经颅多普勒超声脑缺血溶栓分级与阿替普酶静脉溶栓治疗急性前循环不同大动脉闭塞性脑梗死预后相关性研究

目的探讨分析经颅多普勒超声脑缺血溶栓分级与静脉溶栓治疗急性前循环不同大动脉闭塞性脑梗死患者血管再通评价与预后的相关性研究。方法选择急性前循环大动脉闭塞性脑梗死患者,对符合静脉溶栓者给予阿替普酶静脉溶栓治疗,分别于溶栓前及溶栓后24 h行床旁经颅多普勒超声(transcranial Doppler,TCD)检查并记录脑缺血溶栓分级(thrombolysis in brain ischemia,TIBI)。采用美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分记录患者临床神经功能缺损,3个月随访时采用改良Rankin量表(modified Rankin Scale,m RS)评分评估患者预后,分析前循环不同大血管闭塞性脑梗死患者静脉溶栓前后血管再通情况及患者3个月预后。结果共入选46例患者,其中颈内动脉(internal carotid artery,ICA)闭塞患者19例,大脑中动脉(middle cerebral artery,MCA)闭塞患者27例。溶栓前与溶栓后24 h TCD监测TIBI分级提示血管再通者,ICA闭塞组5.26%,MCA闭塞组55.56%。ICA闭塞组与MCA闭塞组比较,MCA闭塞组90 d随访生活自理及良好预后的比例均高于ICA闭塞组,死亡率低于ICA闭塞组,而两组间溶栓后的症状性颅内出血发生率差异无显著性。结论急性前循环大动脉闭塞性脑梗死经静脉溶栓治疗后可获得血管再通,尤其是MCA闭塞患者;溶栓前后TIBI血流分级变化可反映大动脉血管再通情况,且有助于判断患者临床预后。     

An update on the diagnosis and treatment of adult Moyamoya disease taking into consideration controversial issues

Abstract

Moyamoya disease (MMD) is characterized by a chronic progressive steno-occlusive disease at the distal portion of the internal carotid artery (ICA) with abnormal Moyamoya vessel (MMV) development without associated diseases. Recent advances in radiologic tests have increased the number of MMD patients. Beyond detection improvement by magnetic resonance angiography (MRA) or cerebral angiography, predicting factors for disease severity, future hemorrhage, clinical outcome, post-op complications, and technical advances in assessing cerebral hemodynamics have been increasingly reported. Although treatment of pediatric MMD is well established, controversy remains over the treatment in adult patients. In particular, there are debates over the disease entity of adult MMD, contralateral progression in adult unilateral MMD, treatment strategy for asymptomatic adult MMD, and the association of MMD with thyroid disease. The purpose of this review is to provide an update on the diagnosis and treatment of adult MMD while addressing controversial issues.     

大脑中脑动脉供血区急性脑梗死病灶类型与进展性脑梗死的关系

目的 探讨大脑中动脉供血区急性脑梗死病灶类型及其与进展性脑梗死的关系.方法 回顾性分析140例大脑中动脉供血区急性脑梗死患者病历资料及脑MRI、DWI、MRA影像资料,其中进展组71例,非进展组69例.结果 2组脑梗死类型均可见流域性脑梗死、分水岭脑梗死、纹状体内囊梗死、腔隙性梗死,进展组以分水岭脑梗死(45.1%)、纹状体内囊梗死(46.5%)为主,非进展组以流域性脑梗死(44.9%)为主,2组脑梗死病灶类型比较,差异有统计学意义(χ2=24.829,P<0.01).结论 大脑中动脉供血区急性分水岭脑梗死、纹状体内囊梗死易表现为进展性脑梗死.     

Multiple encephalogaleoperiosteal synangiosis for bilateral carotid artery stenosis in a 13-year-old girl: a case report

Introduction

Encephalogaleoperiosteal synangiosis (EGS) has been widely used to treat children with moyamoya disease (MMD). We present the first case of successful multiple EGS in a patient with brain ischemic disease who presented with different cerebrovascular findings from MMD.

Methods

A 13-year-old girl had an increased frequency of transient ischemic attacks that affected her right extremities. Digital subtraction angiography showed tapering of the internal carotid artery (ICA). The anterior cerebral artery (ACA) and middle cerebral artery (MCA) were visible on vertebral angiogram, but not on carotid angiogram. The intact circle of Willis and lack of hypervascularity of the lenticulostriate arteries were observed. Decreased regional cerebral blood flow (CBF) in the bilateral ACA and MCA territories quantified by ¹²³I-N-isopropyl-p-iodoamphetamine-single photon emission computed tomography indicated the need for extracranial-intracranial bypass surgery. Multiple EGS procedures were performed instead of direct anastomosis, which is the standard procedure for intracranial ICA stenosis, because the space for the craniotomy was limited by transdural anastomosis.

Results

Despite the fact that the diagnosis of MMD was questionable, the hemispheres were well vascularized, and the neurology and CBF improved postoperatively.

Conclusion

The preserved circle of Willis and lack of moyamoya vessels were inconsistent with the features of MMD. However, childhood onset, bilateralness, chronic intracranial ICA stenosis, and transdural anastomosis indicated the same underling pathogenicity as MMD. It is hypothesized that ICA stenosis occurred immediately proximal to the posterior communicating artery in this case. This would have produced the atypical finding of the remaining circle of Willis without growth of the basal moyamoya vessels.

     

Duplicated Middle Cerebral Artery Aneurysms Treated by Coil Embolization; A Report of Two Cases and Literature Review

BackgroundDuplication of the middle cerebral artery (DMCA) is an anomalous vessel arising from the internal carotid artery (ICA). Aneurysms at the origin of a DMCA have been reported; however, most have been treated with clipping surgery. Here, we describe two cases of aneurysms at the origin of a DMCA treated with coil embolization.Case presentationCase 1: A seventy-three year-old man presented with severe headache and was diagnosed with subarachnoid hemorrhage (SAH). Digital subtraction angiography (DSA) and 3-dimensional (3-D) DSA showed an aneurysm arising from a DMCA. Coil embolization was performed with DMCA patency. The patient had an uneventful postoperative course.Case 1A 44-year-old woman presented with a history of clipping for an IC-anterior choroidal artery (AchA) aneurysm 8 years prior. Magnetic resonance imaging (MRI) showed regrowth of the aneurysm. 3-D DSA showed an IC-DMCA aneurysm located laterally and distal to the AchA. The DMCA arose from the bottom of the aneurysm. Coil embolization was performed without DMCA occlusion and showed no postoperative ischemic changes.ConclusionAn IC-DMCA aneurysm is rare and may be misdiagnosed as an AchA aneurysm. Clinicians should perform a 3D-DSA evaluation if the aneurysm arises from the lateral wall of the IC to obtain a precise diagnosis and to preserve the DMCA during coil embolization.     

Internal carotid artery agenesis: diagnosis,clinical spectrum,associated conditions and its importance in the era of stroke interventions

Abstract

Background: Internal carotid artery (ICA) agenesis has been usually reported as an asymptomatic condition in association with other congenital anomalies. However, it is less well described in the context of clinical neurological syndromes.

Method: Five cases of ICA agenesis are reviewed. The diagnosis of ICA agenesis was based on the absence of bony carotid canal on computed tomography. Brain CT and magnetic resonance image (MRI) scans were done in all the patients and four vessels digital angiograms were obtained in two. Clinical presentation, coexistent radiological findings and associated abnormalities are reviewed.

Findings: The initial presentations were pulsatile tinnitus, ischemic stroke, migraine, Horner's syndrome, and subarachnoid hemorrhage. Collateral circulation was supplied via the posterior communicating artery and the anterior communicating artery. Ophthalmic artery was supplied by meningeal arteries. On CT, all cases demonstrated agenesis of the bony carotid canal. Smaller cavernous sinus were detected in all cases, enlargement of the foramen spinosum was found in three patients and hyper-pneumatization of the petrous apex was detected in two cases. In one patient a cerebral aneurysms was detected and treated with an endovascular approach. Other associated vascular abnormalities were aortic origin of the vertebral artery in two patients, ICA coiling in two cases and fenestration of basilar artery in one case.

Conclusion: ICA agenesis is usually asymptomatic but occasionally may be associated with ischemic stroke. Collateral supply is usually effective in preventing stroke but may become inefficient leading to ischemia. Associated anomalies such as cerebral aneurysms are commonly depicted on the same side as the ICA agenesis and may represent a potential life-threatening condition.     

Neuro-endoscopic management of hemorrhagic moyamoya disease in the acute stage: single institute experience

ABSTRACT

Background: Management of hemorrhagic moyamoya disease (MMD) is one of the most challenging issues in neurosurgical practice. Recently, surgical revascularization by superficial temporal artery-middle cerebral artery anastomosis was reported to significantly reduce the risk of re-bleeding in hemorrhagic-onset MMD patients in the chronic state, but the optimal treatment strategy in the acute phase of hemorrhagic MMD is undetermined. Thus, we retrospectively analyzed our surgical results for hemorrhagic MMD in the acute stage, focusing on the efficacy of neuro-endoscopic management for hematoma removal.

Materials and methods: Among 26 consecutive hemorrhagic MMD patients who were managed at our institution in the acute stage, 8 patients with intracerebral hemorrhage underwent surgical evacuation of the hematoma. All patients were diagnosed with MMD before surgery by magnetic resonance angiography and/or catheter angiography.

Results: The initial surgical procedure was neuro-endoscopic hematoma removal in seven patients and microsurgical hematoma removal by craniotomy in one patient. One patient treated by the neuro-endoscopic procedure required subsequent small craniotomy due to difficulty in hemostasis. Satisfactory hematoma evacuation was achieved in all eight patients, as demonstrated by post-operative computed tomography, although one patient who was deeply comatose before surgery died in the early post-operative period.

Conclusion: Neuro-endoscopic hematoma removal may be the optimal management method for hemorrhagic MMD in the acute stage in terms of the maximum preservation of pre-existing collateral anastomosis without affecting the potential donor vessels used for future revascularization surgery.

Abbreviations: MMD: Moyamoya disease; STA: Superficial temporal artery; MCA: Middle cerebral artery; JAM: Japan Adult Moyamoya; ICH: Intracerebral hemorrhage; IVH: Intraventricular hemorrhage; SAH: Subarachnoid hemorrhage; CT: Computed tomography; TE: Total evacuation; PE: Partial evacuation; SMR: Light mass reduction; MR: Magnetic resonance; mRS: Modified Rankin scale; GCS: Glasgow Coma Scale; ICP: Intracranial pressure.     

Preoperative brain temperature imaging on proton magnetic resonance spectroscopy predicts hemispheric ischemia during carotid endarterectomy for unilateral carotid stenosis with inadequate collateral blood flow

Objective Preoperative magnetic resonance (MR) angiography sometimes shows the absence of collateral flow via the circle of Willis. This study examined whether brain temperature (BT) imaging on multi-voxel proton MR spectroscopy after this finding increases the accuracy of predicting hemispheric ischemia during internal carotid artery (ICA) clamping during endarterectomy for patients with symptomatic unilateral carotid stenosis.

Methods In 52 patients with ICA stenosis (≥70%) and absence of collateral blood flow via the circle of Willis on preoperative MR angiography, BT imaging was displayed using proton multi-voxel MR spectroscopy. The difference between BTs in the affected and contralateral hemispheres (BT_{affected hemisphere} ? BT_{contralateral hemisphere}) in the deep white matter of the centrum semiovale was calculated and defined as hemispheric ΔBT. Development of cerebral hemispheric ischemia during ICA clamping was determined from intraoperative electroencephalography (EEG).

Results Multivariate analysis revealed that high preoperative hemispheric ΔBT was significantly associated with development of EEG-defined hemispheric ischemia (95% confidence intervals [CIs], 5.376–15.452; p = 0.006). The positive-predictive value for development of EEG-defined hemispheric ischemia was significantly greater for preoperative hemispheric ΔBT following preoperative MR angiography (95%CI, 42–87%) than for preoperative MR angiography alone (95%CI, 13–37%).

Conclusions For patients without collateral flow via the circle of Willis, BT imaging increases the predictive accuracy for development of hemispheric ischemia during ICA clamping during CEA.     

Accuracy and Criteria for Localizing Arterial Occlusion With Transcranial Doppler

The authors determined transcranial Doppler (TCD) accuracy for the proximal internal carotid artery (ICA), distal ICA, proximal middle cerebral artery (MCA), distal MCA, anterior cerebral artery (ACA), posterior cerebral artery (PCA), terminal vertebral artery (tVA), and basilar artery (BA) occlusion in cerebral ischemia patients. Detailed diagnostic criteria were prospectively applied for TCD interpretation independent of angiographic findings. Of 320 consecutive patients referred to the neurosonology service with symptoms of cerebral ischemia, 190 (59%) patients also underwent angiography (MRA or DSA). 48 of those 190 patients had angiographic occlusion and 12 of those 48 patients had involvement of multiple vessels. Median time from TCD until angiography was performed was 1 hour (41 patients had angiography before TCD). TCD showed 40 true positive, 8 false negative, 8 false positive, and 134 true negative studies with sensitivity 83.0%, specificity 94.4%, positive predictive value 83.0%, negative predictive value 94.4%, and accuracy 91.6% to determine all sites of occlusion. Sensitivity for each individual occlusion site was: proximal ICA 94%, distaiiCA 81%, MCA 93%, tVA 56%, BA 60%. Specificity ranged from 96% to 98%. TCD is sensitive and specific in determining the site of the arterial occlusion using detailed diagnostic criteria, including proximal ICA and distal MCA lesions. TCD has the highest accuracy for ICA and MCA occlusions. If the results of TCD are normal, there is at least a 94% chance that angiographic studies will be negative. Key words: ultrasound, transcranial Doppler sonography, stroke, occlusion, angiography.     

Long-term changes of hemodynamics and metabolism after carotid artery occlusion

OBJECTIVE: To investigate whether in selected patients with internal carotid artery (ICA) occlusion and initially normal oxygen extraction fraction (OEF) measured with PET, subsequent changes of cerebral hemodynamics and metabolism occur during long-term follow-up and, if so, whether the changes are associated with atrophy of the corpus callosum or subsequent ischemic strokes. BACKGROUND: The course of the changes in cerebral hemodynamics and metabolism after ICA occlusion remain unclear. After ICA occlusion, an increase in OEF may increase the risk of cerebral ischemia, and an increase in cortical ischemia would cause progression of callosal atrophy. METHODS: The authors used PET and MRI to examine twice seven medically treated patients with unilateral ICA occlusion and initially normal OEF at intervals ranging from 24 to 64 (mean +/- SD, 42 +/- 17) months. No intervening ischemic attacks occurred between the two examinations. RESULTS: In the hemisphere with ICA occlusion, OEF increased and blood flow decreased during follow-up. At the follow-up evaluation, abnormally increased OEF values were found in three patients, in whom ipsilateral ischemic strokes occurred during subsequent follow-up (18 +/- 6 months). A decrease in oxygen metabolism also occurred and was significantly correlated with the decrease of callosal size. CONCLUSIONS: These preliminary findings in a small, selected patient sample suggest that in patients with ICA occlusion and initially normal OEF, deteriorations of cerebral hemodynamics and metabolism during long-term follow-up may be associated with callosal atrophy or subsequent ischemic strokes.     

头颅CT灌注成像在球囊闭塞试验中的辅助作用

目的探讨头颅CT灌注成像（CTP）在球囊闭塞试验（BOT）中的辅助判断作用。方法 20例经DSA确诊的颈内动脉巨大动脉瘤患者,临床判断为BOT阴性的同时行头颅CTP,通过比较双侧半球的脑血流量（CBF）、脑血容量（CBV）及达峰时间（TTP）对脑血流动力学进行评估。结果 20例患者均在BOT过程中完成CTP且无任何脑缺血症状,17例（85.0%）灌注对称,判断为耐受性良好,16例行永久性颈内动脉球囊闭塞术（其中4例联合动脉瘤部分栓塞术）,1例行颈内动脉慢性阻断术;3例（15.0%）灌注不对称,主要为阻断侧TTP延长,CBV正常或轻度升高,而CBF基本正常,即存在早期的脑血流动力学损害,认为其无法耐受颈内动脉的永久闭塞,其中2例行颅内外动脉搭桥联合动脉瘤孤立术,1例行支架辅助的动脉瘤致密栓塞术,载瘤动脉保留完整。所有患者随访15～32个月,均无远期缺血并发症。结论 CTP能检出BOT阴性者潜在的脑血流动力学损害,可以更客观地评估其对颈内动脉永久闭塞的耐受力,是BOT的重要补充。     

Ocular Ischemic Syndrome due to Internal Carotid Artery Occlusion with Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF-1) is associated with multiple vascular abnormalities, including internal carotid artery (ICA) stenosis/occlusion. Depending on the site of stenosis/occlusion of the ICA, both cerebral circulation and ocular circulation can be impaired. We describe a rare pediatric case of ocular ischemic syndrome (OIS) due to ICA occlusion in NF-1. The patient diagnosed with NF-1 suffered right ICA occlusion at 12 years of age, and developed right dense vitreous hemorrhage due to OIS at 13 years of age. The patient underwent right cerebral revascularization surgery to improve cerebral and ocular ischemia, but the visual acuity of the right eye did not improve. This case suggests that attention should be paid not only to cerebral ischemia but also to ocular ischemia in patients with ICA stenosis/occlusion of NF-1. Surgical interventions such as cerebral revascularization surgery should be considered in the early stages of OIS to protect visual function, and careful follow-up is required.     

Cerebral ischemia in patients with orthostatic syncope--the significance of orthostatic hypotension and large vessel disease in the cervical and intracranial region]

We performed 90 degrees head-up tilting test for 10 minutes in 100 patients (66 men and 34 women) aged 50 years or more suffering from transient orthostatic syncope and measured their systolic blood pressure. Orthostatic hypotension (OH) was found in 51 patients, predominantly in men (38 cases). OH was complicated by large vessel disease (LV) as shown by MR angiography or carotid artery ultrasonography in 19 cases (37.3%). Progressive cerebral ischemia was found more frequently in patients with both OH and LV than in those with OH alone. Within the patients with OH alone, the drop in orthostatic blood pressure was greater in cases where progressive cerebral ischemia was present. In patients with both OH and LV, the minimum orthostatic systolic blood pressure was lower in those with progressive cerebral ischemia. These facts show that the marked drop in orthostatic blood pressure may be related to cerebral ischemic lesions and that the combination of OH and LV may develop cerebral ischemia in older patients with transient orthostatic syncope.     

Plasma nitrite as an indicator of cerebral ischemia during extracranial/intracranial bypass surgery in moyamoya patients

Background and PurposeNitric oxide (NO) plays a key role in ischemia and shows potential as a biomarker for ischemia. We measured mixed venous nitrite (NO₂^-) as a proxy for NO, during controlled cerebral ischemia in patients with moyamoya disease (MMD) during direct extracranial/intracranial (EC/IC) bypass surgery with temporary occlusion of the M4 branch of the middle cerebral artery (MCA) to permit anastomosis with the superficial temporal artery (STA). This small, focal ischemic event is not reliably detected using cerebral oximetry, somatosensory evoked potentials (SSEPs) or electroencephalography (EEG).MethodsWe enrolled nine adult MMD patients (n=8 female, n=1 male) undergoing direct EC/IC bypass surgery. Nitrite was measured at least one hour prior to MCA occlusion, and before, during and after anastomosis. Cortical function was monitored using either multi-lead EEG and SSEPs, or frontal EEG activity.ResultsMixed venous NO₂^- was significantly elevated (p<0.05) within 12 min following arterial occlusion vs. baseline. An M4 branch of the MCA was cross clamped for a median duration of 18 (IQR = 5) minutes during anastomosis. One patient with elevated NO₂^- showed a transient neurologic deficit that resolved 3 days post-operatively.ConclusionsMixed venous NO₂^- was significantly elevated shortly following cerebral artery occlusion vs. baseline in a majority of the study subjects, suggesting that NO₂^- is a potential biomarker for ischemia. Since all patients received identical burst suppression anesthesia and vasopressors, the fact that NO₂^- was not elevated during cross-clamp in all patients supports the conclusion that the NO₂^- elevation is likely due to ischemia.     

Hemodynamic reserve and high-intensity transient signals in moyamoya disease

BACKGROUND: Moyamoya disease (MMD) as a rare obstructive cerebrovascular disease is assumed to present with ischemic symptoms due to hemodynamic compromise. However, alternative mechanisms, such as cerebral embolism in low-flow territories, may also contribute to clinical symptoms. The incidence of high-intensity transient signals (HITS) and the degree of hemodynamic compromise were studied in symptomatic patients with MMD. METHODS: Twenty-four patients (17 female, 7 male; mean age 33 +/- 13 years) with clinical symptoms attributable to cerebral ischemia and the angiographic features of MMD (21 definite form, 3 probable MMD; 22 patients 'late stage' MMD, 2 patients 'early stage' MMD) in 45 affected hemispheres were enrolled in the present study. Patients underwent parallel estimation of hemodynamic compromise by means of functional blood flow (rCBF) studies using SPECT, PET or xenon-CT and HITS detection by TCD. RESULTS: Hemodynamic compromise was observed in 37/40 (92%) hemispheres studied. During TCD monitoring, HITS were detected in 3 patients (12.5%), with a total frequency of 3 (6.6%) in the 45 hemispheres investigated. All patients with HITS showed hemodynamic compromise in functional rCBF studies. In these patients, HITS were recorded ipsilateral to the symptomatic hemisphere. HITS occurred in late stage MMD patients only once, while both cases with early stage MMD demonstrated multiple HITS. CONCLUSIONS: The incidence of HITS in patients with MMD appears to be lower compared to patients with atherosclerotic or atherothrombotic arterial obstructions. In addition, ischemia-related symptoms in 'late stage' MMD seem to be caused by hemodynamic compromise in the majority of these patients.     

Evaluation of angiographic changes of the anterior choroidal and posterior communicating arteries for predicting cerebrovascular lesions in adult moyamoya disease

To ascertain the relationship between angiographic changes of the anterior choroidal and posterior communicating arteries (AChA-PComA) and cerebrovascular lesions in adult patients with moyamoya disease (MMD), we reviewed cerebral angiograms from 132 adult patients with MMD (68 with ischemia and 64 with hemorrhage). The angiographic findings of the AChA-PComA in each symptomatic hemisphere were graded on a scale of 0 to 3. The data were statistically analyzed for correlation with cerebrovascular lesions. Extension with abnormal branches and excessive dilation of the AChA-PComA accounted for 28 of the hemorrhagic lesions (28/64, 43.8%), especially intraventricular hemorrhage (16/28, 57.1%; p < 0.001). Additionally, when the occlusion was proximal to the PComA of the internal carotid artery, the posterior circulation territory was susceptible to ischemic lesions or subarachnoid hemorrhage (SAH) (p < 0.001), particularly aneurysmal SAH (p < 0.001). The angiographic characteristics of AChA-PComA may predict the onset of certain cerebrovascular lesions in adult patients with MMD.     

Progression of unilateral moyamoya disease: A clinical series

BACKGROUND: The natural history of unilateral moyamoya disease (MMD) in adult patients is not clearly described in the literature. We present a series of 18 patients with unilateral MMD and analyze the risk factors for progression to bilateral disease. METHODS: A retrospective review of 157 MMD patients treated at Stanford University Medical Center from 1991 to 2005 identified 28 patients with unilateral MMD (defined as none, equivocal or mild involvement on the contralateral side). RESULTS: Eighteen patients (5 males and 13 females) were identified with unilateral MMD and angiographic follow-up of > or =5 months. Mean radiologic follow-up (+/- standard error of the mean) was 19.3 +/- 3.4 months and mean clinical follow-up was 24.5 +/- 3.7 months. Five patients had childhood onset MMD and 13 patients had adult onset disease. Angiographic progression from unilateral to bilateral disease was seen in 7 patients (38.9%) at a mean follow-up of 12.7 +/- 2.4 months. Four of the 7 patients had significant clinical and radiologic progression requiring surgical intervention. Five of 7 patients that progressed had adult onset MMD. The presence of equivocal or mild stenotic changes of the contralateral anterior cerebral artery (ACA), middle cerebral artery (MCA) or internal carotid artery (ICA) was an important predictor of progression (p < 0.01); 6 of 8 patients (75%) with equivocal or mild contralateral disease progressed, whereas only 1 of 10 patients (10.0%) with no initial contralateral disease progressed to bilateral MMD. One patient had mild or equivocal MCA, ICA and ACA stenosis at the time of initial diagnosis and this patient progressed. CONCLUSIONS: Contralateral progression in the adult form occurs more commonly than previously reported. The presence of minor changes in the contralateral ACA, intracranial ICA and MCA is an important predictor of increased risk of progression. Patients with a completely normal angiogram on the contralateral side have a very low risk of progression.     

缺血型烟雾病脑硬膜动脉血管融通术后血管重建效果及影响因素

目的 探讨缺血型烟雾病脑硬膜动脉血管融通术（encephalo-duro-arterio-synangiosis,EDAS）后血管重建效果及影响因素。方法 回顾性分析在我院接受EDAS术治疗的120例缺血型烟雾病患者的临床资料,对性别、首次手术年龄、术前脑糖代谢情况、脑梗死类型、手术侧别、颈内动脉分期、大脑后动脉分期、前后循环间代偿以及左右侧代偿与术后动脉向颅内生长情况之间进行多因素logistic回归分析。结果 本组病例中102例患者接受双侧手术,18例接受单侧手术,总共手术为222例侧。术后动脉向颅内生长的有174例侧,血管重建有效率78.4%。多因素logistic回归分析显示首次手术年龄［优势比（odds ratio,OR）为1.03,95%可信区间（confidence interval,CI）1.012～1.049］,大脑后动脉分期（OR =0.767,95%CI 0.601～0.977,P =0.0319）,左右侧代偿（OR =0.499,95%CI 0.280～0.891,P =0.0188）及脑梗死类型与血管重建效果有关。相对于正常脑组织,皮层梗死（OR =0.275,95%CI 0.133～0.569,P =0.0005）、皮层下白质梗死（OR =0.317,95%CI 0.131～0.763,P =0.0104）和点状梗死（OR =0.392,95%CI 0.193～0.796,P =0.0096）血管重建效果更好。结论 EDAS可以有效建立颅内外血管重建。首次手术年龄越低、大脑后动脉分期越高、有左右侧代偿可以获得更好的术后血管重建;相对于正常脑组织,出现皮层梗死、皮层下白质梗死和点状梗死类型脑组织可获得更好血管重建效果     

儿童缺血型烟雾病的临床和影像分析

【摘要】
目的 分析儿童缺血型烟雾病患者的临床和影像特点,探讨脑梗死的相关因素。
方法 回顾性分析2011年6月～2012年6月收治的27例儿童缺血型烟雾病患者的临床及影像学资料。
大脑半球分为无脑梗死半球32侧和脑梗死半球22侧,将患者性别、年龄、造影特点（包括54侧半球
的Suzuki分期、大脑后动脉分期,眼动脉、颞浅动脉、脑膜动脉、枕动脉、上颌动脉和后循环向前循
环代偿）与脑梗死的发生进行统计分析。
结果 27例患者的临床资料显示性别和年龄与脑梗死的发生差异不具有显著性（性别χ2=2.095,
P =0.148;年龄χ2=4.286,P =0.453）。根据半球计算：皮质脑梗死17侧（17/22）,额叶梗死14侧
（14/22）,皮质下脑梗死9侧（9/22）。无梗死侧半球和梗死侧半球Suzuki分期以及大脑后动脉分期
的差异具有显著性（Suzuki分期Z=－3.054,P =0.002;大脑后动脉分期Z=－4.557,P <0.001）。眼动脉、
颞浅动脉、脑膜动脉、枕动脉、上颌动脉和后循环向前循环代偿与脑梗死的发生差异不具有显著性。
结论 本研究显示儿童缺血型烟雾病皮质脑梗死较皮质下脑梗死常见。在皮质脑梗死中,额叶脑
梗死最常见。脑梗死的发生与Suzuki分期和大脑后动脉受累程度有关。