单侧颈动脉闭塞脑梗死和侧支代偿情况分析

目的 通过计算机断层扫描（computer tomography,CT）和磁共振成像（magnetic resonance imaging,MRI）研究闭塞颈动脉同侧半球的梗死情况,分析不同侧支的代偿能力,增进我们对梗死机制的理解。方法 颈部血管彩色超声证实的43例单侧颈动脉闭塞患者,将颈动脉闭塞同侧的大脑半球分为大脑中动脉皮层区域、前皮层分水岭区域、后皮层分水岭区域、内分水岭区域、穿支动脉供血区域,比较各个解剖区域发生梗死情况,并分析侧支代偿种类和不同解剖部位梗死的关系。结果 颈动脉闭塞时,内分水岭区发生梗死最多见19例（44.2%）,8例前皮层分水岭梗死有6例伴有内分水岭区梗死。后交通动脉（posterior communicating artery,PCoA）出现是减少内分水岭区梗死的保护性因素[比值比（odd ratio,OR）为0.226,95%可信区间（confidence interval,CI）在0.058～0.833间,P =0.027]。结论 颈动脉闭塞时,内分水岭区发生梗死最多见,提示内分水岭区是对血流下降最敏感的区域。PCoA开放能够减少内分水岭区梗死。     

缺血性卒中病变血管和侧支循环代偿的研究

目的 观察缺血性卒中患者的责任病变血管及其侧支循环代偿方式,探讨脑动脉闭塞或严重狭窄时侧支循环的代偿作用与牛津郡社区卒中项目(OCSP)临床症状分型之间的关系.方法对211例缺血性卒中患者采用OCSP分型(完全型前循环梗死36例,部分前循环梗死94例,后循环梗死31例,腔隙性梗死50例),进行数字减影全脑血管造影检查,判定梗死的责任血管、侧支循环是否建立及代偿方式.结果 检出有病变血管的患者198例,共累及病变血管206支,责任血管为颈内动脉98条、大脑中动脉54条、椎动脉27条、颈总动脉6条、基底动脉5条、锁骨下动脉4条、大脑前动脉及大脑后动脉各2条;经Willis环代偿98例,软脑膜支吻合115例,颅外代偿46例.结论脑动脉病变最多位于颈内动脉、大脑中动脉,其次位于椎动脉,前循环病变较后循环病变具有更高的梗死发生率;侧支循环代偿以Willis环最充分,软脑膜支吻合最常见;脑梗死的临床分型受病变血管与侧支循环代偿的综合影响.     

颈动脉病变与前循环梗死亚型关系

目的研究颈动脉病变与前循环梗死亚型之间的关系。方法采用彩色多普勒超声对116例颈内动脉系统脑梗死患者双侧颈总及颈内动脉进行探查,观察颈动脉病变特点,分析不同类型粥样斑块与脑梗死亚型的相关性。结果①68·2%的脑梗死患者存在不同程度的颈动脉病变,69·8%的患者颈动脉轻度狭窄;②左侧半球梗死的患者其同侧颈动脉粥样斑块数量远大于对侧,右侧半球梗死的患者其同侧斑块数量也大于对侧(P<0·005),同时随着颈部病变血管和斑块数量增加,颅内病变范围及程度也增加(P<0·005);③皮质支及动脉主干型脑梗死患者中不稳定性斑块35例,稳定性斑块9例;中央支梗死、分水岭区梗死及白质损害患者中不稳定性斑块分别为5例、4例、9例,稳定性斑块为17例、7例、20例。结论①颈内动脉系统病变与前循环梗死相关,同时颈动脉狭窄程度并不是前循环梗死唯一相关因素,颈动脉粥样斑块性质可能与其密切相关;②颈动脉病变与颅内病灶存在对应关系,同时颈动脉粥样硬化的程度和范围与脑梗死的程度相关,而且Willis环不仅对脑血流供应起调节和代偿作用,同时也促使微血栓向对侧及其他血管转移;③不稳定性斑块与皮质支脑梗死及动脉主干型脑梗死相关而稳定性斑块则与中央支脑梗死、分水岭区梗死及弥漫白质损害相关。     

脑分水岭梗死的临床特点及其发病机制研究

目的探讨脑分水岭梗死的临床特点及其发病机制。方法根据脑血管分布的影像学模板,回顾分析124例脑分水岭梗死患者的临床资料,确定并分析皮质分水岭梗死、皮质下型分水岭梗死和混合分水岭梗死3组患者的临床特征及病理生理机制。结果3组脑分水岭梗死患者的临床特征间差别无显著性意义(P＞0．05);皮质分水岭梗死的发病率与皮质下型分水岭梗死间差别有显著性意义(P＜0．001)。其中接受DSA检查的95例患者中,75．0%的皮质分水岭梗死有严重血管狭窄,60．7%皮质下型分水岭梗死有严重血管狭窄,9例混合分水岭梗死患者均有严重血管狭窄。结论分水岭梗死与脑动脉血管狭窄有密切的关系。     

同型半胱氨酸与脑分水岭梗死的关系

目的探讨血浆同型半胱氨酸(Hcy)与脑分水岭梗死(CWI)的关系以及Hcy水平与其严重程度的关系。方法采用荧光偏振免疫分析检测法(FPIA)测定62例脑分水岭梗死(CWI)患者与58例健康者血浆Hcy水平,同时记录入院时神经功能缺损评分(NIHSS),并分析两者间的关系。结果病例组血浆Hcy水平高于对照组(P<0.01);病例组不同亚型脑分水岭梗死间血浆Hcy水平差异无统计学意义(P>0.05);中、重型脑分水岭梗死组血浆Hcy浓度显著高于轻型组(P<0.01)。结论血浆Hcy水平可能与脑分水岭梗死的发生及神经功能缺损程度有关。     

评估分水岭脑梗死患者侧支代偿对早期神经功能的影响

目的探讨不同分型分水岭脑梗死的侧支代偿情况及其对早期神经功能的影响。方法选取2018-01-2018-12郑州大学第一附属医院收治的33例分水岭脑梗死(cerebral watershed infarction,CWI)患者作为研究对象,并行DSA检查评估侧支循环分级,对比侧支代偿良好和较差2组患者的临床特征。结果皮质下型相对较多13例(40%),良好侧支循环组血管再通率较侧支循环较差组高(P0.05),1周后NIHSS评分2组相比也有显著差异(P0.05)。结论评估分水岭脑梗死患者的侧支代偿情况对判断患者的早期预后具有重要的参考价值。     

脑分水岭梗死CT、MRI与病因研究

目的:探讨脑分水岭梗死的CT、MRI表现及其与病因之间的关系,为脑分水岭梗死的防治提供依据。方法:分析46例经头颅CT或MRI证实的脑分水岭梗死的临床资料、病因和影像学改变。结果:双侧脑分水岭梗死14例,占30.4％,其中皮层前型4例,皮层下型10例,主要病因为低血压,低血压伴颈动脉狭窄;单侧脑分水岭梗死32例,占67.39％,其中皮层前型14例,皮层后型15例,皮层下型3例,主要病因为颈动脉狭窄、糖尿病、低血压及血液流变学异常。结论:双侧脑分水岭梗死主要病因为低血压或低血压伴颈动脉狭窄;单侧脑分水岭梗死主要病因为颈动脉狭窄、糖尿病、低血压、血液流变学异常及血脂异常等,为脑分水岭梗死的预防和治疗提供依据。     

大脑中动脉重度狭窄或闭塞患者脑梗死病灶类型与CT灌注成像分析

目的比较大脑中动脉(MCA)重度狭窄或闭塞患者不同脑梗死病灶类型的灌注状态。方法对89例MCA严重狭窄或闭塞患者进行头颅320排CTA+CT灌注成像检查,比较不同梗死病灶类型患者MCA闭塞率、侧支循环程度、MCA供血区灌注情况。结果 89例患者中,穿支动脉梗死(PAI)8例(9.0%)、皮质分支动脉梗死(PI)7例(7.9%)、大面积梗死(LTI)7例(7.9%)、分水岭梗死(BZI)43例(48.3%)、多发性脑梗死(MI)13例(14.6%)、无梗死灶11例(12.4%);不同类型梗死灶间MCA M1段病变、血管闭塞及不良侧支循环比率差异无统计学意义(均P0.05)。不同类型梗死灶局部脑血流量(rCBF)患健比、达峰时间(TTP)患健比差异有统计学意义(均P0.05)。BZI组rCBF患健比显著高于LTI组与无梗死灶组(均P0.05);LTI组及BZI组TTP患健比显著高于无梗死灶组及PAI组(均P0.05),MI组TTP患健比较无梗死灶组升高(P0.05)。LTI组MCA供血区低灌注发生率显著高于无梗死灶组(P0.05)。不同亚型BZI组间低灌注异常及不良侧支循环率差异有统计学意义(均P0.05),各灌注参数、MCA M1段病变及闭塞比率差异无统计学意义(均P0.05)。结论 LTI为失代偿期表现,低灌注发生率最高,其余类型为代偿期表现。皮质下型分水岭梗死较其他亚型侧支循环差,低灌注发生率更高,与血流动力学受损为主要病因的观点相符。MCA重度狭窄或闭塞患者脑梗死病灶类型以BZI为主。     

CTA评估分水岭脑梗死患者侧枝循环的初步研究

目的初步探讨侧枝代偿在分水岭脑梗死(CWI)发病中的作用。方法应用CT血管成像(CTA)技术,回顾性分析于我院住院治疗的139例分水岭脑梗死(包括皮质型、内侧型及混合型)患者的颅内动脉,比较各组患者相关血管病变及侧枝代偿情况。结果 (1)CTA显示110例患者存在颈动脉系统病变,其中49例为颈内动脉(ICA)狭窄/闭塞,61例为大脑中动脉(MCA)狭窄/闭塞;(2)在内侧型分水岭梗死(IWI)患者中,存在MCA狭窄/闭塞者(46例)高于ICA狭窄/闭塞(31例)和无明显狭窄(16例),差异有统计学意义(P=0.000);(3)ICA狭窄/闭塞时,前交通动脉(ACOA)未开放者在IWI患者所占比例(25/31例)明显多于皮质型分水岭梗死患者(5/11例)和混合型分水岭梗死患者(3/7例),差别有统计学意义(P=0.033);(4)MCA狭窄/闭塞时,软脑膜侧枝代偿较差者在皮质型分水岭梗死患者所占比例(6/9例)明显多于IWI患者(11/46例)和混合型分水岭梗死患者(1/6例),差别有统计学意义(P=0.028)。结论颈动脉系统病变所致的IWI受MCA的狭窄/闭塞影响程度更大;ICA狭窄/闭塞所致IWI梗死与ACOA缺乏或发育不良有关,ACOA的存在可以明显减少IWI发生;MCA病变时软脑膜代偿的出现可增加受累皮质的血供,软脑膜侧枝代偿较差可促进皮质型分水岭脑梗死的发生。     

TCD脑血流动力学参数与大面积脑梗死颅内侧支循环代偿及神经预后的关系

目的 探讨经颅多普勒超声（TCD）脑血流动力学参数与大面积梗死颅内侧支循环代偿及神经预后的关系。方法 选取2021-08—2022-08在南充市中心医院治疗的大面积梗死患者86例,其中单纯前交通动脉（ACoA）代偿患者20例,单纯后交通动脉（PCoA）代偿患者18例,单纯眼动脉（OA）代偿患者15例,ACoA合并PCoA代偿患者20例,无侧支代偿患者13例;根据改良Rankin量表（mRS）评估,预后良好患者68例,预后不良患者18例;比较各分层患者TCD脑血流动力学参数：大脑中动脉收缩期峰值流速（Vs）、舒张期峰值流速（Vd）、平均血流速度（Vm）、搏动指数（PI）和阻力指数（RI）的差异,分析其与患者颅内侧支循环代偿及神经预后的关系。结果 入院2周后大脑中动脉Vs、Vd和Vm比较中：ACoA合并PCoA代偿组>ACoA代偿组>PCoA代偿组>OA代偿组>无侧支代偿组,差异有统计学意义（P<0.05）;入院2周后大脑中动脉PI、RI比较中：ACoA合并PCoA代偿组相似文献   

肾上腺髓质素对局灶性脑缺血再灌注大鼠神经元凋亡、梗死体积及Egr-1的影响

Objective To observe the influence of adrenomedullin (ADM) on neuron apoptosis, infarction volume of brain, and the expression of early growth response 1 (Egr-1) mRNA in ischemia-reperfusion rats. Methods The arteria cerebri media was tied for 2 h to construct the ischemia model. Infarction volume was detected by triphenltetrazolium chloride (TTC) staining, neuronal apoptosis and necrosis was detected with terminal deoxynucleotidyl transferase nick labeling (TUNEL) method, and the Egr-1 mRNA expression was examined by in situ hybridization (ISH). Results Infarction volume after ischemia-reperfusion is (269 +/- 20) mm(3). Infarction volume after injection of ADM through different ways are femoral vein (239 +/- 17) mm(3) (decreased by 11.2%), arteria carotis (214 +/- 14) mm(3) (by 20.4%) and lateral cerebral ventricle (209 +/- 13) mm(3) (by 22.3%), respectively. The results indicate that injecting ADM through arteria carotis and lateral cerebral ventricle is much more effective than it through femoral vein (P < 0.05). The TUNEL-positive cells in cerebral cortex or hippocampus are few in the sham operation group, but much more in the ischemia-reperfusion group. After being supplied with ADM, especially through arteria carotis interna or lateral cerebral ventricle way, the TUNEL-positive cells decreased obviously. Expression of Egr-1 mRNA was low in the cerebral cortex of the sham operation group rats, enhanced in the ischemia and reperfusion group rats, and enhanced markedly after treatment with ADM, especially through arteria carotis interna or lateral cerebral ventricle way (P < 0.01). Conclusion Injection of ADM through different ways could alleviate neural dysfunction, decrease neuron apoptosis and brain infarction volume, and increase the expression of Egr-1 mRNA.     

VEGF基因修饰MSCs移植对脑梗死大鼠血管源性机制的实验研究

目的观察经尾静脉注射携带VEGF基因的MSCs移植对脑梗死模型大鼠血管生成方面的影响。方法采用直接贴壁全骨髓法分离纯化MSCs,通过脂质体转染技术将pIRES2-EGFP-VEGF导入MSCs,另采用改良Zea Longa线栓法将40只SD大鼠制成左侧大脑中动脉栓塞/再灌注模型,并随机分4组:VEGF-MSCs组、MSCs组、PBS组、Model组;造模24 h后Model组不做处理,前3组大鼠分别经尾静脉注射1 ml VEGF-MSCs、MSCs、PBS悬液;细胞移植7d后用免疫组织化学法测定脑梗死周围Ang-2、CD34的表达水平。结果 VEGF-MSCs组和MSCs组Ang-2、CD34阳性表达水平较PBS组、Model组高(P<0.05),且VEGF-MSCs组较MSCs组更高(P<0.05);Model组与PBS组差异不明显(P>0.05)。结论经尾静脉注射携带VEGF基因的MSCs移植入MCAO模型大鼠可以促进缺血脑组织新生血管的形成,其机制可能为VEGF上调缺血周边区域Ang-2、CD34的表达水平。     

Statin enhancement of collateralization in acute stroke

Collateral circulation influences cerebral infarction occurrence and size. Statins may improve ischemic stroke outcomes. We evaluated the relationship between prestroke statin use and pretreatment angiographic collateral grade among acute ischemic stroke patients presenting with occlusion of a major cerebral artery. After adjusting for covariates, the statin-treated group had significantly higher collateral scores than non-statin users, suggesting an association between statin use and better collateralization during acute stroke.     

Relationship between visual field defect and arterial occlusion in the posterior cerebral circulation

(1) The extent and severity of visual field loss has been compared in a series of 14 patients with occlusions of the posterior cerebral artery or its branches, all verified angiographically. Atheroma, embolism, and migraine were the commonest types of underlying vascular disease. (2) Occlusion of the main trunk of the artery was associated with severe and permanent field loss usually with some sparing of the central area and, in one case, of some field adjacent to the vertical meridian. It is suggested that this is due to collateral blood flow reaching the margins of the posterior cerebral territory from the adjacent middle cerebral territory via pial anastomoses. (3) Single or multiple occlusions of the main branches of the posterior cerebral artery gave variable amounts of field loss with considerable recovery in some cases. Collateral blood flow from the middle cerebral territory and from other branches of the posterior cerebral artery was demonstrated and the variation may be due to the size and number of pial anastomoses and to systemic factors such as blood pressure and vascular reactivity. (4) Occlusion of smaller branches of the calcarine artery produced localized zones of capillary underperfusion near the posterior cerebral pole. These corresponded to scotomatous paracentral defects in the visual field which were often permanent and showed no central sparing. The potential capacity of the collateral system may be limited by occlusion of intracerebral arteries or by involvement of segments of the pial arteries in the disease process.     

Cerebral hemodynamics in relation to patterns of collateral flow.

BACKGROUND AND PURPOSE: We sought to investigate the relation between collateral flow via different pathways and hemodynamic parameters measured by dynamic susceptibility contrast-enhanced MRI in patients with severe carotid artery disease. METHODS: Dynamic susceptibility contrast-enhanced MRI was performed in 66 patients and 33 control subjects. Patients had severe stenosis (>70%, n=12), unilateral occlusion (n=38), or bilateral occlusion (n=16) of the internal carotid artery (ICA). Cerebripetal flow and collateral flow via the circle of Willis were investigated with MR angiography. Collateral flow via the ophthalmic artery was investigated with transcranial Doppler sonography. RESULTS: Patients with ICA stenosis had well-preserved cerebral perfusion and were in general not dependent on collateral supply. Patients with unilateral ICA occlusion had impaired cerebral perfusion. However, appearance time, peak time, and mean transit time in white matter were less increased in patients with than in patients without collateral flow via the circle of Willis (P<0.05). Furthermore, patients with collateral flow via both anterior and posterior communicating arteries had less increased regional cerebral blood volume than patients with collateral flow via the posterior communicating artery only (P<0.05). Patients with bilateral ICA occlusion had severely compromised hemodynamic status despite recruitment of collateral supply. CONCLUSIONS: In patients with unilateral ICA occlusion, the pattern of collateral supply has significant influence on hemodynamic status. Collateral flow via the anterior communicating artery is a sign of well-preserved hemodynamic status, whereas no collateral flow via the circle of Willis or flow via only the posterior communicating artery is a sign of deteriorated cerebral perfusion.     

Experimental cerebral infarction. Part 1: Production of thalamic infarction in dogs

Difficulties in achieving focal temporary cerebral ischemia in experimental animals have delayed study of the prevention and treatment of cerebral infarction. We have succeeded in producing focal cerebral infarction by temporary occlusion of brain arteries. Infarction confined to the anterior portion of the thalamus was obtained by simultaneous occlusion of the 4 cerebral arteries: internal carotid, anterior cerebral, middle cerebral and posterior communicating arteries for 60-120 minutes. This experimental model in dogs is unique, since thalamic infarction can be produced with high frequency, and the dogs can be kept alive and managed for sufficient periods after temporary artery clipping. With this model it is possible to investigate cerebral infarction not only from the pathophysiological viewpoint, but also from the viewpoint of prevention and treatment of cerebral infarction in man.     

A model of proximal middle cerebral artery occlusion in rat

A highly reproducible model of middle cerebral artery (MCA) occlusion in rat is described. Reproducibility relates to MCA occlusion at its most proximal portion and the surgical approach through a widened foramen ovale, thus avoiding craniotomy and brain retraction. Spontaneous ventilation is maintained, avoiding intubation. Collateral circulation to cortex is preserved, permitting optimal metabolic and pharmacologic studies of the ischemic regions destined for infarction.     

Infarction of the territory supplied by the contralateral superior cerebellar artery in a case of descending transtentorial herniation

Infarction of the territory supplied by the contralateral superior cerebellar artery in cases of descending transtentorial herniation has not been reported. The authors experienced a primitive neuroectodermal tumor in a patient whose consciousness deteriorated transiently due to descending transtentorial herniation. On the magnetic resonance imaging taken 8 days after the herniation, lesions thought to be infarction of territories supplied by the ipsilateral posterior cerebral artery and the contralateral superior cerebellar artery were noted. The possible mechanism of this peculiar pattern of infarction is discussed.     

脑静脉窦血栓形成的CT、MRI影像特点及文献回顾

目的探讨脑静脉窦血栓形成的CT、MRI影像特点,以便早期诊断、及时治疗、有效减少误诊误治. 方法回顾性分析5例脑静脉窦血栓患者的影像特征及相关文献. 结果5例患者均有不同程度的头痛、烦躁、神经系统定位体征,MRI表现为一侧或双侧顶叶近大脑镰处梗塞或夹杂有出血性改变. 结论头痛、烦躁、神经系统定位体征是脑静脉窦血栓的常见症状和体征.MRI的特征性表现为脑肿胀,顶叶的局部性梗死,多数伴有出血.     

Intracranial venous pressures,hydrocephalus and effects of cerebrospinal fluid shunts

Data concerning venous anatomy, interstitial fluid pressure and cerebral blood flow indicate that obstruction of cerebral venous outflow (as a whole or involving the deep venous system alone) is the essential cause of hydrocephalus. Choroidal and ventricular veins both belong to the deep system. Choroidal venous pressure determines cerebrospinal fluid pressure; pressure in the ventricular veins determines interstitial fluid pressure in the paraventricular white matter. A decrease in deep cerebral blood flow causes paraventricular atrophy. CSFP is higher than interstitial fluid pressure, normally and in venous obstruction. Thus, CSFP prevents venocongestive edema (but not inflammatory edema) of the brain. Collateral venous pathways are described. Venous obstruction causes hydrocephalus only when it leads to insufficient blood flow. Cerebrospinal fluid shunting causes increased CBF as essential therapeutic effect in hydrocephalus, but also causes venocongestive brain edema, which explains the decrease in ventricle size and the side effects of shunting.Presented at the XVI Annual Meeting of the International Society for Pediatric Neurosurgery, Rome 1988