经颅多普勒超声及彩色多普勒超声联合检测在诊断锁骨下动脉盗血综合征中的应用

目的 通过分析锁骨下动脉盗血综合征(SSS)患者经颅多普勒超声(TCD)及彩色多普勒超声(CDU)的检测结果,探讨二者对SSS的诊断价值.方法 SSS患者94例,均经TCD和CDU确诊,且有11例经DSA检查证实.采用德国EME公司的TC-8080经颅多普勒超声及美国GE公司的LOGIQ BOOK彩色多普勒超声.根据同侧椎动脉(Ip-VA)检测的血流方向,将盗血程度分为:I度盗血(Ip-VA收缩期有切迹);II度盗血(Ip-VA舒张期正向,收缩期反向);III度盗血(Ip-VA完全反向).结果 94例SSS患者中多发性动脉硬化88例,大动脉炎6例,其中锁骨下动脉狭窄96条,平均管径为0.9～3.9mm,血流速度范围150～500cm/s,闭塞4条.I度盗血占45%;II度盗血占35%;HI度盗血占20%.基底动脉参与盗血的患者6例,大脑后动脉参与盗血2例.11例行DSA检查患者中,有4例闭塞或几乎闭塞.4例狭窄在75%～95%,3例狭窄在50%～74%.结论 将TCD与CDU相结合不仅可以观察盗血的程度和途径,而且可以明确狭窄的病因及程度,且二者无创、经济、简便,可作为锁骨下动脉盗血综合征的首选检查手段,并可用于评价治疗效果及长期随诊.

Abstract：

Objective By oserving the phenomenon of subclavain steal syndrome(SSS) with Transcranial Doppler ultrasonography (TCD) and Color Doppler ultrasonography ( CDU) ,to analyze the diagnostic value of them in SSS. Methods 94 patients were diagnosed as SSS by TCD and CDU, 11 of them were verified with digital substract angiography ( DSA). Double MCA, ACA,PCA, VA and BA were examined with 2MHz probe of TCD. The lumen and intima-media of carotid, vertebral , subclacian and innominate arteries were displayed with two-dimensional ultrasonography and their blood flow velocity and direction were detected by color and spectral Doppler ultrasonography with LOGIQ BOOK computed sonography. According to the direction of ipsilateral VA (ip-VA ) , the subclavian steal syndrome ( SSS) were defined as stage I ( deceleration in systole) , stage II ( alteration flow with reversed flow in systole and normal flow in diastole) and stage III ( reversed flow completely). The steal pathway was defined as basilar artery steal pathway (with steal waveform in basilar artery ( BA) ) or non-basilar artery steal pathway ( normal direction in BA). Results 88 patients of SSS were caused by atherosclerosis, 6 patients by aortoarteritis. 96 had subclavian arterial stenosis with lumen diameter 0. 9 ～3. 9mm and the velocity 150 ～500cm/s,occlusion of subclavian occurred in 4 patients 45% had steal stage I ,35% had steal stage II ,20% had steal stage III. 6 patients had basilar artery steal pathway and 2 patients had posterior cerebral arteryl steal pathway. Occlusion or nearly occlusion of subclavian were 4 patients with DSA. The severity of subclavain of 4 patients was 75% ～95% and other 3 was 50% ～ 74 %. Conclusion TCD combine with CDU is a sensitive and reliable method for evaluating the steal phenomena in patients with subclavian artery stenosis, they can not only observe the degree and path ways of steal phenomena , but also can indetify the etiopathogensis and severity of stenosis, and they are economic, convenient, no-injured, so they can be the first and foremost dignosis method for SSS, they also can be used to evaluate therapeutic effect and long-term follow-up.     

Transcranial color-coded sonography for vertebrobasilar disorders in end-stage renal disease

Because vertebrobasilar arterial disorders seem to be common in patients with end-stage renal disease, a neuroradiological evaluation of vertebrobasilar circulation is necessary for patients with possible vertebrobasilar insufficiency. In three patients on maintenance hemodialysis, contrast-enhanced transcranial color-coded real-time sonography (TCCS) through a suboccipital window delineated occlusion of bilateral vertebral arteries with reversal of the basilar artery, reversal of the left vertebral artery mimicking left subclavian steal phenomenon, and dolichoectasia of the basilar artery and bilateral vertebral arteries with signals of turbulent flow. TCCS has several advantages over computed tomographic angiography and magnetic resonance angiography, including the direction of blood flow, handy performance even during hemodialysis, and contrast agent free from nephrotoxicity. Thus, TCCS is useful in the evaluation of intracranial circulation in patients with end-stage renal disease.     

血管内支架成形术治疗症状性锁骨下动脉重度狭窄临床研究

研究背景锁骨下动脉狭窄主要临床表现为锁骨下动脉盗血综合征,血管内支架成形术为其主要治疗方法,本文旨在探讨症状性锁骨下动脉重度狭窄血管内支架成形术的疗效和安全性。方法回顾分析2012年6-11月经血管内支架成形术治疗20例症状性锁骨下动脉重度狭窄患者的临床资料。结果所有患者支架植入均获成功,术后全脑血管造影提示锁骨下动脉残余狭窄率<20%,椎动脉呈顺向血流,锁骨下动脉盗血现象完全消失,同侧椎动脉颅内段血流通畅,临床症状改善;术后无一例出现支架相关性手术并发症。术后10天至6个月时,血管超声及CTA检查未见支架内再狭窄,血管形态良好、血流通畅。结论血管内支架成形术治疗症状性锁骨下动脉重度狭窄是一种微创、安全、有效的治疗方法。     

Subclavian Steal and a Persistent Trigeminal Artery

A persistent trigeminal artery (PTA) has been found in a number of cerebrovascular diseases. A 73-year-old asymptomatic woman was noted to have a left PTA and left subclavian steal by catheter angiography. Carotid duplex revealed a peak systolic flow velocity of 294 cm/s in the internal carotid artery (ICA) and an ICA to common carotid artery ratio > 4, suggestive of a high-grade stenosis. Only a low-grade stenosis was identified by catheter angiography. The elevated flow velocities in the left ICA were attributed to increased collateral blood flow across the stenosis to the left PTA, which compensated for the subclavian steal. Transcranial Doppler found an alternating flow pattern in the basilar artery (mean flow velocity [MFV] = 18 cm/s) and left vertebral artery (MFV = 43 cm/s). During brachial hyperemia, the MFV increased by 178% in the basilar artery and 102% in the left vertebral artery. The data suggest that a PTA may compensate for subclavian steal and may have a protective hemodynamic role in this setting.     

Chronic brainstem ischemia in subclavian steal syndrome

Subclavian steal syndrome is usually an incidental finding and rarely causes vertebrobasilar ischemia. We present a 58-year-old man who, over six months, experienced progressive slowing in both talking and walking. Cervical duplex sonography revealed severe stenosis of the right subclavian artery; fixed retrograde flow was noted in the right vertebral artery on transcranial Doppler. The hyperemia–ischemia cuff test resulted in considerable reduction in flow velocities in both posterior cerebral arteries. We attributed his slowness to chronic vertebrobasilar ischemia and surgical revascularization was performed. His symptoms subsided immediately after surgery. The improved perfusion in the posterior circulation was demonstrated on technetium-99 hexamethylpropyleneamine oxime single photon-emission CT. Early diagnosis and prompt treatment resulted in an improved quality of life.     

Imaging of the intracranial vertebrobasilar system using color-coded ultrasound.

BACKGROUND: Anatomic variety and difficult accessibility of the vertebrobasilar arteries pose considerable problems to conventional ultrasound. We evaluated the diagnostic potential of transcranial color-coded sonography in the distal part of this system. METHODS: We insonated the intracranial section of the vertebrobasilar arteries through the foramen magnum window in 24 healthy individuals using a Doppler color flow imaging system in connection with a 2.5-MHz sector transducer. Magnetic resonance images in special inclination planes were performed and compared with the color-coded duplex images in five cases. RESULTS: The B-mode image of the craniocervical junction and the intracranial parenchymal structures in addition to the color-coded blood flow allowed an unambiguous identification of the vertebrobasilar arteries (vertebral artery, 96%; basilar artery, 79%; and posterior inferior cerebellar artery, 50%). Blood flow velocities were measured considering the insonation angles: vertebral arteries, 50/24 cm/sec (30 degrees); basilar artery, 59/28 cm/sec (4 degrees); and posterior inferior cerebellar artery, 56/30 cm/sec (20 degrees) [peak systolic/end diastolic blood flow velocity (mean angle correction)]. CONCLUSIONS: Transcranial color-coded sonography enables accurate identification and differentiation of the intracranial vertebrobasilar arteries and improves accuracy of Doppler measurements. It may prove useful for evaluation of tortuosity and for hemodynamic studies in this vascular territory.     

Hemodynamic Effects of Innominate Artery Occlusive Disease on Anterior Cerebral Artery

Stenoses of the innominate artery (IA) may affect flow conditions in the carotid arteries. However, alternating flow in ipsilateral anterior cerebral artery (ACA) due to IA stenosis is extremely rare. A 49-year-old woman who was evaluated for symptomatic cerebrovascular disease presented with right latent subclavian and right carotid system steal. Transcranial Doppler examination displayed systolic deceleration wave-forms in the right terminal internal carotid artery and alternating flow in the right ACA. Magnetic resonance angiography demonstrated tight stenosis of the right IA. For a thorough study of the hemodynamic effects of IA stenosis, a combination of duplex and transcranial Doppler examination is required.     

重度锁骨下动脉盗血综合征的侧支代偿及临床特点

目的探讨重度锁骨下动脉盗血综合征(SSS)的侧支代偿及临床特点。方法回顾性分析12例经全脑数字减影血管造影(DSA)证实为重度SSS患者的临床资料。结果 12例SSS患者主要临床表现为发作性头晕、视物旋转、跌倒等,活动同侧上肢后症状加重;DSA示左侧锁骨下动脉重度狭窄或闭塞10例,双侧锁骨下动脉重度狭窄2例;侧支代偿途径椎动脉-椎动脉-锁骨下动脉10例,颈内动脉-后交通动脉-大脑后动脉/基底动脉8例,颈外动脉-枕动脉下支-椎动脉肌支动脉-椎动脉-锁骨下动脉9例。8例患者行锁骨下动脉支架成形术后临床症状完全消失;2例患者因锁骨下动脉闭塞及对侧椎动脉中度狭窄而接受对侧椎动脉支架成形术,术后症状减轻;随访3个月～2.5年,症状无复发。结论重度SSS临床表现主要为发作性头晕,侧支代偿途径主要为椎动脉-椎动脉-锁骨下动脉,支架成形术可纠正血流动脉动力学紊乱,缓解临床症状。     

锁骨下动脉盗血综合征经颅多普勒超声检查临床价值

目的研究锁骨下动脉盗血综合征(SSS)的经颅多普勒超声(TCD)表现,并结合数字减影血管造影(DSA)检查探讨TCD对于SSS的诊断和治疗的临床意义和应用价值。方法分析69例经TCD诊断为SSS患者的血流动力学变化,根据患侧椎动脉(VA)频谱特点将盗血分为Ⅰ、Ⅱ、Ⅲ期盗血。初步判断盗血途径,分为健侧VA和/或基底动脉(BA)参与盗血。其中部分患者(39例)行DSA检查,根据DSA检查结果将锁骨下动脉(SubA)狭窄程度分为轻度狭窄(狭窄程度≤50%)、中度狭窄(狭窄程度51～75%)、重度狭窄(狭窄程度76～95%)和闭塞四组。并将各组检查结果与TCD检查结果进行对照分析研究。结果在TCD检查示Ⅰ期盗血的6例患者中,DSA示SubA轻度狭窄患者3例,中度狭窄3例;TCD检查示Ⅱ期盗血的16例患者中,DSA示SubA中度狭窄患者8例,重度狭窄7例,闭塞1例;TCD检查示Ⅲ期盗血的17例患者中,DSA示SubA中度狭窄2例,重度狭窄8例,闭塞7例。TCD检查所发现的盗血程度与DSA检查发现的SubA狭窄程度呈正相关(r=0.78)。结论 TCD是诊断SSS敏感而可靠的方法,为临床早期诊断和治疗提供了可靠的依据。     

Hemodynamics of the vertebral artery in subclavian steal syndrome and subclavian steal phenomenon]

To evaluate hemodynamics of the vertebral artery (VA) in subclavian steal syndrome (SSS) and subclavian steal phenomenon (SSP), blood flow velocities of the bilateral VAs were measured by duplex ultrasonography in four patients with SSS and eight patients with SSP. The reversal of flow in the VA was noted in both systolic and diastolic phases in all of the SSS group, and was recorded only in a systolic phase in all but one of the SSP group. The antegrade mean flow velocities in the VA on the unaffected side in the SSS group were significantly higher than those in the SSP group. This indicates that collateral blood flow through the VA in the SSS group is still insufficient to compensate the blood requirement of the upper extremity on the affected side. In conclusion, hemodynamics of the VA in the SSS group could be distinguished from those in the SSP group by duplex ultrasonography.     

A patient with vertebrobasilar transient ischaemic attacks and provokable basilar steal

In a 65-year-old woman with vertebrobasilar transient ischaemic attacks (TIAs) and subclavian steal, a steal phenomenon in the basilar artery could be demonstrated by transcranial Doppler sonography after provocation with postischaemic hyperaemia of the arm on the affected side. It was not possible to provoke symptoms or signs at the time. The significance of finding a steal phenomenon in the basilar artery even in a patient with a history of vertebrobasilar TIAs is discussed.     

Carotid Steal Syndrome: A Case Study

The progression of subclavian arterial stenosis and the subsequent formation of collateral pathways serve to alter the pressure gradients in subclavian steal syndrome, altering ipsilateral vertebral artery flow from its normal state to “latent,” “transient,” and “continuous” steals. A similar altered flow in the carotid arteries can be observed with stenosis of the proximal common or innominate artery. A 59-year-old man was seen in the vascular laboratory for evaluation of symptomatic peripheral arterial disease. An incidental asymptomatic stenosis of the right innominate and left proximal subclavian artery was found . Further cerebral vascular evaluation displayed a continuous right subclavian steal and a latent steal in the right internal carotid artery. Transcranial Doppler examination displayed “transient” steal in the terminal right internal carotid artery. Combining duplex and transcranial Doppler evaluation s allows sequential evaluation of the progression of arterial disease and its effect on the flow patterns in the cerebral vasculature.     

Transcranial Doppler ultrasonography of carotid-basilar collateral circulation in subclavian steal

The combination of a carotid-basilar and a vertebro-vertebral collateral circulation was verified directly in a patient with a complete subclavian steal by means of transcranial Doppler ultrasonography. The patient showed permanently reversed blood flow in the basilar artery. The subclavian steal influenced the hemodynamics of the circle of Willis at rest and during functional tests of the collaterally supplied arm. Our investigation provides the first direct experimental evidence of increased blood flow velocity in the carotid artery after decompressing the collaterally supplied arm.     

经颅多普勒与彩色多普勒超声显像技术联合应用对锁骨下动脉盗血综合征的诊断价值

目的 探讨经颅多普勒(TCD)与彩色多普勒超声显像(CDFI)技术联合应用对锁骨下动脉盗血综合征(SSS)的诊断价值.方法 对25例临床表现为椎一基底动脉供血不足的经TCD与CDFI联合检测证实的SSS患者的TCD与CDFI资料进行分析.结果 TCD检测显示:25例患者患侧椎动脉均为正向血流(血流信号逆转),其中完全性盗血8例(32%),部分性盗血17例(68%).CDFI检测显示:25例患者中23例(92%)锁骨下动脉起始段探及动脉粥样硬化斑块,2例(8%)动脉内膜增厚,25例血管内径明显变窄,甚至完全闭塞;血流柬变细或无血流信号;患侧椎动脉管腔内呈红蓝交替的双向血流或转为完全出颅方向的血流,并出现相应血流动力学改变.结论 TCD与CDFI联合应用对SSS能更准确地作出诊断.     

Basilar artery blood flow in subclavian steal

Subclavian "steal", when blood siphons from one vertebral artery to the other, has been suggested as a cause of brain stem ischaemia and stroke. We investigated 33 patients using transcranial Doppler to determine the direction and velocity of basilar blood flow. All patients had severe subclavian stenosis with reversed vertebral blood flow in the ipsilateral artery previously demonstrated by extracranial Doppler. Basilar flow was normal in direction in all cases, but its velocity was significantly increased (p less than 0.0008) compared to age- and sex-matched controls. These findings, in conjunction with previous observations using extracranial Doppler techniques, suggest that subclavian steal is little more than a harmless haemodynamic phenomenon.     

Provokable bilateral vertebral artery compression diagnosed with transcranial Doppler.

BACKGROUND: Head and neck movements may cause vascular compression that produces a syndrome of vertebrobasilar insufficiency. Vertebrobasilar circulation was examined noninvasively in two patients who were able to provoke these symptoms repeatedly on demand. CASE DESCRIPTIONS: Blood flow velocities in the basilar artery (case 1) and both posterior cerebral arteries (both cases) were measured continuously by transcranial Doppler sonography while the patients voluntarily performed the offending maneuvers and reproduced their symptoms. The provocative maneuvers evoked an immediate and precipitous drop in blood flow velocity, producing symptoms within seconds. Upon relief, the blood flow velocities showed a transient overshoot before returning to baseline values. CONCLUSIONS: These observations indicate that the symptoms of vertebrobasilar insufficiency were due to real reductions in blood flow and demonstrate the usefulness of transcranial Doppler sonography to diagnose bilateral extracranial vertebral artery compression.     

Effect of subclavian syndrome on the basilar artery

Fifty-five patients with a permanent or intermittent subclavian steal syndrome demonstrated by continuous wave Doppler were included in a prospective study: 25 patients without vertebro-basilar symptoms, 8 symptomatic patients with defined vertebro-basilar symptoms and 22 with hemodynamic vertebro-basilar occurences. The basilar artery velocity was recorded by Transcranial Doppler Sonography in baseline conditions, and after a hyperaemia test to the upper limb. A spontaneous, incomplete basilar steal was diagnosed in seven patients, and a complete basilar steal in one patient, (14.5% of the cases). After hyperaemia test, 18 other incomplete basilar steal were observed. The occurence of a basilar steal was higher in the vertebro-basilar group (57% of the cases) especially in 7 of the 8 cases with defined vertebro-basilar symptoms; it was lower in the patients without vertebro-basilar occurences (36% of the cases). This basilar steal was also seen in five of the six symptomatic patients with opposite vertebral artery stenosis above a 50% diameter. Transcranial Doppler Sonography could help to define a subgroup of subclavian steal syndrome with a high risk of strokes.     

The Venturi effect and cerebrovascular ultrasound

BACKGROUND: One of the most frequent diagnostic pitfalls in cerebrovascular ultrasound is the evaluation of the vertebrobasilar system in the case of vertebral artery (VA) hypoplasia because the diagnostic findings are sometimes suggestive of significant pathologies, but may be completely normal as well. The Venturi effect is a phenomenon of hydrodynamics which describes a drop in hydrostatic pressure along areas of high flow velocities. METHOD: We review the physical background of the Venturi effect and describe how it can explain both physiological and pathological flow phenomena encountered during cerebrovascular ultrasound investigations. We focused on flow phenomena at the vertebrobasilar junction by theoretically calculating conditions with different influx angles and flow velocities on two-dimensional digital subtraction angiography images. In the discussion, we also address other areas of cerebrovascular ultrasound, where the Venturi effect is of particular interest. RESULTS AND CONCLUSIONS: The blood flow velocity within the VAs and the angle between a hypoplastic VA and the basilar artery (BA) are important determinants of the intraluminal pressures of these arteries and thus their resistances. In the case of angles below 90 degrees between the distal VA and the BA, abnormal extracranial flow profiles may suggest downstream VA stenosis or occlusion, whereas in the case of angles above 90 degrees, a diagnosis of an AV fistula downstream to the V4 segment may be assumed. Furthermore, various hemodynamic effects at the site of a stenosis of the brain supplying arteries can also be explained by a transstenotic pressure drop created by the Venturi effect, particularly the generation of musical murmurs. The systolic dip ('systolic deceleration') at the origin of the VA due to subclavian artery stenosis is also a consequence of the Venturi effect.     

彩色多普勒超声诊断锁骨下动脉盗血综合征

目的总结锁骨下动脉盗血综合征（SSS）的病因、二维超声表现、彩色多普勒及频谱多普勒特点,评价超声对此病的诊断价值。方法应用Philips Sonos 4500型彩色多普勒超声诊断仪对15例锁骨下动脉盗血综合征患者椎动脉颅外段、锁骨下动脉、无名动脉、双上肢动脉进行超声检查,观察其超声表现及血流动力学变化。结果15例患者中动脉粥样硬化12例,大动脉炎3例。完全性盗血8例,部分性盗血7例。结论SSS的主要病因是动脉粥样硬化和大动脉炎,彩色多普勒超声可对SSS作出明确诊新、有效评价其血流动力学变化。     

Treatment of subclavian steal syndrome by percutaneous transluminal angioplasty: a case report

It has been known that significant narrowing of the subclavian or innominate artery may cause cerebrovascular ischemic symptoms, especially vertebrobasilar insufficiency. This condition has been named as the subclavian steal syndrome (SSS). Recently, percutaneous transluminal angioplasty (PTA) has been developed and used in treating occlusive vascular lesions. In this report, we presented a 61-year-old man who suffered from SSS and treated by PTA. He complained of dizziness and dysesthesia on his left upper extremity which got worse on exertion. The left radial pulse was diminished and the left brachial blood pressure was lower about 50 mmHg than the right. Bruits were recognized over the left suprasubclavicular area. Arch aortogram revealed an 80% stenosis of the proximal left subclavian artery and retrograde flow of the left vertebral artery on late arterial phase. PTA was successfully performed at the same time as angiography via the right femoral artery without any complications. His clinical symptoms improved immediately following PTA. A month after PTA, left retrograde vertebral angiogram demonstrated that the dilation of the treated segment of the left subclavian artery continuously remained. Because of several advantages such as a technical easiness and a more safety, PTA will be a useful therapeutic tool for not only SSS but also other obstructive diseases of brachiocephalic arteries prior to some surgical treatments. However, it is necessary to avoid some possible complications, especially embolism into the cerebral circulation in this technique, and the careful procedure should be done under the co-operation with vascular surgeons and radiologists.