22日入院.患者7 d前晚间上网时无明显诱因突感视物模糊、变形,伴头晕及视物旋转,几分钟后意识不清,12 h后意识渐好转,视物成双,问话回答反应慢,不切题.既往史、个人史无特殊.体检:血压95/65 mm Hg(1 mm Hg=0.133 kPa),心率70次/min,律齐,各瓣膜区可闻及3/6级收缩期吹风样杂音.意识清楚,语言流利.高级皮质功能粗测正常.左侧眼球位置高于右侧,双眼球垂直运动欠灵活,有复视.     

表现为反复短暂性脑缺血发作的高血压脑干脑病1例并文献复习

正1病例资料患者,女,37岁,教师,以"发作性右侧肢体麻木、力弱1 d"为主诉(于2019年3月8日)入院。患者于入院前1 d上午正讲课时突发右侧肢体麻木,继而力弱,右上下肢活动不能,伴言语不清,无头晕、头痛、呕吐、意识障碍、抽搐等,症状持续约数分钟缓解,未行诊治。当晚约11点上述症状再次发作,约数分钟后缓解,到当地县医院住院,就诊时血压258/120 mm Hg,查颅脑CT排除出血,给予药物治疗(具体不详)。次日晨上述症状再发,持续将近1 min缓解,来我院。既往史:高血压病史7 y,7 y前及8 m前两次妊娠(剖宫产),妊娠期间有妊高症,终止妊娠后血压波动于150~140/100~90 mm Hg,未规律用药;     

动静脉溶栓桥接治疗基底动脉尖综合征1例体会

正1临床资料患者男,42岁,因"突发双下肢乏力伴视野缺损3h"于2015-01-02入住我院神经内科二病区,既往有高血压、糖尿病史多年,具体不祥,入院体格检查:血压170/105 mmHg,嗜睡状,双侧瞳孔等大等圆,直径2.5mm,对光反射稍迟钝,双侧视野缺损,右侧为主,伸舌尚居中,双下肢肌力3级,上肢正常,无肌张力亢进,双侧巴宾斯基征可疑阳性。入院时NIHSS评分为10分。入院后立即行磁共振检查,见图1、2、3。     

听诊阴性的左房黏液瘤致脑栓塞一例

临床资料 患者男性,46岁,因"突发意识不清、右侧肢体无力8 h"入院.2007年10月2日晚10时患者在看电视时突发呼之不应、右侧肢体不能活动,于3日晨2时送至我院就诊.发病前3 d有发热,体温最高达37.5℃,既往3年前有右胫骨下段骨折史,否认高血压、糖尿病、冠心病史.体检:血压110/70 mm Hg(1 mm Hg=0.133 kPa),呼之不应,双侧瞳孔等大等圆,直径3 mm,对光反射存在,眼震(一),右侧中枢性面舌瘫;左侧肢体见自主活动,右侧肢体肌力0级,右侧Babinski征(+).     

椎-基底动脉扩张延长症1例报告

椎-基底动脉扩张延长症(vertebrobasilar dolichoectasia,VBD)是目前正处于研究和探索阶段的一种脑血管变异性疾病,现将我院收治的1例VBD报告如下. 1 临床资料 患者,男,76岁,因"一过性意识不清、右侧肢体无力2d"于 2012年4月15 日入院.患者于2d前由座位站起时突发头晕,继之意识不清,摔倒在地,无抽搐,无尿便失禁,约1 min意识转清,醒后自觉右侧肢体无力,伴言语略不清,病来无视物成双,无饮水呛咳.既往高血压病史10年、左侧面肌痉挛3年.查体:BP 140/90mmHg,神清,言语略不清,眼球运动充分,无眼震,双侧额纹对称,右侧鼻唇沟浅,左侧面肌痉挛,伸舌右偏,右侧肢体肌力4级,腱反射对称,右Babinski(+).     

A simple technique to prevent and correct graft vessel kinking in the subcutaneous tunnel: technical note

Object

A simple method for preventing and correcting graft kinking for vascular reconstructive surgery through a subcutaneous tunnel is described.

Patients and methods

Using a chest tube, 1-0 silk suture and cerebral aneurysmal clips, the problem of postoperative ischemic complications due to kinking can be solved.

Conclusion

The main advantages of this method are its simplicity and low cost. Using this method does not require any special equipment and the problem of postoperative ischemic complications due to vascular injury, kinking and vasospasms can be addressed.     

Importance of the perforating arteries in the proximal part of the PICA for surgical approaches to the brain stem and fourth ventricle - an anatomical study

Objective

The purpose of this study is to examine the perforating arteries (PAs) in the proximal part of the posterior inferior cerebellar artery (PICA) for surgical approaches to the brain stem and fourth ventricle, and to stress their importance in microsurgical procedures.

Methods

Twenty-six adult cadaver obtained from routine autopsies were used. During the examination, the PAs and the segmental structure of the proximal part of the PICAs and their relation to the neighbouring anatomical structures were demonstrated.

Results

We classified the PICAs into 4 types on the basis of the distance of the middle point of the width of the caudal loop to the midline, and their presence or absence as Group A (symmetrical, anterior medullary type: 26.9%), Group B (lateral medullary type: 15.4%), Group C (asymmetrical type: 38.5%), and Group D (unilateral type: 19.2%). The number of the PAs in the tonsillomedullary segment and the caudal loop was higher than those originating from the other segments.

Conclusions

Approaches to the medial or lateral of the PICA should be made in a way that protects the PAs (avoiding retraction of the PICA). Otherwise the PAs will be damaged and as a result brain stem ischaemia may occur, which can have serious clinical outcomes.     

Risk factors for multiple intracranial aneurysms rupture: A retrospective study

Background and purpose

The presence of predicting the rupture risk of intracranial aneurysms has recently generated considerable controversy. We retrospectively investigated the risk factors for multiple intracranial aneurysms related to rupture.

Methods

Between July 2007 and July 2011, 134 patients with 294 aneurysms were identified after review. Every patient had two or more aneurysms. Univariate and multivariate logistic regression models were used to analyze the risk factors for multiple intracranial aneurysms with age, gender, site and size.

Results

134 patients were divided into three groups according to patient age category (<45, 45–65, >65 years of age). The incidence of aneurysms ruptured in the second group was significantly higher. Three groups showed significant difference (P = 0.001 versus >65 years of age). Thirteen of 35 AComA aneurysms were ruptured, accounting for 26% of all ruptured aneurysms, and the rate of rupture at AComA aneurysms in patients was 37.1%. The rate of aneurysm rupture in the AComA was significantly higher than that in other sites (P = 0.001). In all 294 aneurysms, 88.1% of the aneurysms were 5 mm or less, of which 58.2% were less than 3 mm. In the ruptured aneurysms, 68% were 5 mm or less.

Conclusions

Our study reveals the pattern of ruptured multiple intracranial aneurysms, in terms of age, size and location of aneurysms. Age, size, and site of aneurysm should be considered in the decision whether to treat an unruptured aneurysm or not. Especially, in cases of multiple aneurysm, the AComA aneurysm is most prone to hemorrhage.     

基于多对比度磁共振血管壁成像技术对前循环症状性颅内外动脉粥样硬化斑块特征的对比研究

目的 基于多对比度MRI血管壁成像技术,比较颅内动脉、颅外动脉粥样硬化斑块的特征。 方法 回顾经3D多对比度头颈联合MRI血管壁成像检查确定存在前循环症状性颅内外动脉粥样硬化 斑块的患者资料。观察斑块分布情况;测量斑块负荷,包括斑块最大管壁厚度、长度、管腔狭窄程度; 分析斑块内成分,包括脂质坏死核、出血、钙化,对比分析颅内动脉和颅外动脉粥样硬化斑块的影像 学特征。 结果 在入组的45例患者中,共检出颅内、外动脉粥样硬化斑块203个,其中颅外动脉斑块156 个（76.8%）,颅内动脉斑块47个（23.2%）。颅外动脉粥样硬化斑块最大管壁厚度（[ 3.2±1.0）mm vs （1.9±0.4）mm,P <0.001]、斑块长度[10.7（7.5～13.7）mm vs 4.3（2.6～6.3）mm,P <0.001]大于颅内动 脉,而颅内动脉管腔狭窄程度[28.0%（20.0%～38.5%）vs 18.8%（10.8%～30.5%）,P <0.001]重于颅外 动脉。颅外动脉粥样硬化斑块内脂质坏死核的发生率高于颅内动脉（66.0% vs 21.3%,P <0.001）,而 斑块内出血的发生率颅内动脉高于颅外颈动脉（27.7% vs 13.5%,P =0.027）。 结论 在合并有颅内外动脉粥样硬化斑块的患者中,颅外动脉的斑块最大管壁厚度、斑块内脂质 坏死核的发生率高于颅内动脉,而管腔狭窄程度、斑块内出血的发生率低于颅内动脉。     

Is the surgical repair of unruptured atherosclerotic aneurysms at a higher risk of intraoperative ischemia?

Background

The incidence of ischemia might be increased in the surgical repair of atherosclerotic unruptured aneurysms compared to non-atherosclerotic aneurysms. The atherosclerotic wall might increase the occurrence of thrombembolic events or its rigidity might endanger the occlusion of perforators within the aneurysm vicinity.

Methods

87 patients (53 patients without and 34 patients with atherosclerotic unruptured aneurysms, 50.5 ± 9.7 years) were analyzed for severity of atherosclerosis within the aneurysm and the aneurysm bearing vessel, surgical maneuvers, intraoperative alterations in evoked potentials and clinical and neuroradiological results.

Results

Temporary vessel occlusion (25% vs. 50%, p = 0.021), repositioning of a permanent clip (21% vs. 56%, p = 0.001) and aneurysm remnants (2% vs. 18%, p = 0.012) occurred more often in patients with atherosclerotic aneurysms. At 6 months, 3/34 patients with atherosclerosis (8.8%) had an unfavorable outcome, all patients without atherosclerosis had a favorable outcome (p = 0.056).

Conclusion

The surgical repair of unruptured aneurysms is safe but patients with atherosclerotic altered vessels and aneurysms accounted to a minor increase in unfavorable outcome and an increased risk of morbidity at 6 months postoperatively. This factor should be taken into consideration when performing surgery of atherosclerotic, unruptured aneurysms.     

New method of thrombus preparation using a fluid model for evaluation of thrombectomy devices in a swine model

Background

Mechanical thrombectomy is a promising new modality of interventional stroke treatment. Preparation of thrombus is a very important step for the evaluation of the mechanical thrombectomy devices. The objective of this study was to explore a new method of thrombus preparation with fluid model (FM) for assessment of thrombectomy devices used in the recanalization of acute ischemic stroke.

Methods

Elongation test and catheter injection test were used to evaluate the mechanical properties of thrombi prepared by FM and static model (SM). Histological structures of two artificial clots and specimens of stroke patients were compared. Radiopacity of thrombus made by FM was evaluated in a swine embolization model.

Results

The maximum tensile length of thrombi prepared by FM and SM were significantly higher (4.28 ± 0.23 cm vs 3.16 ± 0.13 cm, P < 0.01) and showed less breakage on catheter injection test (13% vs 60%, P < 0.05). Histological features of thrombi prepared by FM showed mixed thrombus structure, similar to thromboemboli retrieved from acute stroke patients, while clots generated by SM were replete with erythrocytes. A total of twelve vessels in two swine were successfully occluded (TIMI 0 or 1), with sufficient radiopacity of each injected thrombus.

Conclusion

The thrombus prepared by FM had good mechanical stability, sufficient radiopacity, and similar histological structure of thromboemboli retrieved from stroke patients, which make it possible to be used in the evaluation of thrombectomy devices.     

Vascular complications of stereotactic radiosurgery for arteriovenous malformations

Objective

Although vasculopathy and de novo aneurysm formation are known complications of traditional radiation therapy, their occurrence following AVM SRS is rare and thus infrequently addressed in the literature. We sought to evaluate these phenomena through a review of our institutional experience.

Methods

Our review afforded 32 patients treated with LINAC-based SRS over an eight year period. We noted obliteration rates, complication rates and long-term outcomes, with particular attention paid to follow-up angiographic studies.

Results

After a mean follow-up of 4.3 years, the overall obliteration rate was 50%, increasing to 87% for AVMs less than 3 cm. Eight patients had nine hemorrhages following SRS (25%). One occurred in the context of a de novo arterial pseudoaneurysm and another in the context of a new venous varix. Two patients with post-SRS hemorrhage had intranidal aneurysms that were not as apparent on initial angiography. Two patients that did not suffer from latency period hemorrhage developed dysplastic changes of feeding arteries, and one patient suffered from early venous thrombosis with resultant permanent hemiparesis from infarction. After a mean follow-up of 4.3 years, 8 patients were clinically improved (25%), 19 were the same (59%), and 5 were worse (16%), including 2 that died as a result of latency period hemorrhage.

Conclusion

While radiosurgery of AVMs is safe and successful in the vast majority of cases, vasculopathic complications including de novo aneurysm and varix development, early venous occlusion and stenotic vasculopathy, while infrequent, can occur. Closer long-term angiographic surveillance of these patients may thus be warranted.     

颈内动脉和大脑中动脉狭窄与闭塞患者的64排螺旋CT脑容积灌注成像

目的探讨64排螺旋CT脑容积灌注成像（CT perfusion imaging,CTP）与头颈CT血管成像（CT angiography,CTA）联合应用在颈内动脉（internal carotid artery,ICA）或大脑中动脉（middlecerebral artery,MCA）狭窄与闭塞患者中的应用价值.方法对5名健康人及17例患者（ICA狭窄11例、MCA狭窄6例）行CT平扫、CTP和CTA检查,分析灌注延迟表现与病变动脉及其狭窄程度的关系.结果17例患者8例CT平扫未见异常,9例有腔隙性脑梗死和（或）陈旧脑梗死.平均通过时间（mean transit time,MTT）和达峰时间（time to peak,TTP）图灌注延迟表现分为3型：Ⅰ型病变仅累及MCA区,Ⅱ型病变仅累及分水岭区,Ⅲ型病变累及MCA和分水岭区.ICA重度狭窄或闭塞患者Ⅲ型7例,MCA重度狭窄或闭塞患者Ⅰ型4例.64排CT可同时获得容积CTP和颅底动脉环动态CTA,其动态CTA图像质量与常规CTA近似.结论MTT、TTP能够敏感显示灌注损伤,对ICA或MCA重度狭窄或闭塞诊断、治疗及脑梗死发病机制研究有重要价值.64排CT可得到包括基底节在内的上下8个层面的图像,可以更多地显示16层以下螺旋CT显示不到的病变,如脑干、小脑的梗死等.CTP联合CTA能够早期诊断脑梗死,并同时从功能和形态学上综合分析脑缺血的程度和原因,获得更详细的信息,为临床医师尽早进行合理治疗提供客观的影像学依据.     

颈动脉内膜剥脱术治疗中重度颈动脉狭窄的临床研究

目的以颈动脉支架置入术(CAS)为对照,分析颈动脉内膜剥脱术(CEA)在治疗中重度颈动脉狭窄的临床价值。方法将100例颈动脉狭窄患者按手术方法不同分为观察组(CEA)和对照组(CAS),记录2组围术期手术相关并发症;记录手术用时、住院时间、治疗费用;随访12个月,记录2组包括死亡在内的不良反应发生率及改良Rankin评分情况。结果观察组与对照组在围术期手术相关并发症、住院时间、术后6个月不良反应发生率及改良Rankin评分比较均无明显差异(P均0.05)。但观察组治疗经费低于对照组(P0.05)。结论颈动脉支架置入术治疗中重度颈动脉狭窄效果良好,术后近期和远期疗效及治疗安全性与颈动脉内膜剥脱术相当,但颈动脉内膜剥离术费用成本较低,并发症少。