头颈部CT血管造影对急性缺血性脑卒中早期的诊断价值

目的:分析应用头颈部非创伤性血管成像技术(简称CT血管造影)(CT angiography,CTA)实施颈动脉狭窄诊断对于急性缺血性脑卒早期诊断的应用价值.方法:选取2020年5月—2021年5月宁津县人民医院收治的50例疑似颈动脉狭窄急性缺血性脑卒中患者,对入组患者均实施头颈部CTA扫描及颈部血管彩超,对比数字减影血...     

超选择动脉溶栓及经皮腔内血管成型术治疗脑梗死

目的 评价超选择动脉溶栓及经皮腔内血管成形术（PTA）治疗急性治脑梗死的临床疗效。方法 对30例急性脑梗死病人,经股动脉或颈动脉插管,用微导丝将微导管送至血管闭塞部位,注入尿激酶（UK）行溶栓治疗,对6例颅外段血管狭窄者,采用PTA消除,并注入罂粟碱扩张颅内血管。结果 颈内动脉闭塞10例、大脑中动脉16例、椎基动脉系统4例,血管完全再通15例,部分再通12例,治疗3月后日常生活能力指数（BI）评分：100分20例,75-95分6例,占86.7%。结论：早期超选择动脉溶栓配合PTA和罂粟碱可明显提高闭塞血管再通率,是目前治疗急性脑梗死有效的方法。     

缺血性脑卒中患者颈部血管狭窄的诊断及介入治疗

目的探讨山西长治地区缺血性脑卒中患者颈部血管狭窄的诊断及介入治疗情况。 方法对山西长治市人民医院神经内科2008年1月至2013年12月所有住院的急性缺血性脑卒中患者,先采用非创伤性检查筛查出颈部血管狭窄患者,征得患者同意后行数字减影血管造影(DSA)检查,确诊颈部血管狭窄符合介入治疗指征的缺血性脑卒中患者,根据患者最终是否接受介入治疗分为介入治疗组及非介入治疗组(对照组)。分别于出院后3、6个月,1、2年进行随访,了解疾病复发情况,采用改良RanKin量表进行评分(MRS)以评估患者生存质量,并比较两组患者差异。 结果共筛查出可疑颈部血管狭窄患者72例,DSA造影显示：颅外颈内动脉狭窄31例,椎动脉狭窄14例,锁骨下动脉狭窄13例;颅内颈内动脉系统狭窄10例,颅内椎基底动脉系统狭窄17例;其中多发狭窄25例。36例颅外颈部血管狭窄符合介入治疗适应证,其中16例接受介入治疗(治疗组),20例未接受介入治疗(对照组)。在所有接受介入治疗的患者中,接受颅外颈部血管支架置入术者15例,接受球囊扩张术者1例,介入治疗成功率100%,无严重并发症及死亡病例。与对照组相比治疗组患者复发次数明显减少(χ²＝8.23,P＝0.004),生存状态更好(χ²＝8.22,P＝0.004)。 结论山西长治地区缺血性脑卒中患者,脑动脉狭窄前循环脑梗死的血管病变,以颈内动脉起始部狭窄为主;后循环脑梗死的颅外血管病变,以椎动脉起始部位狭窄为主,其次是锁骨下动脉起始部狭窄致锁骨下动脉盗血,另外后循环脑梗死的血管病变中颅内椎动脉狭窄也不少见。     

脑血管储备对缺血性卒中的预测价值

目的探讨脑血管储备的改变是否能预测有颈动脉或者大脑中动脉狭窄或闭塞患者的缺血性卒中的发生。方法采用灌注CT和吸入5％CO2方法测定脑血管储备。研究对象为37例颈内动脉或大脑中动脉狭窄或者闭塞的患者,平均年龄（58．0±11．9）岁。分为两组：储备下降组（脑血管储备〈10％）和储备正常组（脑血管储备≥10％）。所有患者采用药物治疗,通过定期门诊或者电话随访。结果脑血管储备下降组17例,脑血管储备正常组20例。在平均56．9个月的随访中,总共有7例发生缺血性卒中,均发生于脑血管储备下降侧的脑组织,并且都属于脑血管储备下降组（7／17）。缺血性脑卒中的年发生率在脑血管储备下降组和正常组分别是8．7％和0％。Kaplan—Meier生存分析提示脑血管储备下降组发生卒中的风险显著高于正常组（P=0．002,Log-rank法）。结论对于颈内动脉、大脑中动脉狭窄或闭塞的患者,脑血管储备的下降可能预示着未来易于发生缺血性卒中。     

Carotid endarterectomy for unilateral carotid system transient cerebral ischemia

This study involved 151 consecutive patients who had transient focal cerebral ischemia (TIA) in one carotid arterial system and who had carotid endarterectomy on the side corresponding to the ischemic symptoms. Each patient was examined preoperatively by a neurologist, who also judged the postoperative morbidity and mortality. All patients were operated on by one surgeon. A major or minor ischemic stroke occurred in 3% of patients during operation or within 30 days thereafter. The mortality was less than 1% at 1 month. After the first month, ischemic stroke occurred at a rate of 2% per year, and two-thirds of the strokes were ipsilateral to the endarterectomy. Long-term mortality was 3% per year. Long-term stroke morbidity was less than would have been expected for a comparable group of patients with TIA, and the percentage of deaths due to a cardiac cause was greater than expected, owing to a relative shift from stroke mortality to cardiac mortality. No patient who had a cerebral blood flow of 40 ml or greater per 100 g of brain per minute during occlusion for endarterectomy had a stroke during operation or during 4 1/2 years of follow-up.     

Duplex sonographic predictors of restenosis,vascular and neurological events after carotid endarterectomy

BACKGROUND: Although excellent short- and long-term results have been achieved with surgery in extracranial internal carotid artery stenosis, recurrent stenosis continues to play an important role in post-endarterectomy. Therefore, a close follow-up of patients is warranted. The value of postoperative duplex sonographic evaluations in postoperative follow-up is highly disputed. The study evaluates duplex sonographic parameters as predictors of carotid restenosis, general vascular events and ipsilateral neurological symptoms, in order to assess the role of duplex sonography in follow-up after carotid endarterectomy. METHODS: A retrospective cohort study with a follow-up period ranging from 7 months to 7.5 years was performed in 150 patients who underwent carotid endarterectomy. Pre- and postoperative duplex sonographic and clinical data were analyzed by life-table analysis and multivariate Cox regression with respect to carotid restenosis, vascular and ipsilateral neurological events. MAIN FINDINGS: Duplex sonographic predictors of carotid restenosis include the postoperative degree of stenosis (residual stenosis > or = 30% or more: relative risk (RR) = 1.56; 1.05-2.32), pre- to postoperative reduction of stenosis (higher than 50%: RR = 0.61; 0.45-0.83), and residual plaques in the operated carotid artery (RR = 1.96; 1.31-2.93). Some of these morphological parameters such as reduction of stenosis are also predictive of vascular events (RR = 1.25; 1.01-1.56) and ipsilateral neurological events (RR = 1.52; 1.05-2.19). In 12 cases restenosis was discovered by duplex sonography and in 3 cases by evaluation of clinical symptoms. In 5 cases restenosis was treated by repeat surgery. Contralaterally, progressive or newly developed carotid stenoses were observed in 17 cases, and only 5 were discovered on the basis of clinical symptoms. Fourteen contralateral stenoses required surgery. Overall, 12 patients underwent treatment for stroke prevention on the basis of duplex follow-up findings (8% of the study population). CONCLUSIONS: Postoperative duplex sonography allows for the identification of patients at risk for carotid restenosis as well as those at risk for other vascular events. As expected, regular examinations permit early detection of restenosis requiring surgical treatment. However, a large number of contralateral stenoses requiring surgical treatment were detected by routine duplex sonographic examinations. The timing of follow-up intervals may be oriented towards the perioperative outcome of duplex sonography.     

Short- and long-term outcome after carotid artery stenting with neuroprotection: single-center experience within a prospective registry

BACKGROUND : Carotid artery stenting is an alternative method to surgical endarterectomy for treatment of carotid artery stenosis. METHODS AND RESULTS : Three hundred and seventy-one consecutive patients (71+/-9 years) undergoing 405 carotid artery interventions at a single cardiologic center were studied prospectively within a therapy registry. In general, the interventional procedure was performed using neuroprotective devices to prevent distal embolization. Stents were used routinely whenever possible. Independent neurological assessment took place prior to and after carotid stenting. The neurological event rate was assessed in the early (<30 days) and late post interventional period. In asymptomatic patients, 286 interventions were done with a 30-day stroke rate of 1.3% (ipsilateral 1.0%). In symptomatic patients, strokes occurred in a significantly (p<0.005) higher rate of 5.0% after 119 interventions (all ipsilateral). At long-term follow-up (mean 728+/-548 days) additional strokes occurred ipsilateral to the side of carotid intervention in 0.4% of asymptomatic patients (1.7% of symptomatic patients); contralateral strokes were seen at long-term follow-up in 1.1% of asymptomatic (1.7% of symptomatic) patients. Due to their comorbidities, 1.6% of patients died early, and an additional 11.1% late after carotid stenting. CONCLUSION : Carotid artery stenting with the general use of neuroprotective devices yields acceptable shortterm results with respect to neurological events. Asymptomatic patients have significantly less periprocedural strokes than symptomatic patients. Neurological events during long-term follow-up are rare, in particular ipsilateral to the side of carotid stenting. Thus, carotid artery stenting with neuroprotection is a safe method for carotid revascularization, with acceptable periprocedural events, particularly in asymptomatic patients, and a good long-term neurologic outcome.     

彩色多普勒超声诊断缺血性脑血管病:与CTA、DSA对比分析

目的 探讨彩色多普勒超声（CDU）诊断缺血性脑血管病（ICVD）的价值。方法 回顾性分析107例ICVD患者（缺血组）及79例无ICVD患者（对照组）的TCCD和（或）TCD及颈动脉超声资料,观察颅外动脉及颅内动脉超声征象,并与CTA或DSA结果进行对照。采用Logistic回归模型评价CDU检测指标与ICVD的相关性。结果 经CTA或DSA证实,缺血组颅内动脉狭窄22例（22/107,20.56%）,颅外动脉狭窄77例（77/107,71.96%）;对照组颅内动脉均无狭窄,颅外动脉狭窄34例（34/79,43.04%）。缺血组与对照组比较,颅外动脉的IMT、斑块数量及性质、管腔狭窄程度差异均有统计学意义（P均<0.05）。CDU诊断ICVD患者颅内动脉狭窄与CTA或DSA的一致性中等（Kappa=0.730）,诊断颅外动脉狭窄的一致性良好（Kappa=0.883）。ICA狭窄（P=0.005）、软斑/溃疡斑（P=0.002）、VA狭窄（P=0.029）与ICVD的发生相关。结论 CDU诊断ICVD患者颈动脉狭窄与CTA或DSA具有较好的相关性,ICA狭窄、软斑/溃疡斑、椎动脉狭窄是ICVD的危险因素。     

The role of surgery in ischemic stroke.

Surgery in the management of stroke is useful primarily as a stroke-preventive measure for patients with extracranial carotid artery occlusive disease. Ideally, lesions that are potential sources of ischemia are removed before a fixed neurologic deficit can occur. Patients with transient ischemic attacks and no deficit or only minor neurologic deficit comprise the largest group of surgical candidates. Diagnostic angiography must be carried out before endarterectomy and should include aortic arch studies of both extracranial and intracranial carotid arteries. Placement of an intra-arterial catheter at the beginning of surgery provides the best method of monitoring arterial pressure. A postoperative angiogram allows visual confirmation of the patency of reconstructed vessels. Such confirmation is particularly important if patients have severely stenotic bilateral carotid artery disease. The surgical mortality for all patients with TIAs is between 1% and 2% in those clinics in which this type of operation is commonly done.     

颈动脉重度狭窄患者侧支循环分级与临床结局的相关性

目的 应用数字减影血管造影(DSA)研究颈内动脉重度狭窄患者侧支循环开放途径和程度,并观察其对患者临床结局的影响.方法 经全脑DSA检查证实存在颈内动脉重度狭窄(70%～99%)患者49例,评价其侧支循环开放的途径和程度.观察12个月后新发脑梗死、短暂脑缺血发作(TIA)或脑出血的发病情况.结果①49例患者,无侧支循环开放9例(18.4%,9/49),初级侧支循环开放39例(79.6%,39/49),次级侧支循环开放25例(51.0%,25/49).开放途径与临床结局无明显相关.②49例患者侧支开放程度0级9例(18.4%,9/49),并发症发生率44.44%(4/9),1、2级15例(30.6%,15/49),并发症发生率50.66%(8/15),3、4级25例(51.0%,25/49),并发症发生率24.00%(6/25),3、4级患者缺血性脑血管病发生率显著高于0级和1、2级患者(X2值分别为4.856、3.242,P均＜0.05).结论 颈内动脉重度狭窄时,侧支循环代偿途径与临床结局无明显相关,侧支循环程度与临床结局显著相关.     

Results, complications, and follow-up of 415 bypass operations for occlusive disease of the carotid system

Selected patients with acute or continuing ischemic symptoms from occlusions or inaccessible stenotic lesions of the internal carotid artery or middle cerebral artery have been considered candidates for a carotid artery-middle cerebral artery bypass procedure at our institution since July 1974. We report herein an 8-year experience through June 1982 with 415 operations in 403 patients in whom a branch of the superficial temporal artery was anastomosed to a branch of the middle cerebral artery. Patients selected for operation usually had had more than one form of ischemic symptom. The primary indication for operation was transient ischemic attacks, and the most common vascular pathologic condition was internal carotid artery occlusion. Preoperatively, 183 patients were taking antiplatelet agents and 157 were taking anticoagulants. Neurologic function 6 months postoperatively was equal to or better than the function preoperatively in 95% of survivors. The bypass pedicle was patent in 99% of patients studied. The mortality and morbidity associated with the surgical procedure varied on the basis of the patient's preoperative neurologic condition but were 1% and 4%, respectively, for the entire group at 30 days postoperatively. Of the 54 deaths during the entire follow-up period, 27 were cardiogenic and 6 were from ischemic stroke. On the basis of patient-months of follow-up, stroke was 8 times more likely to occur within 6 months after operation than thereafter.     

彩色多普勒超声及血管造影对颈动脉狭窄或闭塞患者的诊断价值

目的比较彩色多普勒超声（CDFI）与数字减影血管造影（DSA）诊断颈动脉狭窄或闭塞价值,分析两者诊断结果不一致的原因。 方法回顾性分析2010年8月至2014年7月在山东省聊城市第二人民医院血管超声科首次经CDFI诊断为颈动脉狭窄或闭塞,并同期行DSA检查的215例患者临床资料,Kappa检验CDFI与DSA诊断结果的一致性,对诊断结果不一致患者,复查CDFI及回顾DSA动态图像阅片,分析两者诊断结果不一致的原因。 结果首次CDFI检查与DSA检查检查结果符合率达90.7%（195/215）;两种检查方法结果一致性好（Kappa=0.7731,P<0.01）。两者诊断不一致患者经复查CDFI及回顾DSA动态图像阅片发现,其中4.7%（10例）因治疗后病情变化所致不符,1.4%（3例）因两项检查成像原理不同,3.2%（7例）因两项检查医师诊断结果不符。 结论CDFI检查颅外段颈动脉狭窄或闭塞与DSA检查结果一致性好,对部分诊断结果不一致患者应综合分析,提高诊断准确性,两项检查结果具有互补性。     

Cardioembolic stroke: Protective effect of a severe internal carotid artery stenosis in a patient with cardiac embolism

Cardioembolic stroke is generally caused by intracranial artery occlusion. Clots may be identified in the intracranial vessels by means of conventional neuroimaging in the acute phase. High‐resolution ultrasonography may show some features suggestive of cardiac emboli when occluding extracranial carotid arteries. We describe a patient with cardioembolic ischemic stroke in the right hemisphere in whom a left internal carotid artery stenosis paradoxically protected the ipsilateral hemisphere from distal intracranial embolism. The patient also presented multiple acute ischemic embolic lesions in the right middle cerebral artery territory and in the right occipital lobe, which was fed by the posterior cerebral artery, anomally originating from the right carotid siphon. Interestingly, the left internal carotid artery—which showed a severe preexisting stenosis—was occluded by the cardiac clot, whereas the right internal carotid artery only presented a moderate stenosis that had probably allowed the clots to pass. Therefore, the severe left internal carotid artery stenosis may have blocked the cardiac embolus, preventing it from reaching the ipsilateral hemisphere. © 2013 Wiley Periodicals, Inc. J Clin Ultrasound 41 :22–27, 2013     

血管超声评价颈动脉蹼的结构特征

目的通过血管超声评估颈动脉蹼（CW）的结构特征。 方法连续纳入2018年1月至2019年6月于首都医科大学宣武医院就诊的经超声检查并经CT血管造影（CTA）证实的CW患者共66例。根据超声对狭窄程度的判定,将患者分为颈动脉<50%狭窄组54例,≥50%狭窄组12例。应用超声测量CW的长度、厚度、与管壁间锐性夹角,记录CW上端的血流方向特征（顺向或逆向血流）、CW与管壁间血栓形成情况,比较2组间CW结构特征的差异,并分析不同颈动脉狭窄程度对缺血性脑卒中发生的影响。 结果首次诊断为CW的患者为42例（42/66,63.6%）,余24例患者首次检查分别诊断为溃疡斑块21例（21/66,31.8%）和夹层3例（3/66,4.5%）。<50%狭窄组与≥50%狭窄组CW的长度、厚度、方向、周边血栓情况差异均无统计学意义（P均>0.05）。<50%狭窄组CW与管壁间夹角显著小于≥50%狭窄组（中位数：39o vs 73o,P=0.002）,而<50%狭窄组中夹角≤60o的发生率也显著高于≥50%狭窄组（74.1% vs 41.7%,P=0.042）。<50%狭窄组CW处的颈动脉残余内径明显大于≥50%狭窄组,而收缩期峰值流速明显低于≥50%狭窄组,2组比较,差异均有统计学意义（P均<0.001）。缺血性脑卒中患者与非卒中患者的颈动脉狭窄程度差异无统计学意义（P=0.321）。 结论超声通过二维及彩色多普勒模式可评估CW的结构特征,CW与管壁间夹角较大时更易导致局部血管狭窄≥50%,但血管狭窄并非导致CW患者脑卒中的重要原因。     

老年颅外段颈动脉狭窄的血管内治疗及围手术期护理

目的探讨老年颅外段颈动脉狭窄患者经皮血管内支架置入血管成形治疗及围手术期护理等相关问题。方法21例老年颅外段颈动脉狭窄患者经全脑数字减影血管造影(DSA)检查诊断后,均采用经股动脉入路应用自膨式支架行经皮血管内支架置入血管内成形术治疗。结果21例(次)支架置放均获成功。DSA显示狭窄段的颈动脉直径明显扩大。仅1例出现部分运动性失语。随访2~24个月,全部患者均未再发生脑缺血,其中2例行DSA复查,6例行多普勒超声复查,均无再狭窄发生。结论经皮血管内支架置入血管成形术治疗老年颅外段颈动脉狭窄安全性高,效果可靠,围手术期护理是手术成功的保障。     

症状性颈动脉狭窄与纤维蛋白原水平相关研究

目的 探索症状性颈动脉狭窄与"新"的危险因素纤维蛋白原(Fib)水平的关系,为症状性颈动脉狭窄发生发展的防治提供依据.方法 以颈动脉彩色多普勒超声或CT血管造影(CTA)或数字减影血管造影(DSA)显示颈动脉狭窄≥50%为依据,将急性缺血性脑血管病(ICVD)患者315例随机分为两组:症状性颈动脉狭窄患者(狭窄组)17...     

颞浅动脉-大脑中动脉搭桥术治疗大脑中动脉狭窄或闭塞16例疗效分析

目的:探讨颞浅动脉-大脑中动脉(STA-MCA)搭桥术治疗伴大脑中动脉狭窄或闭塞的缺血性卒中患者的效果。方法:伴大脑中动脉狭窄或闭塞的缺血性卒中患者16例,行STA-MCA搭桥术或STA-MCA搭桥术联合脑-硬脑膜-动脉贴敷(EDAS);术中采用脑血管吲哚菁绿荧光造影、术后行血管超声以确定吻合血管通畅情况;术前、术后1周及出院3个月后采用改良Rankin量表(mRS)对患者进行神经功能评分,随访3个月。结果:所有病例手术均顺利完成;吻合口处血流通畅者15例(93.75%),血流缓慢者1例(6.25%);无患者再发缺血性卒中;术前1周、术后1周及3个月mRS评分良好的患者分别为6例(37.50%)、7例(43.75%)、14例(87.50%);3月时mRS评分良好的患者例数高于术前和术后1周者(P=0.0091,P=0.0233)。结论:STA-MCA搭桥术或联合EDAS治疗大脑中动脉狭窄或闭塞所致脑组织的低灌注效果满意。     

介入支架植入术治疗单侧颈内动脉狭窄的临床探讨

目的：探讨在远端脑保护装置下,结合围术期处理对介入支架治疗单侧颈内动脉狭窄疗效的影响。方法选择2012年6月至2014年1月该院收治的23例单侧颈内动脉狭窄患者,均行数字减影血管造影（DSA）证实单侧狭窄率大于或等于75％,其中C1段狭窄15例,C2段狭窄8例,在远端脑保护伞保护下,行介入支架植入术治疗。术后给予相应药物治疗及预防并发症。结果23例单侧颈内动脉狭窄患者,经DSA证实,术后狭窄率均低于30％,手术成功率100％,其中1例患者术中球囊扩张时出现血管痉挛（4．3％）,2例患者出现穿刺点皮肤及鼻黏膜出血,3例患者出现了不同程度的头痛、恶心、呕吐等症状,对症处理后症状均消失,术后6个月随访,均无栓塞及其他并发症发生。术后随访6个月,患者收缩压和舒张压明显下降（P＜0．05）。介入前后,在年龄（以60岁为界）、性别（女／男）、高血压、陈旧性脑梗死、糖尿病、血脂异常、吸烟（3年以上）等临床病理特征中,差异均无统计学意义（P＞0．05）。结论介入支架植入术能够有效治疗单侧颈内动脉段狭窄,通过术中应用保护伞并在围术期加强观察及对症治疗能够有效地减少和控制手术并发症,改善手术预后。     

Long-term mortality and stroke morbidity after superficial temporal artery-middle cerebral artery bypass operation

Among 239 patients with transient ischemic attacks, mild stroke, or transient monocular visual symptoms who had superficial temporal artery-to-middle cerebral artery (STA-MCA) bypass, no deaths occurred during the operation or within 30 days thereafter. After the first month, mortality on an actuarial basis was 3% per year. Survival at 5 years was 84% in comparison with an expected survival of 89% for persons of comparable age and sex in a general population. Among the 25 deaths that occurred during follow-up, 2 were due to stroke and 16 to cardiac causes. Of 28 strokes that occurred, 5 occurred during operation or that same day, and 3 others occurred within 30 days postoperatively. Thereafter, strokes occurred at the rate of 2.5% per year on an actuarial basis; a third of the strokes occurred contralateral to the surgical site. No difference was found in survival or in survival free of stroke among patients who had proven carotid artery occlusion (N = 157), carotid siphon stenosis (N = 53), or MCA stenosis or occlusion (N = 29). In regard to the probability of stroke, this group of patients compares favorably with population studies of patients with transient ischemic attacks of undetermined cause. When this surgical group was compared with 130 nonsurgical patients who had had ischemic symptoms related to proven internal carotid artery occlusion between 1965 and 1975, however, we could not conclude that the risk of occurrence of stroke was less in patients who had STA-MCA bypass than in the nonsurgical patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardioembolic stroke: an update

Cardioembolic stroke accounts for approximately 15% of all strokes and is thought to be one of the more preventable types of strokes. Features that have been reported to support cardioembolism as a mechanism for ischemic stroke have included documented cardiac source of embolism, maximal neurologic deficit at onset, multiple cerebrovascular territories involved, enhanced tendency toward hemorrhagic transformation, enhanced risk of syncope or seizure associated with presentation, and lower likelihood of premonitory transient ischemic attacks. Features that tend to make cardioembolic stroke less likely include significant cerebral atherosclerosis, step-wise progression of the neurologic deficit within a finite period of time, vascular distribution such as entire internal carotid artery territory with combined middle cerebral artery and anterior cerebral artery involvement or watershed distribution, and premonitory transient ischemic attacks. A number of cardiac conditions can promote thromboembolism, and there is risk stratification reflective of the specific condition or coexistent conditions. Anticoagulant therapy generally has been found to be the most effective means of preventing cardiogenic brain embolism, but the intensity of anticoagulation needs to be optimized to reflect the risk-to-benefit ratio for the particular patient.