头颈静脉回流障碍的形态学及血流动力学的临床研究

发布时间：2018-05-18 11:39

本文选题：静脉回流障碍 + 颈静脉狭窄/闭塞　；参考：《吉林大学》2015年博士论文

【摘要】：脑静脉系统一直被认为仅仅是收集血液回心脏的通路然而近年的研究发现脑静脉系统在脑血流调节中起着重要的作用，脑静脉回流障碍可以引起严重颅内压增高，脑灌注压下降，脑功能障碍而且某些神经系统疾病与脑静脉系统异常相关，如短暂性全面遗忘症ǐ短暂性单眼失明ǐ恐慌症等既往研究报道，颈静脉瓣膜关闭不全导致的颈静脉返流是脑静脉回流障碍的发病机制，颈静脉瓣膜的功能是防止颈静脉逆流及胸内压力上传颅内，当颈静脉瓣膜关闭不全时，，Valsalva动作（valsalva maneuver, VM）诱发的胸内压力增高将上传颅内导致颈静脉返流，但一系列研究并未发现任何与颈静脉瓣膜关闭不全存在对应关系的颅内静脉回流模式的形态学改变，人们开始探索是否有其他因素可导致脑静脉回流障碍颈内静脉（internal jugular vein，IJV）是脑静脉回流心脏的主要回流通路，头ǐ颈静脉先天发育不良或者狭窄/闭塞是否会导致颈内静脉形态和血流动力学改变尚不清楚我们提出假设，除了颈静脉瓣膜关闭不全，是否头ǐ颈静脉先天发育不良或者狭窄/闭塞也会导致颈内静脉回流障碍，并影响脑静脉回流及脑循环，出现脑功能障碍正是带着这个问题，我们利用核磁共振成像技术（magnetic resonance imaging, MR imaging）及颈部静脉超声技术，进行了关于头颈静脉回流障碍发病机制的初步研究旨在阐明头ǐ颈静脉狭窄/闭塞或者先天发育不良对颈内静脉回流障碍及脑静脉系统及脑循环的影响，为头颈静脉回流障碍导致颅内静脉充血/高压的发病机制提供证据本研究共分四个部分：第一部分：头颈静脉回流障碍是短暂性全面遗忘症发病机制的新证据既往研究报道，Valsalva动作诱发的因颈静脉瓣膜关闭不全导致的颈静脉返流是短暂性全面遗忘症（transient global amnesia, TGA）的发病机制然而研究发现VM期间短暂增高的胸腹压力主要是通过椎静脉系统上传颅内及通过颈内静脉下传，所以通畅的颈内静脉对颅内释放短暂增高的压力及脑静脉的回流非常重要，单纯的颈静脉瓣膜关闭不全并不会引发颈静脉回流障碍导致的短暂性全面遗忘症因此我们假设颈静脉受压所致的颈内静脉回流障碍是TGA发病机制中的决定性因素方法：本研究是病例对照研究，利用MR，包括应用造影剂的增强轴向T1加权核磁共振成像（contrast-enhanced axialT1-weighted MR imaging, Contrast T1）与时间分辨对比剂动态成像（time-resolved imagingof contrast kinetics, TRICKS），及未应用造影剂的核磁共振静脉血管成像（magneticresonance venography, MRV），评估双侧颈内静脉与左侧头臂静脉（brachiocephalic vein,BCV）的形态学，及横窦（transverse sinus, TS）的不对称性，其中颈内静脉被分成上ǐ中及下段结果：与对照组比较，TGA者双侧颈内静脉上段（left:37.8%vs.17.8%,P=0.0393; right:57.8%vs.15.6%, P0.0012）及左侧头臂静脉（60%vs.8.9%, P0.0004）中ǐ重度狭窄/闭塞，及横窦发育不良（53.3%%vs.31.1%, P=0.0405）的比例显著高静脉回流的任何部位狭窄/闭塞（包括颈内静脉任意部位或者左侧头臂静脉狭窄/闭塞）的比例在病例组显著高于对照组（91.1%vs.33.3%, P0.0004） MRV发现左侧横窦的管径在病例组较对照组显著小（0.31±0.21vs.0.41±0.19, P=0.0290），而Contrast T1发现左侧横窦的管径在病例组与对照组无差异，这个结果符合回流静脉近心端狭窄/闭塞结论：头颈静脉回流障碍是引起TGA的主要原因之一；双侧颈内静脉和/或者左侧头臂静脉狭窄/闭塞及横窦发育不良是导致头颈静脉回流障碍的重要因素第二部分：横窦发育不良导致头颈静脉回流障碍的新证据以往认为左侧横窦发育不良多为生理性变异，无明显临床意义最近研究发现横窦发育不良与一些神经系统疾病密切相关本研究应用MR和颈部静脉超声探索了横窦发育不良与TGAǐTMBǐ恐慌症的相关性，及超声诊断横窦发育不良的临床应用价值方法：本研究回顾性分析了三个病例对照研究的数据，包括TGA，短暂性单眼失明（transient monocular blindness，TMB）及恐慌症（panic disorders），同时行MR检查及颈部静脉超声检查共131例MR测量横窦的管径，及明确颈静脉狭窄/闭塞的部位和程度颈部静脉超声测量颈内静脉（中段J2及上段J3）的截面积（cross-sectional lumen area,CSA, cm2）ǐ血流速度（time-average-mean velocity, TAMV, cm/s）及血流量（flow volume,FV, ml/min）结果：MRV显示发育不良的横窦69例中，30例被Contrast T1证实其管径小（被定义为解剖型横窦发育不良），39例被Contrast T1证实其管径不小（被定义为低血流型横窦发育不良），后者至少存在颈内静脉任意一个部位和/或者左侧头臂静脉狭窄/闭塞（P=0.0002） Contrast T1显示发育不良对侧的横窦管径无代偿性增大颈部静脉超声研究显示，横窦发育不良侧上段颈内静脉（J3）截面积显著小（P0.0001）对侧/同侧上段颈内静脉（J3）截面积的比值1.55作为诊断横窦发育不良的截断点，其敏感性0.80，特异性0.81，阳性预测值0.82结论：横窦发育不良可分为解剖型及低血流型两种类型颈内静脉流量低，管径小与横窦发育不良导致的颈静脉回流障碍密切相关，其中低血流型与颈静脉狭窄/闭塞导致的颈静脉回流障碍相关，解剖型与横窦本身发育不良导致的颈静脉回流障碍相关颈静脉回流障碍是TGAǐTMBǐ恐慌症的主要原因之一第三部分：VM期间颈内静脉无回流可作为头颈静脉回流障碍的新证据研究已知VM期间短暂增高的胸腹压力主要是通过椎静脉系统上传，通过颈内静脉下传，所以通畅的颈内静脉对释放短暂增高的压力及脑静脉的回流非常重要研究的第一ǐ二部分，利用MR证实了TGA者存在颈静脉狭窄/闭塞或者横窦先天发育不良，这支持脑静脉回流障碍的理论，本部分应用超声进一步研究TGA者颈内静脉相应的功能或者血流动力学改变，进一步验证脑静脉回流障碍的理论我们假设头ǐ颈静脉狭窄/闭塞或者先天发育不良将导致颈内静脉的血流动力学改变，进一步评估头颈静脉狭窄/闭塞或者先天发育不良与颈静脉回流障碍之间的相关性方法：本研究是病例对照研究利用颈部静脉超声，观察TGA组与正常对照组，平静呼吸状态下颈内静脉（包括J2和J3）的血流速度ǐ截面积及血流量，及VM期间颈内静脉是否回流结果：与对照组比较，平静呼吸状态下，TGA组双侧上段颈内静脉（J3）及中段（J2）的血流速度及血流量均低，左侧著；且VM期间，TGA组上段（J3）ǐ中段（J2）颈内静脉无回流的比例高，以右侧著VM期间，与无颈静脉狭窄/闭塞或者横窦先天发育不良比较，颈静脉存在狭窄/闭塞或者先天发育不良者中，颈内静脉无回流的比例高，以右侧颈内静脉狭窄/闭塞，及横窦发育不良者著结论：颈内静脉低流速低流量且VM期间颈内静脉无回流与颈静脉狭窄/闭塞或者横窦先天发育不良致颈静脉回流障碍相关，支持头颈静脉回流障碍是TGA发病主要原因之一的理论；VM期间颈静脉无回流可作为评估头颈静脉回流障碍的检测手段第四部分：头颈静脉回流障碍的超声诊断标准为了更深入研究头ǐ颈静脉回流障碍与神经疾病的相关性，以MR的颈静脉回流障碍的形态学作为对照，超声观察颈静脉回流障碍相应的血流动力学改变，初步建立颈静脉回流障碍的超声诊断标准方法：回顾性分析110例同时进行MR包括Contrast T1ǐTRICKS及MRV，及静脉超声检查包括不同呼吸诱发试验，如平静呼吸状态ǐ深吸气ǐ呼气及VM排除标准是VM不能持续15秒钟，及吹气压力不能达到40mmHg MR评估颈内静脉（internal jugular vein, JIV）与头臂静脉（brachiocephalic vein, BCV）狭窄/闭塞及横窦发育不良，超声评估不同呼吸状态下IJV及椎静脉的血流动力学参数，如截面积（cross-sectional lumen area, CSA, cm2）ǐ血流速度（time-average-mean velocity, TAMV,cm/s）及血流量（flow volume, FV, ml/min）结果：比较有或无IJV重度狭窄/闭塞：当上段颈内静脉（C1）重度狭窄/闭塞（MR结果）时，超声提示同侧中段颈内静脉(J2)的CSA小，尤其在吸气时，被压侧显著变小；当中段颈内静脉（C4）重度狭窄/闭塞（MR结果）时，超声提示同侧上段颈内静脉（J3）平静呼吸状态FV低但是因为超声数据的变异性太大，利用统计学方法ROC曲线（receiver-operating characteristic, ROC)，无法找出C1或者C4狭窄/闭塞时有效的超声诊断截断点比较有或无左侧BCV重度狭窄/闭塞：中段颈内静脉（J2）的TAMV及FV均显著低，但CSA显著高，提示静脉下游被压利用ROC曲线进一步评估BCV是否存在狭窄/闭塞的诊断的最佳截断点，发现左侧中段颈内静脉（J2）平静呼吸状态的TAMV值8.0(cm/s)时，可以兼顾敏感性与特异性，敏感性0.78，特异性0.61，阳性预测值0.63结论：本研究通过MR与颈静脉超声对比研究，发现超声评估颈内静脉回流障碍与MR评估静脉的形态学存在相应关系MR能够明确诊断静脉是否存在狭窄/闭塞ǐ狭窄/闭塞的部位及程度，及横窦先天发育不良超声通过不同呼吸状态下颈内静脉的血流速度ǐ血流量及管径及VM期间颈内静脉是否回流诊断颈静脉是否存在回流障碍联合MR及超声，不但明确颈静脉存在回流障碍，而且明确部位及程度本研究是头颈静脉回流障碍与神经系统疾病临床相关性的研究我们通过MR及颈部静脉超声的对比研究，发现了头ǐ颈静脉狭窄/闭塞，及横窦先天发育不良导致的颈静脉回流障碍是TGAǐTMBǐ恐慌症主要的发病原因之一；超声检查颈内静脉的低流速低流量及VM期间颈内静脉无回流可以作为评估颈静脉回流障碍的检测手段；MR及超声联合检查可以明确颈静脉回流障碍与横窦发育不良ǐ颈静脉狭窄/闭塞的相关性
[Abstract]:The cerebral venous system has been thought to be the only way to collect blood back to the heart. However, recent studies have found that the cerebral venous system plays an important role in the regulation of cerebral blood flow. Cerebral venous backflow disorder can cause severe intracranial pressure, cerebral perfusion pressure, cerebral dysfunction and some nervous system diseases and cerebral venous system abnormalities. Such as transient global amnesia, transient monocular blindness, panic disorder, etc.
Previous studies have reported that jugular regurgitation caused by insufficiency of jugular valvular insufficiency is the pathogenesis of cerebral venous reflux disorder. The function of the jugular valve is to prevent the jugular reflux and intrathoracic pressure to upload to the intracranial. When the jugular valve insufficiency is incomplete, the increased intrathoracic pressure induced by the Valsalva action (Valsalva maneuver, VM) will upload the intracranial pressure. But a series of studies did not find any morphological changes in the pattern of intracranial venous reflux associated with the occlusion of the jugular valvular insufficiency, and people began to explore whether there were other factors that could lead to cerebral venous reflux disorder.
The internal jugular vein (internal jugular vein, IJV) is the main recirculation pathway of the cerebral venous reflux. It is not clear whether the congenital hypoplasia of the jugular vein or the stenosis / occlusion will lead to the changes of the internal jugular vein and the hemodynamics. The stenosis / occlusion can also lead to the obstruction of the internal jugular vein, which affects the cerebral venous return and the cerebral circulation. It is the problem that the brain dysfunction is happening. We use the magnetic resonance imaging (MR imaging) and the neck venous ultrasound technique to make a preliminary study on the pathogenesis of the head and neck venous backflow disorder. The aim of this study is to elucidate the effects of cervical venous stenosis / occlusion or congenital dysplasia on the internal jugular venous flow disorder, cerebral venous system and cerebral circulation, and to provide evidence for the pathogenesis of intracranial venous congestion / high pressure caused by the head and neck venous reflux disorder, which are divided into four parts:
Part one: new evidence for the pathogenesis of transient global amnesia.
Previous studies have reported that Valsalva induced jugular regurgitation caused by jugular insufficiency in the jugular vein is the pathogenesis of transient global amnesia (TGA). However, it is found that the transient increased thoracic and abdominal pressure during VM is mainly transmitted through the vertebral vein system and through the internal jugular vein. The unobstructed internal jugular vein is important for the transient pressure of intracranial release and the reflux of the cerebral veins. Simple jugular insufficiency does not lead to transient total amnesia caused by the obstruction of the jugular vein. Therefore, we hypothesized that the internal jugular venous reflux caused by the compression of the jugular vein is the decisive factor in the pathogenesis of TGA. This study was a case-control study, using MR, including enhanced axial T1 weighted magnetic resonance imaging (contrast-enhanced axialT1-weighted MR imaging, Contrast T1) with contrast agent (Contrast T1) and time resolved contrast agent dynamic imaging (time-resolved Imagingof contrast kinetics,), and nuclear magnetic resonance without contrast agent. Magneticresonance venography (MRV) was used to evaluate the morphology of bilateral internal jugular vein and the left head arm vein (brachiocephalic vein, BCV), and the asymmetry of the transverse sinus (transverse sinus, TS). The internal jugular vein was divided into the upper and lower segments of the upper and lower segments. Compared with the control group, the upper part of the bilateral internal jugular vein (left:37.8%v) (left:37.8%v) was compared with the control group S.17.8%, P=0.0393; right:57.8%vs.15.6%, P0.0012) and the severe stenosis / occlusion of the left head arm vein (60%vs.8.9%, P0.0004), and the ratio of 53.3%%vs.31.1%, P=0.0405 to any part of the stenosis / occlusion (including any part of the internal jugular vein or the left cephalosbrachial vein stenosis / occlusion) The diameter of the left transverse sinus was significantly smaller in the case group than the control group (91.1%vs.33.3%, P0.0004) MRV significantly smaller than the control group (0.31 + 0.21vs.0.41 + 0.19, P=0.0290), and Contrast T1 found no difference in the diameter of the left transverse sinus in the case group from the control group. This result was in line with the conclusion of the stenosis / occlusion of the circumfluence end of the reflux vein: the head and neck. Venous backflow disorder is one of the main causes of TGA. Bilateral internal jugular vein and / or left cephalic vein stenosis / occlusion and transverse sinus dysplasia are important factors leading to the obstruction of the head and neck venous reflux.
The second part: new evidence of head and neck venous reflux dysfunction due to transverse sinus dysplasia.
Recent studies have suggested that left lateral sinus dysplasia is mostly physiological variation, and there is no significant clinical significance. Recent studies have found that transverse sinus dysplasia is closely related to some nervous system diseases. The relationship between transverse sinus dysplasia and TGA TMB panic disorder is explored by MR and cervical venous ultrasound, and the clinical application of ultrasound in the diagnosis of transverse sinus dysplasia Value method: This study reviewed the data of three case control studies, including TGA, transient monocular blindness (TMB) and panic disorder (panic disorders). At the same time, a total of 131 cases of MR examination and cervical ultrasonography were used to measure the diameter of the transverse sinus and the location and process of the stenosis / occlusion of the jugular vein. Measurement of the area of the internal jugular vein (cross-sectional lumen area, CSA, cm2) of the internal jugular vein (cross-sectional lumen area, CSA, cm2) and blood flow rate (time-average-mean velocity, TAMV, cm/s) and blood flow in 69 cases of poorly developed transverse sinus. Anatomic transverse sinus dysplasia), 39 cases were confirmed by Contrast T1 (defined as low blood flow type transverse sinus dysplasia), the latter had at least any part of the internal jugular vein and / or the left cephalic vein stenosis / occlusion (P=0.0002) Contrast T1 showing uncompensated lateral transverse sinus tube enlargement of the neck vein Acoustic studies showed that the cross-sectional area of the lateral superior lateral segment of the lateral sinus (J3) was significantly smaller (P0.0001) in the contralateral / proximal segment of the internal jugular vein (J3) as a cut-off point for the diagnosis of transverse sinus dysplasia, with a sensitivity of 0.80, a specificity of 0.81, and a positive predictive value of 0.82: transverse sinus dysplasia could be divided into anatomic and low blood flow pattern two. The low flow of internal jugular vein and small diameter of the internal jugular vein are closely related to the obstruction of the jugular venous reflux caused by the dysplasia of the transverse sinus. The low blood flow pattern is associated with the jugular venous reflux disorder caused by the stenosis / occlusion of the jugular vein. The dissection of the jugular venous reflux caused by the anatomic type and the dysplasia of the transverse sinus is the TGA TMB panic disorder One of the main reasons
The third part: new evidence that the internal jugular vein has no reflux during VM.
The transient increased pressure of the chest and abdomen during VM is known mainly through the vertebral vein system, transmitted through the internal jugular vein, so the unobstructed internal jugular vein is the first two part of the study of the release of transient pressure and the reflux of the brain veins. MR confirms the existence of the stenosis / occlusion of the jugular vein, or congenital sinus of the transverse sinus in TGA. In this part, we use ultrasound to further study the function or hemodynamic changes of the internal jugular vein in TGA, and further verify the theory of cerebral venous reflux disorder. We assume that the hemodynamic changes of the internal jugular vein will be caused by the stenosis / occlusion of the jugular vein or congenital dysplasia. Changes, further assessment of the correlation between the head and neck stenosis / occlusion or congenital dysplasia and the obstruction of the jugular venous reflux. This study was a case-control study using the cervical vein ultrasound to observe the blood flow velocity of the internal jugular vein (including J2 and J3) in the TGA and the normal controls, and the blood flow, and VM Compared with the control group, the blood flow velocity and blood flow rate of the bilateral upper internal jugular vein (J3) and the middle segment (J2) were lower in the TGA group than in the control group, and the left side of the internal jugular vein (J3) and the middle part of the middle segment (J2). And during VM, the proportion of the internal jugular vein non reflux in the upper segment of TGA group (J3) was high, and there was no stenosis / occlusion or occlusion of the jugular vein at the right side of VM. In those with congenital dysplasia of the transverse sinus, among those with stenosis / occlusion or congenital dysplasia of the jugular vein, the proportion of the internal jugular vein without reflux is high, with the right internal jugular vein stenosis / occlusion and the transverse sinus dysplasia the conclusion: the low flow rate of the internal jugular vein and the non reflux of the internal jugular vein during VM and the stenosis / occlusion of the jugular vein or the transverse sinus during the period of the internal jugular vein Congenital dysplasia is associated with the obstruction of the jugular venous backflow, and the support of the head and neck venous backflow is one of the main causes of TGA. The non reflux of the jugular vein during VM may be used as a measure for the assessment of the obstruction of the head and neck venous reflux.
The fourth part: ultrasound diagnostic criteria for head and neck venous reflux disorders.
In order to further study the correlation between the head jugular reflux disorder and the neurological disease, the morphological changes of the MR's jugular reflux disorder were taken as the contrast, the hemodynamic changes of the jugular reflux disorder were observed by ultrasound, and the standard method of ultrasonic diagnosis for the obstruction of the jugular vein was established: a retrospective analysis of 110 cases of MR including Co Ntrast T1 TRICKS and MRV, and venous ultrasound examination included different respiratory evoked tests, such as the quiet breathing state and the VM exclusion criteria that the VM could not last 15 seconds, and the blow pressure could not reach the 40mmHg MR to evaluate the internal jugular vein (internal jugular vein, JIV) and the cephalobrachial vein stenosis / occlusion and The hemodynamic parameters of IJV and vertebral veins in different respiratory states, such as cross-sectional lumen area, CSA, cm2, and blood flow velocity (time-average-mean velocity, TAMV, cm/s) and blood flow (flow volume) were compared with or without severe stenosis / occlusion: when the upper neck was static When pulse (C1) severe stenosis / occlusion (MR result), ultrasound suggests that the CSA of the internal jugular vein (J2) of the middle segment of the ipsilateral is small, especially when inhaled, and the compression side is significantly smaller. When the middle segment of the internal jugular vein (C4) is severe stenosis / occlusion (MR result), ultrasound suggests that the calm respiration of the internal jugular vein (J3) of the ipsilateral upper segment (J3) is low, but because the variability of ultrasonic data is too large. Using the statistical method of ROC (receiver-operating characteristic, ROC), it is impossible to find out the effective ultrasound diagnosis truncation points of C1 or C4 with or without left BCV severe stenosis / occlusion: both TAMV and FV of the middle segment of the internal jugular vein (J2) are significantly lower, but the CSA appears to be higher, suggesting that the downstream of the vein is further evaluated by the ROC curve. The best truncation point in the diagnosis of BCV stenosis / occlusion was estimated. It was found that the sensitivity and specificity, sensitivity 0.78, specificity 0.61, and positive predictive value 0.63 of the TAMV value of the left middle segment of the left middle segment of the internal jugular vein (J2) were 8 (cm/s), and the positive predictive value was 0.63. A comparative study of MR and jugular vein ultrasound was used in this study to find ultrasound assessment of internal jugular static The relationship between venous reflux disorder and MR evaluation of venous morphology was related to MR, the location and degree of stenosis / occlusion of the vein was clearly diagnosed, and the blood flow velocity and diameter of the internal jugular vein in different respiratory states and the diameter of the internal jugular vein and whether the internal jugular vein returned to the neck during VM were diagnosed. Whether there is a reflux disorder in the vein, combined with MR and ultrasound, is not only clear about the presence of reflux obstruction in the jugular vein, but also the location and extent of the disease.
This study is a study of the clinical correlation between the head and neck venous reflux disorder and the nervous system disease. Through comparative study of MR and cervical venous ultrasound, we found that the carotid artery stenosis / occlusion, and the congenital dysplasia of the transverse sinus caused by the congenital dysplasia of the transverse sinus, is one of the causes of the main cause of the TGA TMB panic disorder. The low flow rate of the vein and the non reflux of the internal jugular vein during VM can be used as a measure for the assessment of the obstruction of the jugular vein. The combination of MR and ultrasound can identify the obstruction of the jugular vein and the transverse sinus.
【学位授予单位】：吉林大学
【学位级别】：博士
【学位授予年份】：2015
【分类号】：R743.3

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