双侧小脑梗死模式的探讨

目的探寻双侧小脑梗死的模式和机制。方法经MRI弥散成像(DWI)证实急性期小脑梗死的患者,根据梗死灶的分布将患者分为单侧小脑梗死组(UCI)和双侧小脑梗死组(BCI),并对两组的人口学特征、血管分布、小脑以外梗死灶以及病因进行了比较。结果因急性卒中入院的115例后循环脑梗死患者中,56例为小脑梗死或小脑合并其它部位梗死,其中单侧小脑梗死36例(64.3%),双侧小脑梗死20例(35.7%)。基线资料比较显示,脑卒中史(P=0.002)、纤维蛋白元水平(P=0.036)和入院时NIHSS评分(P=0.001)在双侧小脑梗死组明显高于单侧小脑梗死组。按血管分布区划分,小脑后下动脉(PICA)供血区小脑梗死发生率最高,且更多发生单侧小脑梗死(P=0.006);而双侧小脑梗死更常见于PICA+小脑上动脉(SCA)供血区(P=0.004)。双侧小脑梗死组合并小脑以外梗死灶的发生率明显高于单侧小脑梗死组(P=0.002),特别是合并幕下梗死灶常见(P=0.022)。在卒中机制上,双侧小脑梗死以大动脉粥样硬化性病变更多见(P=0.041),责任动脉病变主要是在椎动脉V4段、V4段与BA接合处的重度狭窄或闭塞。结论双侧小脑梗死并不少见,常见于PICA+SCA供血区;大动脉粥样硬化所致动脉源性栓塞是其卒中重要机制之一。     

破裂椎动脉夹层动脉瘤血管内治疗致Wallenberg综合征一例

病例报告 患者 男,41岁.因突发头痛伴头晕、恶心1d于2011年12月17日入院.检查:一般情况良好,精神不振,颈部抵抗,余神经系统检查未见异常.头颅CT示:蛛网膜下腔出血,出血位于小脑幕、大脑纵裂池及双侧大脑沟回内,脑室系统正常.于12月19日局麻下行DSA显示:右侧椎动脉夹层动脉瘤,梭形,位于右侧小脑后下动脉(PICA)近端约0.8 cm处,大小约3.6mm×5.1 mm;左侧椎动脉正常.双侧股动脉穿刺置管,应用球囊闭塞右侧椎动脉起始部,左侧椎动脉造影显示血流经汇合部返流,右侧PICA显影良好.     

小脑梗死的分型与后循环血管病变

目的 研究有无大血管病变患者小脑梗死灶的特征,探讨小脑梗死分型与后循环血管病变的关系。 方法 收集我科自2006年1月～2008年3月期间住院的小脑梗死患者共35例,所有患者均同时具备颅脑磁共振成像（magnetic resonance imaging,MRI）和血管造影检查,包括计算机断层摄影血管造影（computed tomographic angiography,CTA）、磁共振血管造影（magnetic resonance angiography,MRA）和数字减影血管造影（digital subtraction angiography,DSA）检查。根据血管造影检查的结果将入组患者分为两组：大血管病变组20例,小血管病变组15例,分析两组小脑梗死的分型和后循环血管病变（包括狭窄或闭塞）的关系。 结果 ⑴大血管病变组20例中,颅内血管（椎动脉颅内段或基底动脉）病变最多见（10例,50%）,梗死类型多为分水岭梗死（7例,70%）;其次为颅外血管合并颅内血管（椎动脉颅外段合并颅内段或基底动脉）病变（8例,40%）,梗死灶多为小脑后下动脉（PICA）供血区的区域性梗死（7例,87.5%）;单独颅外血管（椎动脉颅外段）病变最少见（2例,10%）,梗死分布无明显倾向性。⑵小血管病变组15例中,梗死灶亦多位于分水岭区（9例,60%）。 结论 由于小脑血液供应特点,小脑梗死中分水岭梗死和腔隙性梗死较区域性梗死更为常见。小梗死灶（直径≤2cm）可能存在后循环大血管的狭窄或闭塞,应予积极的治疗和干预,以防病情加重。     

血管内治疗双侧创伤性椎动脉夹层一例报告并文献复习

病例报告 患者男,46岁.因车祸伤及头、颈部1d入院.颅脑及颈椎CT示蛛网膜下腔出血,左侧第5颈椎椎板骨折;颅脑CTA示左侧椎动脉Cs水平局限狭窄,远端呈双腔;右侧椎动脉硬膜内段不规则囊状膨出.DSA示左侧颅外段椎动脉C5水平内膜撕脱,远端呈双腔,诊断为椎动脉夹层(图1a,b);右侧颅内段椎动脉小脑后下动脉(PICA)近端可见囊袋状膨出,诊断为夹层动脉瘤(图2a).结合临床症状及影像学检查充分评估后,决定分次行左侧椎动脉支架成型术并右侧夹层段椎动脉栓塞术.     

急性双侧小脑梗死

目的 探讨急性小脑梗死的临床和影像学表现特点和相互关系,病因和发生机制以及预后.方法 选择我科住院的15例双侧小脑多发性梗死患者,对其血管危险因素、临床表现、MRI病变形态、分布和临床的关系,可能的病因性发病机制以及预后进行分析.结果 本组双侧小脑梗死占全部小脑梗死患者的23.8%.急性双侧小脑梗死以双侧PICA供血区的多发性梗死最多见(66.7%).主要临床表现为头晕/眩晕(93.3%)、恶心、呕吐(93.3%)、共济失调(60%)和构音障碍(58.7%).双侧小脑梗死多表现为大病变侧的单侧体征如共济失调.除上述小脑症状外,双侧PICA供血区梗死,特别是内侧支分布区受累(6例)时,突出的临床表现为眩晕,其中4例表现为孤立性假性眩晕;AICA梗死患者的特征表现为双侧耳聋;而SCA供血区梗死的临床表现特点是构音障碍、单侧共济失调,偶可出现大病变对侧的耳聋.Rankin评分均在3分或3分以下,死亡1例.结论 急性小脑多发性梗死主要发生于双侧PICA供血区,主要临床症状和体征为头晕/眩晕、恶心呕吐、共济失调等体征多数限局于单侧肢体,出现于小脑梗死较大的一侧.病因多数为心源性栓塞或主动脉粥样硬化性栓塞所致.预后较好.     

小脑梗死侧别与双侧椎动脉血流量不对称关系的研究

目的研究双侧椎动脉血流量不对称对小脑梗死侧别的影响。方法收集磁共振(MRI)证明小脑梗死并有双侧椎动脉超声结果的101例。双侧椎动脉血流对称判断标准:双侧椎动脉血流量之比≤1:1.7。双侧椎动脉血流不对称判断标准:双侧椎动脉血流量之比>1:1.7,进一步分左侧椎动脉血流减少组和右侧椎动脉血流减少组。以双侧椎动脉血流对称组为对照组,比较双侧椎动脉血流不对称组中血流减少1侧小脑梗死发生率情况。观察双侧椎动脉血流对称组和不对称组动脉粥样硬化危险因素情况。结果在双侧椎动脉血流对称组37例中,其中双侧小脑梗死40.54%(n=15),左侧小脑梗死32.43%(n=12),右侧小脑梗死27.03%(n=10)。双侧椎动脉血流量不对称、左侧椎动脉血流减少组26例,左侧小脑梗死61.54%(n=16),与双侧椎动脉血流对称组相比,左侧小脑梗死发生率显著增高。右侧椎动脉血流减少组与双侧椎动脉血流对称组相比,右侧小脑梗死发生率显著增高。右侧椎动脉血流减少组38例,右侧小脑梗死81.57%(n=31),右侧小脑梗死发生率显著高于双侧椎动脉对称组。在椎动脉血流对称组和显著不对称组间,动脉硬化高危因素情况基本相同。结论在双侧椎动脉血流量不对称情况下,椎动脉血流减少对同侧小脑梗死的发生有一定的影响。     

左侧椎动脉双支起源变异合并左侧颞顶叶AVM的诊治分析（附1例报道并文献复习）

目的 总结左侧椎动脉双支起源变异合并左侧颞顶叶动静脉畸形（AVM）的诊治经验。方法 回顾性分析1例左侧椎动脉双支起源变异合并左侧颞顶叶AVM的临床资料,并结合相关文献进行总结分析。结果 20岁女性,因癫痫发作入院。头部MRI示左侧颞顶叶血管流空影。DSA示左侧颞顶叶AVM,由左侧大脑中动脉颞后支供血,经中央皮层静脉引流至上矢状窦;同时,发现左椎动脉双支起源变异,粗大的一支起源于弓上血管、在左锁骨下功脉与左颈总动脉起点之间,较细的一支起源于左侧锁骨下动脉第一段,两支于第五颈椎下缘汇合。全麻下行l8% ONYX胶栓塞治疗,出院时改良Rankin量表评分0分。术后1周复查头颈部CTA示畸形血管团大部分消失。结论 椎动脉双支起源变异的病人临床罕见,合并AVM的病人则更少见。认识椎动脉起源变异,对合并此类变异的脑血管病的诊断、介入治疗入路选择及避免手术误伤变异椎动脉有较大指导价值。     

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     

三维CT血管造影在脑动静脉畸形诊治中的初步应用经验

目的 评估三维CT血管造影（3D－CTA）在脑动静脉畸形诊断及术前评估中的应用。方法 对我科收治的25例脑动静脉畸形患者采用3D－CTA检查，并同期行脑数字减影血管造影（DSA），比较两种检查的结果。结果 3D－CAT显示了24例动静脉畸形，3D－CTA在显示畸形血管闭、供血动脉和引流静脉的三维构造以及空间关系上优于DSA，并能显示三者与颅骨的关系。3D－CTA虽未能发现1例小型小脑动静脉畸形，但其显示了一个位于小脑后下动脉（PICA）远端的供血动脉动脉瘤，并确定了出血系动脉瘤而非动静脉畸形。3D－CTA可以模拟手术入路时可观察到的血管构造，有助于正确判断动静脉畸形的各种成分，提高手术的安全性。结论 3D－CTA对脑动静脉畸形的诊断及其术前评估有其独特的价值。尤其适合于大型脑动静脉畸形、动静脉畸形合并动脉瘤以及颅内巨大血肿怀疑系动静脉畸形破裂者。它与DSA可互补，但尚无法取代DSA。     

血管内螺圈栓塞罕见的小脑后下动脉瘤

用金属圈栓塞血管治疗脑动脉瘤已有报道,但金属圈经动脉直接进入动脉瘤而保存载瘤血管的报道罕见。本文报道了经动脉内铂圈栓塞成功地治疗3例小脑后下动脉(PICA)瘤。例1,女性,63岁,右颈痛、头痛8月入院。神经系统检查无异常。MRI示颈、延髓交界处一巨大动脉瘤、压迫延髓。脑血管造影证实为不规则双叶状纺锥形动脉瘤,来自右PICA的延髓后段。因瘤体大、颈粗、顶居中,不宜手术。又因PICA管径小,不允许可脱离球囊通过,双叶型瘤体不宜球囊置入。故用经动脉铂圈栓塞术。系统抗凝后,由右椎动脉入路,通过5.5F导管,将14圈0.018吋的铂圈推至动脉瘤处ㄈ蠖鲈煊笆居襊ICA末梢在术中闭塞,其供血区被右小脑上动脉和左PICA代偿供血。     

载瘤动脉闭塞治疗小脑后下动脉以远椎动脉瘤二例报告并文献复习

目的探讨载瘤动脉闭塞治疗小脑后下动脉(PICA)以远椎动脉瘤的方法和效果。方法中山大学附属佛山第一人民医院神经外科自2006年1月至2007年1月对2例PICA以远椎动脉瘤破裂患者行介入载瘤动脉电解可脱弹簧圈(GDC)闭塞治疗,分析患者的临床特征、影像学特点和栓塞疗效。 结果2例患者术后PICA以远载瘤动脉合并动脉瘤均成功获得完全闭塞,无术后并发症发生。术后3个月造影复查证实动脉瘤体无充盈,同时PICA通畅,4年内无再出血发生。 结论对于开颅手术夹必困难的PICA以远椎动脉瘤,在PICA远端处闭塞一侧载瘤椎动脉是一种安全、有效的治疗方法。     

Bilateral Cerebellar Infarctions Caused by a Stenosis of a Congenitally Unpaired Posterior Inferior Cerebellar Artery

Bilateral symmetrical cerebellar infarcts in the territory supplied by the medial posterior inferior cerebellar artery (PICA) branches are extremely rare. In the few cases published, it has not been possible to clearly pinpoint the cause of this infarct pattern. The authors present the case history of a 58-year-old man who had acute headaches accompanied by pronounced rotatory vertigo with nausea and vomiting. The neurological examination revealed bilateral cerebellar signs. Cranial magnetic resonance imaging showed bilateral, nearly symmetrical infarcts in the territory of the medial branches of both PICAs. These bilateral PICA infarctions were caused by a stenosis of an unpaired PICA originating from the left vertebral artery supplying both cerebellar hemispheres.     

Aneurysm of the posterior inferior cerebellar arteries/communicating artery

Only 3 cases of aneurysm associated with the communicating artery between both distal posterior inferior cerebellar arteries (PICAs) have been reported in the literature. We present the 4th case of such an aneurysm arising from the communicating artery itself, which is unrelated to the arterial branches. A hypertensive 68-year-old man presented with a Hunt and Hess grade 4 subarachnoid hemorrhage. Angiographic studies revealed that the ruptured aneurysm arose from the fine communicating artery itself interconnecting both distal PICA vermian branches. The right PICA was absent and its vermian territory was supplied by the left PICA through this communicating artery. At surgery, a saccular aneurysm was noted which developed at the top of the arterial loop under the nodulus of the cerebellar vermis and was trapped. The actual prevalence and clinical significance of aneurism associated with the communicating artery interconnecting both PICAs are unknown, but defective embryonal development may lead to congenital vulnerability of the vascular wall, resulting in aneurysm formation.     

A case of bilateral cerebellar infarction in the distribution of the bilateral superior cerebellar artery]

We reported a case of bilateral cerebellar hemorrhagic infarction in the distribution of the bilateral superior cerebellar artery. A 58-year-old man suddenly developed dizziness and transient loss of consciousness. The neurological examination revealed left hearing disturbance, left sensory disturbance involving face, dysarthria and bilateral ataxia. This patient was considered to be classic clinical syndrome of right superior cerebellar artery. CT and MRI revealed hemorrhagic infarction corresponding to the full territory of the bilateral superior cerebellar artery. The right posterior cerebral artery was filling through the right posterior communicating artery on the right carotid angiography taken 2 hours after the onset. Bilateral vertebral angiography on the 18th day demonstrated no occlusions in the basilar artery and the bilateral superior cerebellar artery. Hemorrhagic infarction corresponding to the full territory of the bilateral superior cerebellar artery, sparing other territories as the present case, is extremely rare. In this case, cerebral embolism (top of the basilar syndrome) was suggested because of existence of atrial fibrillation and sudden onset.     

Rotational vertebral artery syndrome due to compression of nondominant vertebral artery terminating in posterior inferior cerebellar artery

Rotational vertebral artery syndrome (RVAS) is characterized by recurrent attacks of paroxysmal vertigo, nystagmus, and ataxia induced by head rotation. We report on a patient who developed atypical RVAS due to compression of the vertebral artery (VA) terminating in the posterior inferior cerebellar artery (PICA). A 59-year-old man suffered from vertigo and nystagmus induced by leftward head rotation and oculography showed right beating horizontal-torsional and downbeat nystagmus. Cerebral angiography showed hypoplastic right VA terminating in PICA without connection to the basilar artery. The basilar artery received its flow from the left VA only and branched out both anterior inferior cerebellar arteries. Cerebral angiography revealed a complete occlusion of the right distal VA at the level of the C1–2 junction when the head was rotated to a leftward position. In contrast, the blood flow through the left vertebral and basilar arteries remained intact while turning the head to either side. The hemodynamic compromise observed in our patient with RVAS indicates that isolated vertigo and nystagmus may occur due to transient ischemia of the inferior cerebellum or lateral medulla.     

Acute bilateral inferior cerebellar infarction in a patient with neurosyphilis

BACKGROUND: Bilateral simultaneous infarction in the territories of the posterior inferior cerebellar arteries (PICAs) is rare but was recently reported with increasing frequency, probably because of the wider availability of magnetic resonance imaging. The cause of these infarcts is believed to be atherosclerotic or embolic occlusion of a dominant PICA, which perfused the territories of the medial branches of both PICAs. RESULTS: We encountered a patient with simultaneous infarction in the territories of the medial branches of both PICAs. The clinical course, imaging results, and laboratory findings are presented. The patient was diagnosed with neurosyphilis based on a history of chancre, positive serum and cerebrospinal serologies, cerebrospinal pleocytosis, and increased intrathecal immunoglobulin synthesis. We believe that meningovascular syphilis caused the bilateral cerebellar infarct via presumed thromboangiitis of a dominant PICA perfusing both cerebellar hemispheres. The patient was treated with intravenous high doses of penicillin. CONCLUSIONS: This case reminds us that meningovascular syphilis should be considered in younger patients with stroke. Patients with bilateral cerebellar infarction may solely have symptoms of vertigo and ataxia but can develop life-threatening complications because of edema of the infarcted tissue with resultant hydrocephalus and pressure on the brainstem.     

Usefulness of combining CISS and digital subtraction angiography in diagnosis of isolated posterior inferior cerebellar artery dissection

A 63-year-old man was admitted to our stroke center with brain infarction in the left posterior inferior cerebellar artery (PICA) territory. The initial MRI showed no findings suggestive of arterial dissection, and post-discharge MRI showed no temporal changes. Digital subtraction angiography (DSA) revealed vasodilation of the proximal portion of the PICA but it was uncertain whether dissection was present. Discrepancy between the outer contour seen on constructive interference in steady state (CISS) MRI and the inner contour seen on DSA suggested the presence of intramural hematoma. The patient was diagnosed with brain infarction caused by isolated PICA dissection (iPICAD). Imaging evaluation of combined CISS and DSA may be particularly useful for identification of small iPICAD lesions.     

开颅动脉瘤夹闭术治疗介入困难的小脑后下动脉动脉瘤

目的探讨开颅动脉瘤夹闭术治疗介入困难的破裂小脑后下动脉动脉瘤(PICA)的临床疗效。方法回顾性分析2010年9月至2013年4月应用开颅动脉瘤夹闭术治疗6例曾行血管内介入治疗失败的破裂PICA患者的临床资料。结果所有病例术前常规行骨窗位头颅血管成像(CTA)及全脑数字减影血管造影(DSA),明确动脉瘤大小、形态、瘤顶指向、位置,以及与周围组织结构关系,制定最佳手术入路。2例PICA延髓前段及1例延髓侧段动脉瘤采用枕下远外侧入路,1例延髓侧段PICA动脉瘤采用枕下乙状窦后入路,2例PICA扁桃体段动脉瘤采用枕下后正中入路。随访时间为3~28个月,平均10.5个月。所有患者恢复良好,无任何神经功能缺损,格拉斯哥预后评分(GOS)均为5分。CTA或DSA复查示6例PICA动脉瘤夹闭术后均无残留或复发。结论开颅动脉瘤夹闭术是破裂PICA动脉瘤难以实施血管内治疗时的一种安全、可靠的治疗方法,术前骨窗位CTA有助于制定最佳手术入路。     

A case of ischemic disturbance of inner ear

We reported a 51-year-old male with ischemic disturbance of right inner ear resembling Meniere's disease. The patient had a sudden-onset episode of vertigo, right severe hearing disturbance, nausea, vomiting and gait disturbance. Two days after, he had hypersomnia, vertical gaze palsy, double vision, left Horner's sign, and sensory disturbance of pain and temperature of right half body involving face. Brain MRI disclosed high intensity area in T2-weighted image and proton density in bilateral paramedian thalamo-mesencephalic region and right cerebellum (area of the anterior inferior cerebellar artery). Cerebral angiography showed 90% or more stenosis of the right vertebral artery, 50% stenosis of the left vertebral artery before the posterior inferior cerebellar artery (PICA), and 60% stenosis of distal portion of the basilar artery. Furthermore, stem portion of the posterior cerebral artery, and the right anterior cerebellar artery and the left vertebral artery after the PICA were absent or occluded. Right deafness was evaluated to be Jerger type II, namely disturbance of inner ear. Caloric tests showed no response, and right auditory brainstem response showed no waves. Main cause of this vertigo and right deafness was considered to be disturbance of inner ear due to ischemia of right labyrinthine artery, though this patient was not a typical case of the anterior cerebellar artery syndrome. Ischemic disturbances of inner ear have been reported only in patients with the anterior cerebellar artery syndrome, therefore this patient who had only acute ischemic disturbance of inner ear and did not have disturbance of caudo-lateral portion of the pons was considered to be very rare.     

Fibromuscular dysplasia of the vertebral artery presenting with lateral medullary syndrome: a case report

We have recently encountered a rare case of fibromuscular dysplasia (FMD) of the vertebral artery (VA) presenting as lateral medullary syndrome. A 39-year-old male was admitted to our hospital due to vertigo, dysarthria and numbness of the left face and the right limbs. A magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of brain revealed lateral medullary infarction in the territory of the left posterior inferior cerebellar artery (PICA). The angiography of the VA revealed tubular stenosis of the left extracranial VA and a focal vascular kinking as well as web in the right extracranial VA, confirming the diagnosis of FMD. We present this rare case to emphasize that FMD could be one of the risk factors causing lateral medullary syndrome in young people.