椎基底动脉缺血性卒中急诊动脉溶栓疗效分析

目的观察椎基底动脉缺血性卒中急诊动脉溶栓的安全性和疗效。方法对急性椎基底动脉系统缺血性卒中急诊脑血管造影显示，基底动脉主干或其较大主要分支闭塞17例，双侧椎动脉闭塞4例，一侧椎动脉闭塞，另一侧椎动脉或基底动脉严重狭窄5例，未见血管闭塞19例。符合动脉溶栓条件，实施接触性动脉溶栓的病人45例。结果45例病人溶栓后血管成功再通17例（65，4％），血管不成功再通9例（34.6％）。30例疗效好。溶栓后发现基础血管中重度狭窄5例，溶栓后近期复发1例，颅内出血2例，死亡5例，病死率11％。结论椎基底动脉缺血性卒中急诊动脉溶栓是有效的治疗方法，可增加血管再通率，改善椎基底动脉缺血性卒中病人的预后。     

1例Moyamoya病反复脑室出血报道

Moyamoya病又称烟雾病，脑底异常血管网病，是以脑血管造影发现双侧劲内动脉虹吸部及大脑前、中动脉起始部严重狭窄或闭塞，伴有脑底异常血管网为特征的一种慢性脑血管闭塞性疾病。现将1例Moyamoya病反复脑室出血的病例报道如下。     

后循环梗死的影像学改变与脑血管狭窄或闭塞的关系探讨

目的了解后循环梗死病变与脑血管狭窄的关系,探讨后循环梗死的可能原因。方法所有病例均行头部MRI、MRA检查以及全脑血管造影检查。结果MRI显示桥脑病灶28例,延髓外侧病灶5例,中脑病灶2例,小脑病灶7例,枕叶病灶8例,丘脑病灶6例,颞叶病灶4例。DSA显示基底动脉狭窄9例,狭窄率50%~100%;一侧椎动脉起始部闭塞6例,一侧椎动脉起始部狭窄4例,一侧椎动脉颅内V4段未见显影5例,一侧椎动脉颅内段狭窄10例,狭窄率为40~95%;双侧椎动脉V4段以远未见显影2例,一侧大脑后动脉显影不清2例,一侧小脑后下动脉起始部狭窄1例,后循环血管管壁不光滑、迂曲,呈动脉硬化改变者4例,后循环血管无狭窄和斑块形成者5例。结论后循环梗死病变与脑血管狭窄密切相关,DSA检查对明确后循环梗死的病因具有一定的价值。     

家族性烟雾病1例报告

烟雾病(Moyamoya disease,MMD)是以脑血管造影发现双侧颈内动脉虹吸部及大脑前动脉、大脑中动脉起始部严重狭窄或闭塞,伴脑底异常团块状血管为特征的一种慢性脑血管闭塞性疾病;该病血管造影呈烟雾状,故又称烟雾病.     

椎-基底动脉供血不足的全脑血管造影诊断及支架治疗

目的探讨全脑血管造影对椎-基底动脉供血不足(VBI)的诊断作用及支架治疗效果。方法对182例临床诊断为椎-基底动脉供血不足的患者行数字减影血管造影(DSA)检查,并对其中48例适合介入治疗的VBI患者实施脑血管成形及支架治疗(CAS)。结果131例VBI患者存在不同类型的椎-基底动脉病变,包括动脉粥样硬化斑块形成所致狭窄76例、椎动脉起始部扭曲34例、颈椎横突孔骨性狭窄所致椎动脉狭窄2例、先天性椎动脉发育不良18例。动脉粥样硬化斑块所致病变中,包括锁骨下动脉狭窄9例、基底动脉狭窄8例、椎动脉起始部狭窄59例、锁骨下动脉完全闭塞4例。在DSA诊断基础上对适合血管内治疗的48例患者实施了CAS治疗,手术成功率为100%,术后6～12个月随访,48例患者均未见椎-基底动脉系统短暂性脑缺血发作(TIA)及新发后循环供血系统脑梗死。结论DSA对VBI患者的病因诊断有重要的临床指导意义,因为椎-基底动脉狭窄所致的VBI行血管成形及支架治疗可能是今后治疗本病的方法之一。     

400例缺血性脑梗死患者数字减影全脑血管造影分析

目的 分析缺血性脑梗死患者的脑血管病因和病变血管的分布情况.方法 回顾性分析400例缺血性脑梗死数字减影全脑血管造影(DSA)结果,分析脑梗死的血管病因,并对动脉粥样硬化脑梗死者总结分析动脉病变的部位、分布及血管狭窄形态.结果 脑血管造影结果提示88.25％缺血性脑梗死患者为不同程度的动脉粥样硬化引起血管狭窄或闭塞(353例),此外11.75％缺血性脑梗死患者病因是由于动脉夹层、Moyamoya病、椎基底动脉扩张延长症、鼻咽癌放疗后脑动脉病变、血管迂曲、微血管病变等原因引起.353例动脉粥样硬化性脑梗死中单纯前循环血管受累(45.61％)明显多于单纯后循环血管受累(34.27％),P＜0.01;前循环脑梗死中以颈内动脉(56.6％)和大脑中动脉(26.4％)受累最常见;后循环脑梗死中以椎动脉病变(33.0％)最多见.结论 脑血管造影显示缺血性脑梗死患者有最常见病因是动脉粥样硬化脑血管狭窄或闭塞,占88.25％.前循环脑梗死患者血管病变以颈内动脉起始部病变和大脑中动脉病变多见,后循环脑梗死中以椎动脉动脉病变多见.颅外血管狭窄以颈内动脉颅起始部和椎动脉起始部多见,颅内血管狭窄以大脑中动脉和椎动脉颅内段多见.     

基底动脉尖综合征发病机制的深入探讨

目的:探讨基底动脉尖综合征(TOBS)的发病机制。方法:对19例TOBS患者的临床表现和辅助检查进行分析。结果:其中10例患者行DSA检查均有脑底动脉粥样硬化;7例见基底动脉顶端、大脑后动脉及小脑上动脉闭塞,2例双侧椎动脉严重狭窄,基底动脉顶端未见闭塞,而双侧大脑后动脉、小脑上动脉闭塞。2例患者后交通动脉发育异常。全部患者均有血液流变学异常。10例有房颤史。结论:基底动脉尖的主要发病机制为脑栓塞和脑血栓形成,其次为血液流变学异常,如合并后交通动脉畸形,则更易发生基底动脉尖综合征。     

21例椎基底动脉闭塞的临床和病理所见

21例椎基底动脉闭塞发病高峰期临床表现为:(1)昏迷或闭锁综合征。(2)四肢瘫。(3)中枢性高热。(4)呼吸衰竭。(5)去脑强直发作。血管闭塞的原因;血栓形成15例,脑动脉粥样硬化3例,脑栓塞3例。梗塞灶主要波及桥脑、中脑及小脑,少数可波及枕、颞叶、丘脑或延髓。早期脑CT扫描假阴性率较高,脑干诱发电位有助于早期定位诊断。     

椎基底动脉供血不足的临床与数字减影全脑血管造影结果分析

目的:通过数字减影全脑血管造影(DSA)途径探讨椎基底动脉供血不足的发病机制。方法:对159例患者按照有无眩晕或(和)头晕发作分为2组进行DSA检查,其中A组(椎基底动脉供血不足组)80例,B组(对照组)79例,对结果进行综合分析。结果:A组患者共有125处血管病变,其中椎动脉第一段(V1)迂曲39例,椎动脉(VA)起始部狭窄31例,锁骨下动脉(SCA)狭窄8例,分别与B组对照存在差异(P<0.01,P<0.01,P<0.05)。结论:V1迂曲和VA起始部狭窄很可能是椎基底动脉供血不足的重要病理生理基础。     

溶栓联合血管成形术治疗急性颅内椎基底动脉闭塞

作者报导溶栓后经皮腔血管成形术成功地治疗三例急性颅内椎基底动脉闭塞病例。 例1,男64岁,昏迷5小时后入院。头部CT示双侧小脑小梗塞。急诊血管造影颅内左侧椎动脉(VA)闭塞,右侧椎动脉(VA)发育不全。微导管插入左VA,注入尿激酶48万u,血管再通后发现VA、基底动脉(BA)严重狭窄。经股部插入2.5mm经皮腔血管成形(PTA)球囊导管,用3～5个大气压扩张左VA 4次,20秒/次;以同样方式扩张BA,尽管有70％血管狭窄但获得充足的远端血流。患者意识障碍很快恢复。1周后出院留下轻微小脑共济失调。6月后血管造影残留同样多的狭窄,但远端血流充足。例2,男57岁。突发意识障碍、左侧偏瘫。多次头部CT未见异常。血     

Stroke in patients with fusiform vertebrobasilar aneurysms

We studied seven patients with brainstem infarction and large fusiform vertebrobasilar (VB) aneurysms to clarify the clinical, radiologic, and pathologic features. All presented with pontine infarcts; one also had a cerebellar infarct. VB TIAs preceded brainstem infarction in four patients. Angiography and CT documented VB fusiform aneurysmal dilatation. Four had intraluminal thrombi and one had severe basilar artery stenosis. Two distinct clinical pictures emerged: unilateral pontine infarcts with favorable outcome, presumably related to obstruction of a pontine penetrating artery at its origin from the posterior wall of the aneurysmal basilar artery, and major fatal bilateral pontine infarcts from basilar artery occlusion. Two patients came to autopsy. One had thrombus in the dilated basilar artery and a posterior cerebral artery branch embolus with hemorrhagic occipital infarction; the other had basilar artery thrombus with aneurysmal rupture and subarachnoid hemorrhage. Fusiform VB aneurysms caused brainstem stroke by intraluminal thrombus, local embolism, atherostenosis, and obstruction of paramedian penetrating arteries. Subarachnoid hemorrhage is an uncommon complication.     

Characteristics of vascular lesions in patients with posterior circulation infarction according to age and region of infarct

Patients with posterior circulation infarction underwent CT angiography and magnetic resonance angiography. Intracranial and extracranial vasculopathy was evaluated according to age group and location of stroke. Patients aged > 60 years and < 60 years had similar rates of vertebral artery dominance and vertebrobasilar artery developmental or origin anomalies. Vertebrobasilar artery stenosis or occlusion and tortuosity occurred more frequently in patients aged > 60 years than < 60 years. The rates of vertebrobasilar artery anomalies and tortuosity were high in patients with posterior circulation infarction. Vertebrobasilar artery tortuosity occurred more frequently in patients aged > 60 years, whereas vertebrobasilar artery developmental anomalies occurred with similar frequency in patients aged < 60 years and > 60 years. Patients with infarction of the brainstem or cerebellum were more likely to have vertebral artery stenosis or occlusion, basilar artery stenosis or occlusion, vertebral artery dominance or tortuosity, and basilar artery tortuosity, and patients with infarction of the thalamus, medial temporal, or occipital lobes were more likely to have stenosis or occlusion of the vertebral or basilar arteries. Vertebrobasilar artery tortuosity, vertebral artery dominance (hypoplasia), and congenital variations of the vertebrobasilar system may lead to posterior circulation infarction at different locations in different age groups.     

数字减影血管造影对缺血性脑血管病诊断及治疗的意义

目的:探讨数字减影血管造影检查(DSA)对缺血性脑血管病血管病变诊断的意义。方法:选取有脑缺血症状的经TCD检查发现血管狭窄的21例病人,行DSA检查。结果:颈内动脉系统TIA患者3例,DSA证实为大脑中动脉狭窄2例,烟雾病1例,椎基底动脉供血不足8例中双侧椎动脉发育不全1例,一侧或双侧椎动脉狭窄5例,锁骨下动脉盗血2例。8例脑梗塞患者中已经出现一侧颈内动脉闭塞的有两例,但均已出现侧枝循环的建立,另6例均为颈内动脉或大脑中动脉的狭窄,2例脑干梗塞患者均有椎动脉的狭窄。结论:数字减影血管造影是评价头颈部血管狭窄、闭塞和选择治疗方案的金标准,它对缺血性脑血管病的进一步治疗起着重要的作用。     

"Fou rire prodromique" as the presentation of pontine ischaemia secondary to vertebrobasilar stenosis.

"Fou rire prodromique" (prodrome of crazy laughter) is a rare form of pathological laughter of uncertain pathophysiology. A patient is presented with pathological laughter as the first manifestation of pontine ischaemia due to vertebrobasilar stenosis. A 65 year old man developed uncontrollable and unemotional laughter for almost an hour followed by transient right facial-brachial paresis. He had fluctuation of laughter, right facial brachial paresis, and occasional crying. Magnetic resonance imaging, magnetic resonance angiogram (MRA), and an angiogram showed small left pontine and cerebellar infarcts, left vertebral artery occlusion, and right vertebral and basilar artery stenosis. His condition deteriorated to bilateral brain stem infarction and he died. Necropsy confirmed the extensive brain stem infarction. Pathological laughter can be the very first presenting manifestation of ischaemia of the ventrotegmental junction of the upper pons. It is hypothesised that the pathological laughter in this patient was secondary to ischaemic ephaptic stimulation of the descending corticopontine/ bulbar pathways.     

脑桥梗死部位与椎基底动脉狭窄或闭塞的关系

目的 探讨脑桥梗死部位与椎基底动脉狭窄或闭塞之间的关系.方法 连续入选2005年2月至2007年9月收住北京宣武医院神经内科的新发脑桥部梗死患者139例,所有病例均行头部MRI以及全脑血管造影检查,排除有可疑心源性栓子来源的患者.将病例分为A(旁中央动脉组)、B(短旋动脉组)、C(长旋动脉组)、D(混合组)4组,并对各组进行与椎动脉、基底动脉狭窄或闭塞以及无血管病变的相关性研究.结果 139例患者中A、B、C、D组各占78(56.1%)、3(2.2%)、7(5.0%)、51(36.7%)例.左或右侧椎动脉闭塞者56例(40.3%),左或右椎动脉狭窄者60例(43.2%),基底动脉闭塞者14例(10.1%),基底动脉狭窄者14例(10.1%),无后循环血管改变者16例(11.5%).A组与椎动脉闭塞、基底动脉闭塞及无血管病变者相关,x2值分别为3.945、6.824、4.485,P值分别为0.043、0.021、O.041.D组与基底动脉闭塞相关,x2值为10.952,P值为0.006.对以上两者进行Logistic回归分析,发现A组与椎动脉闭塞更相关(OR值为2.261),D组与基底动脉闭塞更相关(OR值为15.750).结论 脑桥不同部位的梗死与椎基底动脉的狭窄或闭塞关系密切,提示临床医生在遇到相关病例时,应提高警惕,及时做血管检查.

Abstract：

Objective To investigate the correlation between stenosis or occlusion of vertebralbasilar artery and the location of infarctions in pontine. Methods All 139 patients with acute pontine infarction who were admitted to the Department of Neurology,Xuanwu Hospital,Beijing,during February,2005 and September,2007 were studied. All patients received the examinations of head MRI and digital subtraction angiography (DSA). Patients with possible cardiac embolism were excluded from the study. All the cases were then divided into four groups: A( paracentral artery group); B (short rotary artery group); C (long rotary artery group) and D (combined group). Results In all 139 cases,78 cases (56. 1% ) were in A group,3 (2. 2% ) in B group,7 (5.0%) in C group and 51 (36.7%) in D group. Fifty-six cases (40. 3% ) have occlusion in vertebral artery,60 cases (43.2%) have stenosis of vertebral artery. Cases having stenosis or occlusion in basilar artery are 14 cases (10. 1% ) each. Sixteen cases (11.5%) have unimpaired vertebral-basilar artery. A group is related to occlusion of vertebral artery and basilar artery and unimpaired artery ( x2 =3. 945,6. 824,4. 485 ,P = 0. 043,0. 021,0. 041 respectively). D group is related to occlusion of basilar artery ( x2 = 10. 952,P = 0. 006). Logistic binary analysis found that A group is more related with occlusion of vertebral artery ( OR = 2. 261 ),while D group is more related to occlusion of basilar artery ( OR = 15. 750). Conclusions There is a significant correlation between stenosis or occlusion of vertebral-basilar artery and the locations of infarctions in pontine. The physicians are suggested to perform the examinations on cerebral vessels such as brain MRI or DSA in patients with infarctions in pontine.     

A case report of bilateral cerebral peduncular infarction manifesting tetraparesis and pseudobalbur palsy]

A 63-year-old female had presented with right hemiparesis and slight dysarthria. MRI had showed the infarction of left pons and left peduncle. Three months later she further presented with left hemiparesis, severe dysarthria and swallowing disturbance. MRI showed bilateral cerebral peduncular infarction. And the angiogram showed the occlusion of basilar artery at the just distal portion of the superior cerebellar artery. We recognized our case as the infarction due to the basilar artery occlusion. The 16 cases of bilateral cerebral peduncular infarction were reported. In these reports, the symptoms of bilateral cerebral peduncular infarction were locked-in syndrome in 15 cases and persistent vegetative state in only one case. Our patient presented with tetraparesis and pseudobalbur palsy not with locked-in syndrome, probably because the area of infarction was limited within almost lateral portion of peduncle. The sparing of posterior cerebral artery was one of the reason of such a condition. This is the first report of bilateral cerebral peduncular infarction manifesting tetraparesis and pseudobalbur palsy.     

A case of severe stenosis of bilateral distal vertebral artery successfully treated with anastomosis operation]

A 65-year-old male complained of loss of consciousness for several minutes, transient diplopia and dizziness. He had no neurological deficits nor abnormalities in MR imaging. However, flow velocity of bilateral vertebral artery on ultrasonography indicated severe stenosis of bilateral distal vertebral artery. Brain angiography revealed severe stenosis of bilateral distal vertebral artery as well as occlusion of right middle cerebral artery (MCA). Single photon emission CT (SPECT: ECD-RVR method with acetazolamide loading) showed decreased cerebral blood flow and poor perfusion reserve in bilateral cerebellar hemisphere and right MCA territory. Superficial temporal artery-superior cerebellar artery (STA-SCA) anastomosis was performed. The patient turned out to have no episodes of unconsciousness attack, transient diplopia and dizziness after operation. Cerebral blood flow (CBF) in the posterior circulation was also improved. Evaluating quantitative CBF measurement by means of ECD-RVR method was useful for evaluating CBF. In cases who have severe stenosis of bilateral distal vertebral artery with complaints of vertebrobasilar insufficiency, STA-SCA anastomosis may be one of the most effective treatments.     

Yawning despite trismus in a patient with locked-in syndrome caused by a thrombosed megadolichobasilar artery

We report a 62-year-old woman with a locked-in syndrome with bilateral masticatory spasms and persistent trismus, who was still able to yawn. A vascular malformation of the basilar artery-megadolichobasilar artery (fusiform aneurysm, vertebrobasilar dolichoectasia) was determined to be the underlying cause of this rare combination of symptoms. A thrombus in the megadolichobasilaris as well as an almost total pontine infarction were demonstrated on CT- and MRI-scans. Thus, trismus may be associated with locked-in syndrome due to megadolichobasilar artery thrombus, although yawning is still possible.     

Pitfall of Electron Beam Computed Tomography Angiography in Diagnosis of Subclavian Steal Syndrome

A patient presented with vertebrobasilar insufficiency during exertion. Vertebral duplex and transcranial Doppler ultrasonography showed reversal of flow in both intracranial and extracranial vertebral and basilar arteries, suggesting bilateral subclavian and vertebrobasilar steal. Electron beam computed tomography angiography (CTA) showed no evidence of subclavian artery stenosis including normal vertebral artery origin on both sides. However, digital subtraction angiography revealed complete occlusion of both subclavian arteries with retrograde flow from both vertebral and basilar arteries to reconstitute both subclavian arteries. This false-negative finding on CTA in detection of subclavian steal syndrome (SSS) is due to inappropriate contrast administration technique and postprocessing method, inability to differentiate flow direction, and lack of hemodynamic time sequences. This study demonstrates a pitfall of CTA in diagnosis of SSS compared to more reliable hemodynamic information obtained by duplex and transcranial Doppler ultrasonography, and digital subtraction angiography.     

动脉溶栓治疗37例椎-基底动脉闭塞患者临床分析

目的 分析急性椎-基底动脉闭塞(VBAO)患者选择性动脉溶栓治疗(IAT)的血管再通效果、预后及其影响因素.方法 37例VBAO患者行选择性IAT,VA系统11例、BA系统26例,通过分析IAT时间、术前ESS、GCS评分等,并分析术后90d mRS评分结果.结果 血管总的再通率为64.86%,椎动脉闭塞(VAO)组再通率为27.27%,基底动脉闭塞(BAO)组为80.77%;开始行IAT的时间≤6h组血管再通率为85.71%,存活率为52.38%;＞6h组分别为37.5%和8.75%.术前GCS评分为12～15分组存活率为72.22%,3～11分组为5.26%;术前ESS评分＞35分组存活率为71.43%,0～35分组为17.39%;血管再通组存活率为50%,血管未通组为15.38%.死亡23例,其中1例死于脑出血.结论 选择性IAT治疗急性VBAO,血管再通生存率较高;IAT治疗的时间、血管闭塞的部位、术前ESS、GCS评分及血管是否再通与IAT疗效密切相关.