106例缺血性脑血管病患者全脑血管造影分析

目的分析缺血性脑血管病患者颅内外动脉狭窄的分布。方法对我院实施DSA检查的106例缺血性脑血管病的结果进行分析,均经头颅CT排除脑出血,TCD及颈动脉彩超检查后怀疑有动脉狭窄的缺血性脑血管病。所有患者均实施选择性全脑血管造影术,椎动脉和颈动脉均有正侧位血管造影像;根据患者的DSA检查结果,分析动脉狭窄的部位、受累血管数目及血管狭窄形态;重度狭窄的病例予以支架治疗和球囊成型术。结果血管造影结果提示89.6%患者有不同程度的血管狭窄或闭塞,其中75.5%为前循环受累,37.7%为后循环受累。前循环受累血管中以颈内动脉(56.6%)和大脑中动脉(26.4%)受累最常见,后循环受累血管中以椎动脉(33.0%)最多见。支架治疗和球囊成型术临床疗效显著。结论缺血性脑血管病造影显示大部分患者有肯定的脑血管狭窄和闭塞。脑梗死患者血管病变以颈内动脉病变为主,椎基底动脉供血不足亦以颈内动脉病变多见,支架治疗和球囊成型可作为重度狭窄的治疗方法。     

侧支循环单侧颈内动脉起始部重度狭窄与缺血性脑血管事件

目的探讨单侧颈内动脉起始部重度狭窄时各侧支循环代偿出现的概率与缺血性脑血管事件的关系。方法选择数字减影血管造影术发现单侧颈内动脉起始部狭窄>70%患者46例,其中缺血性脑血管事件24例作为症状组;无缺血性脑血管事件22例作为无症状组。了解Willis血管环内径及构成,及代偿血管构成情况,分析代偿血管与缺血性脑血管事件的关系。结果 Willis环代偿是主要的侧支循环。症状组后环的变异率明显大于无症状组(P<0.005);症状组前交通动脉的管径明显小于无症状组[(1.36±0.18)mm vs(1.52±0.18)mm,P<0.01]。结论单侧颈内动脉起始部重度脉狭窄患者是否出现缺血性脑血管事件与Willis环的代偿完整性有关,一级供血代偿能力与Willis环是否存在结构变异及前交通动脉、后交通动脉的管径有关。     

Willis环结构及功能对颈动脉重度狭窄患者支架置入术的决策影响

目的探讨CTA、CT灌注成像联合DSA评估单侧颈动脉重度狭窄患者,Willis环结构及功能对颈动脉支架置入的决策影响。方法根据CTA筛选出单侧颈动脉狭窄90%的患者80例,40例经DSA证实有通过前交通动脉和/或后交通动脉向狭窄侧代偿供血,称Willis环代偿组;另40例经DSA证实没有向狭窄侧的代偿血供,称Willis环无代偿组。两组均同时行CTP检查,测量并计算两组大脑中动脉供血区的相对脑血容量(rCBV)、相对脑血流量(rCBF)、相对平均通过时间(rMTT)和相对达峰时间(rTTP)。对40例Willis环无代偿组的颈动脉狭窄患者给与支架置入术,残余狭窄30%,术后7 d再次行CT灌注扫描。Willis环无代偿组术前、术后的相对灌注参数分别与Willis环代偿组比较。结果 Willis环无代偿组术前rMTT、rTTP与Willis环代偿组比较有统计学差异(P0.05),Willis环无代偿组术后与Willis环代偿组rCBV、rCBF、rMTT、rTTP比较均无统计学差异(P0.05)。结论对单侧颈动脉重度狭窄的患者,Willis的结构和功能可明显改变脑血流分布,为颈动脉支架置入术的选择提供参考。     

265例缺血性脑卒中患者DSA结果分析

目的对265例缺血性脑血管病患者的DSA资料进行分析,进一步评价DSA在缺血性脑血管病诊治中的意义。方法对265例确诊为缺血性脑血管病的患者于发病后2h~6个月行全脑血管造影,明确有无脑供血动脉狭窄或闭塞,明确血管狭窄部位及责任动脉,并测定狭窄长度及狭窄程度。结果 265例缺血性脑血管病患者脑供血动脉狭窄或闭塞的发生率为72.1%。缺血性脑血管病患者脑血管狭窄或闭塞的好发部位依次为颈内动脉起始部(16.4%)、大脑中动脉水平段(13.9%)、椎动脉开口处(12.3%)。单发脑供血动脉狭窄或闭塞88例(46.1%),多发脑供血动脉狭窄或闭塞103例(53.9%),其中颅内外动脉串联病变43例(41.7%),颅内外非串联病变60例(58.3%)。责任动脉的检出率为77%。结论对反复卒中及患糖尿病的缺血性卒中患者应行DSA以明确患者有无颅内外脑供血动脉狭窄,以制定包括药物及支架置入术等更为有效的二级预防。     

脑血管侧支循环与缺血性脑血管病

缺血性脑血管病源于局部脑组织血流低于某阚值所致,局部脑组织的血流是由供血动脉的病变程度和侧支循环状况共同决定的,两者是影响血流动力学状况的关键因素。一般认为,血管狭窄程度与缺血性脑血管病发病率相关,侧支循环的建立可增加脑血流量、防止脑缺血的发生。侧支循环血管可以来自硬膜内、硬膜及硬膜外血管,大致可分为原发性侧支循环（即基底动脉环,又称Willis环）和继发性侧支循环（皮质软脑膜支吻合、脑外代偿等）。     

临床颈动脉系统TIA患者的脑血管造影分析

目的:以数字减影脑血管造影为手段,分析颈动脉系统TIA患者脑供血动脉狭窄或闭塞的分布、程度以及侧枝循环建立情况。方法:颈动脉系统TIA患者70例均行脑血管造影检查,包括主动脉弓上造影及至少双侧颈总及锁骨下动脉四根血管造影。明确有无脑供血动脉的狭窄、狭窄的位置、程度及侧枝循环情况。结果:62例患者存在脑供血动脉狭窄或闭塞,共检出病变132处,轻度狭窄40处(30.3%),中度狭窄34处(25.8%),重度39处(29.5%),闭塞19处(14.4%)。可判断责任血管者58例(85.0%):单纯前循环45例,前后循环联合病变有13例。以颈内动脉狭窄80处为对象,研究颈内动脉狭窄或闭塞的侧枝循环情况。汇总邻近可能引起同一侧枝循环通路的病变,共分析病变58处,发现合并侧枝的病变有23处,有侧支数量36处。各种侧支循环中,Willis环出现频度最高,包括前交通代偿13处和后交通代偿5处。其次为软膜血管代偿13处。结论:颈动脉系统TIA患者,颅外血管病变多于颅内血管病变。责任血管不单纯是在前循环,还可以是前后循环联合病变。颈内动脉狭窄或闭塞最常见的侧枝循环是Wlliis环和软脑膜血管,严重的脑供血动脉狭窄更易引发侧枝循环建立。     

CT 检查与颈动脉听诊对缺血性脑卒中的诊断价值

缺血性脑卒中表现为脑组织局部供血动脉突然发生血流灌注减少或完全血流中断,使脑组织供血、供氧、供糖停止,进而引发局部脑组织坏死,损伤脑功能［1］。缺血性脑卒中病情危重,颅脑供血血管狭窄与闭塞是引发缺血性脑卒中的关键［2］,因而临床早期筛查和诊断供血动脉狭窄有利于尽早指导临床制定施治方案,缩短局部颅内组织的缺血时间,延长患者生命,降低致死和致残率。颈动脉是颅脑组织供血的主要路径,颈动脉狭窄已被证实主要因动脉粥样硬化引发。据统计20％～30％的缺血性脑梗死患者因颈动脉疾病引发［3］。老龄化造成血管退行性改变,血管硬化程度增高,老年人体内各处动脉均易发生动脉硬化斑块,引发血管狭窄。尤其颈动脉分叉处,是血管狭窄的多发部位,斑块增大后发生钙化、坏死、脱落、出血等,严重者脑血管闭塞。听诊是临床应用最为广泛的诊断方法,速度快、操作简单、无创伤。本文采用常规CT诊断方法,并辅助颈动脉听诊进行缺血性脑卒中诊断,探讨其价值。     

Willis环不同mTICI代偿分级对单侧颈动脉重度狭窄患者血管重建术的决策影响

目的 探讨经CTA、CTP、DSA联合评估Willis环不同mTICI代偿分级对单侧颈动脉重度狭窄患者脑血流灌注差异。方法 根据CTA筛选出单侧颈动脉狭窄≥70%的患者65例并同时完善了CTP检查,其中33例经DSA压颈试验证实有经前交通动脉和/或后交通动脉向狭窄侧代偿供血(mTICI≥2b)称Willis环代偿良好组;另32例经DSA压颈试验证实没有向狭窄侧的代偿供血,或代偿不充分(mTICI≤2a)称Willis环代偿不良组。对所有患者给与狭窄血管的颈内动脉支架置入手术(CAS),残余狭窄≤30%。所有患者术后3 m内均完善CTP检查,测量并计算两组大脑中动脉供血区术前、术后的相对脑血容量(rCBV)、相对脑血流量(rCBF)、相对平均通过时间(rMTT)和相对达峰时间(rTTP)。两组术前、术后灌注参数自身比较与组间横向比较。结果 两组术前Willis环代偿不良组rMTT、rTTP延长、rCBV略增加与Willis环代偿良好组比较有统计学差异(P<0.05),而rCBF差异不显著(P=0.14);术后Willis环代偿不良组rCBV、rCBF、rMTT、rTTP与Willi...     

颈动脉狭窄并发烟雾病的治疗体会

目的总结颈动脉狭窄并发烟雾病(MMD)患者的治疗的临床体会。方法收集本科收治的10例颈动脉狭窄并发MMD行颈动脉内膜剥脱术(CEA)患者的临床资料,探讨颈动脉狭窄并发MMD患者的治疗方法与疗效。结果所有患者均行CEA,术后5～7d复查头颈上胸段CT血管成像(CTA),可见血流通畅,患者临床痊愈出院。术后3个月随访患者,所有患者症状消失,未出现缺血性脑血管病相关症状。结论颈动脉狭窄并发MMD患者如果颅内大脑前动脉或大脑中动脉正常存在,则应考虑CEA,以保证颅内正常血管的血供。     

颈动脉支架置入术对大脑皮质血流灌注量的影响

目的 研究颈动脉狭窄支架置入术对脑皮质血流灌注量的影响.方法 应用单光子发射计算机断层扫描(SPECT)对18例单侧颈动脉狭窄患者颈动脉支架置入术前后脑皮质血流灌注量进行检测.结果 患者术后双侧大脑前动脉、大脑中动脉、大脑后动脉供血区脑皮质血流灌注量均显著增加(均P<0.05);同时支架置入侧术后大脑中动脉、大脑后动脉供血区脑皮质血流灌注量比值较术前增加更明显(均P<0.05),但大脑前动脉供血区差异无统计学意义.结论 颈动脉狭窄支架置入术可使狭窄侧及对侧脑皮质血流灌注量增加,而狭窄侧大脑中动脉、后动脉增加幅度更明显.     

Absent collateral function of the circle of Willis as risk factor for ischemic stroke

BACKGROUND: Autopsy studies show a higher prevalence of circle of Willis anomalies in brains with signs of ischemic infarction. Our goal was to examine the collateral function of the circle of Willis in ischemic stroke patients and to assess in a case-control study if a collateral deficient circle of Willis is a risk factor for ischemic stroke in patients with severe internal carotid artery (ICA) occlusive disease. METHODS: Our case-control study included 109 patients with an acute ischemic stroke in the anterior circulation and 113 patients with peripheral arterial disease and no known history of cerebral ischemia. The collateral function of the anterior and posterior communicating arteries of the circle of Willis was assessed by means of transcranial color-coded duplex ultrasonography (TCCD) and carotid compression tests. RESULTS: TCCD was successfully performed in 75 case patients (mean age 64 years, range 41-91 years) and in 100 control patients (mean age 61 years, range 35-89 years). In 26 cases and 19 controls, a >/=70% stenosis or occlusion of the ICA was found. A nonfunctional anterior collateral pathway in the circle of Willis was found in 33% of the cases and in 6% of the controls (p < 0.001). The posterior collateral pathway was nonfunctional in 57% of the cases and in 43% of the controls (p = 0.02). In patients with severe ICA occlusive disease, the odds ratios of a nonfunctional anterior and a nonfunctional posterior collateral pathway were 7.33 (95% confidence interval, CI, = 1.19-76.52) and 3.00 (95% CI = 0.77-12.04), respectively. CONCLUSIONS: Patients who suffer ischemic stroke in the anterior circulation have a higher incidence of collateral deficient circles of Willis than those with atherosclerotic vascular disease without ischemic cerebrovascular disease. The presence of a nonfunctional anterior collateral pathway in the circle of Willis in patients with severe ICA occlusive disease is strongly associated with ischemic stroke.     

颈内动脉狭窄相关性脑缺血病变的临床分析

目的 探讨颈内动脉狭窄致脑缺血病变的临床特点及发生机制,为临床指导治疗及判断预后提供依据.方法 回顾分析111 例经CT 血管造影(CTA)证实的颈内动脉狭窄患者的颅内Willis 环形态、TCD 资料及临床表现.结果 颈内动脉轻、中、重度狭窄组脑梗死发生率分别为14.7% 、30.6% 、46.3%,三组间差异具有显...     

单侧颈动脉阻塞性病变时侧支循环募集的特征分析

目的以数字减影血管造影为检查方法,分析单侧颈动脉阻塞性病变时侧支循环的募集特征。方法选择2007年1月～2011年11月北京大学首钢医院神经科DSA检查患者336例,观察每位患者的颈动脉及颅内动脉狭窄程度、Willis环组成及其他侧支循环出现情况。结果 (1)颈动脉狭窄程度与COW各段的完整性均不相关。(2)颈动脉狭窄率≤85%者均未见有代偿侧支。颈动脉86%～99%狭窄者85.7%患者代偿侧支有ACOA和PCA经软脑膜动脉通路,未见PCOA和OA通路;闭塞组则4条通路都有开放,最多是ACOA通路(92.3%),其次是PCA和OA通路(46.2%)。就代偿程度而言,ACOA通路代偿较充分,级别较高。(3)相关分析显示,各代偿通路开放与否及代偿程度均与颈动脉狭窄程度相关,其中ACOA通路、总的侧支通路数和代偿级别与之重度相关。结论 Willis环各段不因颈动脉狭窄程度的发展而改变;侧支循环只出现于颈动脉≥86%狭窄者,各侧支通路开放与否及侧支代偿程度均与颈动脉狭窄程度相关;单侧颈动脉狭窄后,ACOA是最重要的侧支通路。     

rCBF in patients with carotid occlusion. Resting and hypercapnic flow related to collateral pattern

rCBF was measured by 133Xenon inhalation technique in 39 patients with unilateral carotid artery occlusion in a subacute-chronic stage. Resting flow values (ISI) varied between 23.7 and 52.4 ml/100 g/min. An almost constant finding was interhemispheric asymmetry, the degree of which was correlated with the severity of the initial symptoms. An ischemic focus was an insignificant finding. The CO2 response was normal in patients with angiographic signs of circle of Willis collateral flow and without significant contralateral carotid stenosis, whereas it was impaired in patients with a retrograde ophthalmic flow or collateral flow via the circle of Willis and contralateral carotid stenosis greater than or equal to 50%. It is concluded that the CO2 response in useful rCBF variable and may be applied for analysis of collateral flow capacity in patients with carotid artery occlusion considered for bypass surgery.     

Transcranial Doppler in cerebrovascular disease

Doppler analysis of flow in intracranial arteries is now possible using a 2 MHz probe allowing sufficient penetration of bone to obtain signals noninvasively. Thirty-two normal subjects, and 11 patients with cerebrovascular diseases including vasospasm following subarachnoid hemorrhage, middle cerebral artery stenosis, and extracranial internal carotid artery stenosis were studied by transcranial Doppler. Increased peak velocity and spectral broadening of the reflected signal corresponded to clinical and angiographic evidence of middle cerebral artery vasospasm or stenosis. Decreased peak velocity and blunted waveforms occurred in the middle cerebral artery ipsilateral to severe extracranial internal carotid stenosis with poor crossfilling from the contralateral carotid artery. Abnormalities resolved following carotid endarterectomy. Transcranial Doppler identifies vasospasm or stenosis of the middle cerebral artery and may allow noninvasive evaluation of collateral flow across the anterior circle of Willis in patients with extracranial carotid artery stenosis.     

前循环动脉粥样硬化性短暂性脑缺血 发作的血管病变及预后影响因素

目的 探讨首发前循环动脉粥样硬化性短暂性脑缺血发作(TIA)的血管病变及预后影响因素。方法 收集121例首发前循环动脉粥样硬化性TIA患者,发病48 h内入院,应用CT血管造影和颈动脉超声评估血管病变,采用ABCD评分,观察1年内脑血管病的发生率,比较血管病变及ABCD评分对预后的影响。结果(1)121例患者中106例共258支血管狭窄; 71例(58.68%)存在同侧颈部及颅内动脉狭窄≥50%,66例(54.55%)存在多支血管狭窄,33例(27.27%)有Willis 环变异; 66例(54.55%)检出不稳定斑块;(2)随访1年脑血管病发生率18.18%; 多元Logistic回归分析显示除了高血压病、高脂血症、发作时间≥10 min外,同侧颈部及颅内动脉≥50%狭窄(OR=2.65,95% CI:1.30～5.38,P=0.007)是影响预后的独立危险因素; 同侧颈部及颅内动脉狭窄分层后发现,同侧颈部及颅内动脉中度狭窄患者发生脑血管病的比例是正常或轻度狭窄5.92倍(95%CI:1.20～29.27,P=0.029),而重度狭窄或闭塞发生比例是正常或轻度狭窄7.92倍(95%CI:1.75～35.83,P=0.007);(3)与未发生脑血管病组比较,发生脑血管病组的ABCD2、ABCD3和ABCD3-V评分的得分均显著升高(P≤0.01); 3种评分法预测1年内发生脑血管病风险的ROC曲线下面积分别为0.68、0.73和0.80,ABCD3-V评分预测预后准确度最高(P<0.05),最佳界值为7.5分。结论 首发前循环动脉粥样硬化性TIA的血管病变广泛并严重,1年内脑血管病发生率高,同侧颈部及颅内动脉狭窄严重程度及ABCD3-V评分能更准确预测患者的预后。     

Is a fetal origin of the posterior cerebral artery a risk factor for TIA or ischemic stroke?

Background and purpose Fetal origin of the posterior cerebral artery (PCA) is not uncommon. Whether patients with this anomaly have a higher risk of ischemic stroke in the territory of the PCA is not known. The clinical benefit of screening for a fetal origin in patients with TIA or stroke in the territory of the PCA and an ipsilateral atherosclerotic carotid stenosis is not clear. This study assessed the frequency of a fetal origin of the PCA in patients with a TIA or infarct in the territory of the PCA with 16-multidetector-row CT angiography (CTA). Methods 82 patients (52 male; mean age = 64; range 19 to 90 years) with isolated homonymous hemianopia and/or a PCA infarct underwent CTA of the carotid artery and circle of Willis. Results A fetal origin of the PCA at the symptomatic side was present in 14 patients (17 %) and at the asymptomatic side in 18 patients (22%) (OR: 0.7; 95 % CI: 0.3 to 1.7). Severity of stenosis (NASCET criteria) of the ICA at the symptomatic side was < 30%, 30–49% and ≥ 50% in 72, 2 and 8 patients, respectively. Number and frequency of a fetal origin in these groups were 12 (17 %), 0 (0%) and 2 (25 %), respectively. There was no association between a severe carotid stenosis and a fetal origin of the PCA at the symptomatic side. Conclusion This study does not provide arguments for an increased risk of ischemic stroke in the territory of the PCA in patients with a fetal origin of the PCA. A few patients with a TIA or infarct in the territory of the PCA have a fetal origin of the PCA in combination with a high-grade stenosis of the ipsilateral ICA, but not more often than one would expect from chance. Nevertheless, these patients may benefit from carotid endarterectomy.     

颈动脉超声对冠状动脉粥样硬化性心脏病合并缺血性脑血管疾病患者颅内动脉狭窄性病变的预测价值

目的探讨颈动脉超声评价冠状动脉粥样硬化性心脏病(CAD)合并缺血性脑血管(ICVD)患者颅内动脉狭窄性病变的预测价值。方法对209例经血管造影证实冠状动脉狭窄(≥70%)同时合并缺血性脑血管疾病的患者采用彩色多谱勒超声(CDFI)和经颅多普勒超声(TCD)分别检查颈动脉和颅内动脉,并将患者分为脑动脉狭窄组与非狭窄组,分别比较两组患者颈动脉超声检查结果中差异有统计学意义的指标。结果颈动脉球部内-中膜(IMT)增厚、不均质回声斑块、多发斑块、颈动脉狭窄与CAD患者合并颅内动脉狭窄性病变之间具有良好的相关关系,(P<0.05)。结论颈动脉内膜增厚、不均质回声斑块,多发斑块、颈动脉狭窄与CAD合并ICVD患者颅内动脉狭窄性病变之间有明显的相关性。采用CDFI对冠状动脉狭窄的患者进行颈动脉检测,在心脑血管事件高危人群中进行筛选,对临床诊断与治疗具有重要的指导意义。     

Three-dimensional transcranial Doppler blood flow mapping in patients with cerebrovascular disorders

We investigated 60 patients with cerebrovascular disorders using a three-dimensional transcranial Doppler blood flow mapping system. A composite display of the circle of Willis is created with computer assistance, allowing accurate vessel identification and optimal data documentation of blood flow velocity and direction in the basal cerebral arteries. The basilar artery was insonated in every patient; the middle cerebral artery and the most distal internal carotid artery were found in 95% of the patients, the anterior cerebral artery in 85%, and the posterior cerebral artery in 84%. Insonation problems occurred predominantly in elderly women. Transcranial Doppler blood flow mapping showed an abnormal result in 23 of 60 patients (38%). An intracranial stenosis with greater than 50% diameter reduction or occlusion was found in 10 of 31 patients (32%) with completed stroke, reversible ischemic neurologic deficit, or transient ischemic attack. Collateral blood flow mechanisms could be demonstrated in patients with extracranial carotid artery occlusions. Intra-arterial cerebral angiography performed in 21 patients confirmed the transcranial Doppler blood flow mapping diagnosis in 19 (90.5%). In one patient an arteriovenous malformation diagnosed by transcranial Doppler blood flow mapping was confirmed by magnetic resonance imaging.