貌似神经疾病的下肢动脉阻塞性疾病

目的 探讨下肢动脉阻塞性疾病误诊为神经疾病的原因及其与相关疾病鉴别的要点。方法 分析总结9例经Doppler超声，血管造影，手术等确诊为下肢动脉阻塞性疾病的发病形式，临床特征。结果 急性动脉阻塞组误诊脊前动脉综合征2例，周围神经病2例，脑梗死3例。慢性动脉阻塞组误诊腰椎管狭窄综合征伴腰骶神经根病1例，脊髓蛛网膜炎1例，结论 下肢动脉阻塞性疾病可以在早期出现与神经疾病相似的某些症状，应掌握其临床特征，进行筛选性的辅助检查，以便与神经疾病鉴别。     

Isolated supraclinoid occlusive disease of the internal carotid artery

Isolated supraclinoid occlusive disease of the internal carotid artery is a rare cause of cerebral ischemia. The authors of the only review of this subject concluded that it is caused predominantly by factors other than atherosclerosis. We examined 6 patients with isolated supraclinoid occlusive lesions. Five of them had one or more risk factors for atherosclerosis. Thus, the isolated stenosis of that part of the internal carotid artery does not seem to represent a particular pathologic entity.     

Brief loss of consciousness in bilateral carotid occlusive disease

Loss of consciousness is rare in the absence of transient or persistent insult to the diencephalon or mesencephalon. We found three patients with severe atherosclerotic stenosis or occlusion of both internal carotid arteries who experienced brief loss of consciousness. Common characteristics were the absence of clinical or electroencephalographic seizure activities, significant cardiovascular disease, or a history suggestive of vasovagal syncope. Angiographically, the patients had widely patent vertebrobasilar circulation and collaterals from vertebrobasilar to carotid circulation. Episodic loss of consciousness disappeared after carotid endarterectomy. We concluded that bilateral hemispheric ischemia caused brief loss of consciousness, but selective focal ischemia in the subcortical structures superimposed on widespread bihemispheric ischemia may have been responsible. Since loss of consciousness is rare in carotid occlusive diseases, systemic and vertebrobasilar causes must be carefully ruled out in each instance.     

Occipital infarction with hemianopsia from carotid occlusive disease

Extracranial internal carotid artery occlusive disease usually produces stroke in the middle cerebral artery territory or the border zone between the middle and anterior cerebral arteries. It is unusual for occipital infarction in the posterior cerebral artery territory to be caused by internal carotid artery disease despite the fact that the posterior cerebral artery may arise directly from the internal carotid artery as an anatomic variation. We describe a patient with a fetal posterior cerebral artery originating from the internal carotid artery, and the initial manifestation of his extracranial internal carotid artery occlusive disease was hemianopsia from occipital infarction.     

Doppler study of the ophthalmic artery in patients with carotid occlusive disease

Assessing the adequacy of collateral circulatory pathways has become increasingly important in the investigation of cerebral circulation. Using transorbital Doppler ultrasonography (TOD), we examined the ophthalmic artery (OA) in patients with hernodynamic significant internal carotid artery (ICA) occlusive disease. The velocity and the direction of flow in the OA were studied in 45 patients (occlusion n = 27, stenosis > 75% n = 18), and in 30 age matched controls, under baseline conditions and within 30 minutes after the i.v. administration of 1 g acetazolamide as a vasodilatory stimulus. Based on the direction of flow before and after acetazolamide, the 45 patients could be separated into four groups with increasing degree of ICA lesions. In group I the OA flow was anterograde, but the velocity decreased after acetazolamide. In group II the OA direction became retrograde after acetazolamide, indicating collateral flow to the brain. In patients with retrograde OA flow following acetazolamide injection (group 11-IV), the vessel reacted similarly to an intracranial artery, with marked increase in velocity when vasoreactivity was tested. TOD and the acetazolamide test provide useful information about potential collateral OA flow to the brain in patients with ICA occlusive disease.     

Patterns of perfusion-weighted imaging in patients with carotid artery occlusive disease

BACKGROUND: The importance of hemodynamic factors in the pathophysiology of stroke and transient ischemic attacks in patients with internal carotid artery (ICA) stenosis or occlusion remains controversial. OBJECTIVE: To investigate whether perfusion-weighted imaging (PWI) could identify pathophysiologically meaningful categories in patients with symptomatic and asymptomatic ICA occlusive disease. METHODS: Thirty-eight consecutive patients with occlusion (22 patients) or severe stenosis (16 patients) of the ICA, determined by ultrasonography or magnetic resonance angiography, were identified from the Beth Israel Deaconess Medical Center Stroke Database, Boston, Mass. Thirty-five patients were symptomatic (29 who had strokes and 6 who had transient ischemic attacks) and 3 were asymptomatic. All symptomatic patients underwent PWI within the first 24 hours after symptom onset. The patterns of PWI were analyzed according to the degree of ICA stenosis and the clinical presentation. RESULTS: Three patterns of perfusion abnormalities were identified: extensive hypoperfusion involving the middle cerebral arterial and/or anterior cerebral arterial territories (25 patients), localized perfusion deficits involving predominantly the ipsilateral border zone areas (8 patients), and normal perfusion (5 patients). All 3 patterns were found whether or not the ICA was occluded. Patients who had acute stroke most frequently had extensive perfusion deficits involving 1 or 2 territories while patients who had transient ischemic attacks often had hypoperfusion affecting the border zone regions. All asymptomatic patients had normal perfusion. CONCLUSIONS: In our sample the pattern of PWI related to the clinical presentation but not to the degree of ICA disease (occlusive vs severe stenosis). Our study findings add further support to the hypothesis that hypoperfusion is a major contributing factor in the pathophysiology of carotid artery occlusive disease.     

Cerebral vasomotor reactivity of the posterior circulation in patients with carotid occlusive disease

We evaluated the hemodynamic features of the posterior circulation in patients with severe carotid stenosis by assessing and comparing cerebral vasomotor reactivity (VMR) in the middle cerebral (MCA) and vertebral arteries (VA) by transcranial Doppler and the Diamox (1 g acetazolamide i.v.) test. Sixty symptomatic and 111 asymptomatic patients with unilateral severe (>70%) internal carotid artery stenosis were studied. The VMR was 19.2 +/- 18.9% for the MCA ipsilateral to the stenosis and 27.3 +/- 17.4% on the contralateral side (P < 0.0001) for all patients. It was 18.2 +/- 23.2% for the VA ipsilateral to the stenosis and 19.7 +/- 21% on the contralateral side (P = NS). The symptomatic patients' VMR of the MCA on the side of stenosis and the opposite side were 19.2 +/- 17.6 and 29 +/- 17.2%, respectively (P < 0.03). The VMR of the VA remained similar (15.1 +/- 21 and 21.6 +/- 6%, respectively, P = NS). The asymptomatic patients' VMR of the MCA on the side of the stenosis was also lower (19.2 +/- 19.7 vs. 26.5 +/- 17.5% on the opposite side, P < 0.001). In contrast, the VMR in the VA was similar (19.8 +/- 21.4 and 18.7 +/- 19.5%, respectively, P < 0.6, NS). Thus, the VMR of the posterior circulation remained similar regardless of carotid stenosis and a symptomatic/asymptomatic course of carotid occlusive disease, suggesting an independent cerebral vascular reserve capacity of the posterior circulation.     

Cerebral dysautoregulation and the risk of ischemic events in occlusive carotid artery disease

Dynamic cerebral autoregulation assessed from blood pressure transients can be considerably impaired in severe internal carotid artery (ICA) obstruction. It is unknown whether impaired autoregulation indicates an increased risk of subsequent ischemic events in this situation. 165 patients with ICA stenosis (> 70 %) or occlusion were prospectively followed until anterior circulation stroke, transient ischemic attack, carotid recanalization without prior event, death or study end. Transcranial Doppler sonography was used to determine autoregulation in both middle cerebral arteries from spontaneous blood pressure fluctuations (correlation coefficient indices Dx and Mx) and respiratory- induced 0.1 Hz oscillations (phase). Standard CO₂ reactivity (CO₂R) was additionally assessed. All indices were classified as impaired vs. preserved according to reference values from 79 agematched controls. During median follow-up of 24.5 months, there were 16 ischemic events over ipsilateral sides. Competing risk analysis revealed a significant predictive effect on ipsilateral ischemic events for impaired Dx (rate ratio 8.2 [95 % confidence interval 1.7–39], p = 0.0079), phase (5.0 [2–13], p = 0.0007) and CO₂R (9.4 [2.2–40], p = 0.0025). Restricting analysis to severe stenosis alone (n = 103), only impaired phase (rate ratio 8.6 [1.6–45], p = 0.01) remained as a significant predictor. In a continuous statistical model, only Dx and Mx were significant predictors of ischemic events (p = 0.012 and p = 0.016). In conclusion, impaired dynamic cerebral autoregulation indicates an increased risk of subsequent ischemic events in severe obstructive ICA disease. Its clinical application might thus be of help in identifying higher risk patients.     

External carotid occlusive disease as a cause of facial pain

A 47 year old man suffered an acute left hemiparesis after several weeks of right-sided facial pain. Right carotid angiography revealed internal carotid artery thrombosis and severe occlusion of external carotid branches supplying facial structures. An ischaemic aetiology for the facial pain is suggested.     

Neuropsychiatric findings in internal carotid artery occlusive disease with cerebrovascular damage

Summary The syndrome of internal carotid artery occlusive disease has been well described in the last 20 years. Its neurological complications are well-known. The criteria for its diagnosis are firmly established. Its psychiatric semeiology, however, has been ignored in general, although mental disturbances are frequent symptoms of internal carotid insufficiency and occlusion. It is for this reason that a group of patients with internal carotid occlusion who displayed psychiatric symptomatology, some of which was difficult to evaluate, is presented. The cases were selected from the records of 160 patients evaluated for internal carotid artery occlusive disease at the Columbia-Presbyterian Medical Center. Brief case reports are presented to illustrate the wide variability of the psychiatric symptoms in the syndrome, the problems involved in its differential diagnosis, and the role of personality factors in organic brain disease.The neurological signs and symptoms, natural history, the clinical and laboratory techniques helpful in diagnosis, and the etiologies and neuropathology of internal carotid artery occlusive disease are reviewed. An attempt is made to correlate information pertinent to the understanding of the behavioral changes associated with cerebrovascular disease.From the department of psychiatry, the Columbia-Presbyterian Medical Center and the New York State Psychiatric Institute, 722 West 168th Street, New York, New York 10032. The author is at present on naval service at the department of neurology and psychiatry, United States Naval School of Aviation Medicine, Pensacola, Florida. This paper was submitted for publication in May 1962.     

Stroke risk factors and development of collateral flow in carotid occlusive disease

Background and purpose – Blood flow through collateral vessels compensates for reduced blood flow through stenotic or occluded extracranial carotid arteries. Previous studies have shown that extent of collateral flow influences likelihood of stroke and its outcome. Here we analyzed the relationship between stroke risk factors (hypertension, coronary artery disease, diabetes mellitus, tobacco smoking and hypercholesterolemia) and number of patent intracranial collaterals detected by transcranial Doppler ultrasonography. Subjects and methods – We studied 182 patients with various degrees of angiography proven unilateral stenosis of the internal carotid artery. Contribution of the anterior and posterior communicating arteries to the perfusion of the cerebral hemisphere on the side of the stenosis or occlusion was evaluated by a series of compression tests performed during continuous insonation of the middle cerebral artery. The number of detected collateral vessels was correlated with analyzed stroke risk factors. Results – Subjects with stenosis more than 75% or occlusion of the internal carotid artery had a higher frequency of two major intracranial collateral vessels ( P 0.01 and P 0.001, respectively). Hypertensive patients with stenosis more than 75% or total carotid occlusion were more likely to have only a single collateral vessel than patients without hypertension ( P 0.01 and P 0.05, respectively). Other risk factors did not influence the patency of preformed collateral vessels. Conclusions – Hypertension hindered the development of preformed intracranial collateral vessels in our patients with carotid occlusive disease.     

Carotid compression tonography. Correlation with bilateral carotid arteriography in the diagnosis of extracranial carotid occlusive disease.

One hundred twenty two patients ahd carotid compression tonography (CCT) followed by bilateral carotid arteriogaraphy. Inthe group (82 patients) which was felt to have significant occlusive disease of internal carotid at the level of carotid bifurcation (smaller than 50 percent stenosis), the CCT showed a 92 per cent correlation with arteriography. Of the group (48 patients) that underwent endarterectomy, there was a 94 per cent correlation with CCT testing. In 40 patients, with normal arteriogram or with less than 50 percent stenotic lesions on arteriography, there was a larger number (25% of patients with a CCT test which appeared to indicate decreased flow. Various reasons for this are discussed. The high correlation of the CCT test and carotid arteriography in the patients with surgically amenable lesions would suggest that the CCT test is a good noninvasive screening technique for the detection of significant occlusive disease of the extracranialcarotid vascular system.     

Doppler ophthalmic blood pressure measurement in the hemodynamic evaluation of occlusive carotid artery disease

In 102 patients with angiographically proven occlusive carotid artery disease of 60-100% diameter reduction, Doppler ophthalmic artery pressure and blood flow direction were recorded by the recently developed ophthalmomanometry-Doppler technique. Among these 102 patients, 50 presented with complete carotid artery occlusions and 52 with carotid artery diameter stenoses of greater than or equal to 60%. Mean +/- SD Doppler ophthalmic artery pressure was 69 +/- 15 mm Hg ipsilateral to the occlusion and 86 +/- 18 mm Hg ipsilateral to a stenosis of the carotid artery (p less than 0.001). The mean +/- SD Doppler ophthalmic pressure index (ratio of the ophthalmic artery to systemic blood pressure) was lower ipsilateral to the occlusion (0.46 +/- 0.08) than ipsilateral to a carotid artery stenosis (0.54 +/- 0.08; p less than 0.001); in both, the index was clearly diminished compared with normal values (0.68 +/- 0.04; p less than 0.001). It is concluded that the intracranial hemodynamic consequences in the patients with occlusion are on average more profound than in the patients with stenosis. In carotid artery occlusions, the mean +/- SD ipsilateral ophthalmic pressure index was 0.46 +/- 0.06 for antegrade and 0.46 +/- 0.09 for retrograde ophthalmic artery blood flow. In carotid artery stenoses, the mean +/- SD ipsilateral ophthalmic pressure index was 0.55 +/- 0.07 for antegrade and 0.48 +/- 0.06 for retrograde ophthalmic artery blood flow (p less than 0.01). These results indicate that in carotid stenoses the collateral capacity of the ophthalmic artery is insufficient compared with intracranial collaterals, while in carotid occlusions the blood flow direction in the ophthalmic artery does not predict intracranial hemodynamic compensation.     

Noninvasive detection of occlusive disease of the carotid siphon and middle cerebral artery

Recently, transcranial Doppler sonography has been introduced into clinical practice for noninvasive investigation of the large intracranial arteries. To determine its accuracy for detection of stenosing or occluding lesions, 133 consecutive patients were studied by both transcranial Doppler sonography and selective cerebral arteriography. Statistical analysis of findings was done separately for various arterial segments. High values for sensitivity and specificity were found for detecting obstruction of the carotid siphon and main stem of the middle cerebral artery. Diagnostic reliability of transcranial Doppler sonography was also confirmed by the calculation of a chance-corrected measure of agreement (kappa), which was close to + 1 in all subanalyses. Transcranial Doppler sonography seems to be a valuable tool for noninvasive detection of intracranial lesions of the middle cerebral artery and carotid siphon.     

Detection of carotid occlusive disease by pulsed Doppler spectral analysis.

In this study a new pulsed Doppler spectral analysis system was used for the evaluation of extracranial carotid disease. When compared to the arteriography findings in 224 carotid arteries, the Doppler examination correctly detected all stenoses greater than 25%, all occlusions, all normal vessels, and 43% of stenosis causing a diameter reduction of less than 25%.