椎动脉发育不全与后循环脑梗死相关性研究

发布时间：2018-07-25 10:28

【摘要】：背景脑血管疾病已成为我国首位的疾病死亡原因，其中脑梗死占全部脑血管疾病的80%左右，而后循环脑梗死约占所有脑梗死的20%，较前循环脑梗死少见。后循环为延髓、脑桥、中脑、小脑及枕叶等重要基本生命中枢所在区域供血，该供血区一旦出现脑梗死后，将引起严重的神经功能缺损，临床症状一般较重，病情凶险，其致残率、病死率均较高。但与前循环颈内动脉剥脱术及支架植入术研究相比，，目前对后循环脑梗死的二级预防措施相对有限，所以对后循环脑梗死危险因素的研究非常必要。脑梗死的危险因素很多，简单地分类可包括可控制危险因素和不可控制危险因素；其常见的可控制危险因素包括高血压病、糖尿病、高脂血症、抽烟等，而脑血管发育不全被认为是不可控制的危险因素之一；有文献报道，椎动脉发育不全(Vertebral arteryhypoplasia，VAH)可能是后循环脑梗死的独立危险因素之一。但通过数字减影血管造影术(digital subtraction angiography，DSA)评估椎动脉发育不全来研究椎动脉发育不全与后循环脑梗死相关性的研究尚未见报道。目的探讨DSA对椎动脉发育不全的诊断价值，椎动脉发育不全是否是后循环脑梗死的独立危险因素之一。初步探讨椎动脉发育不全与再发后循环脑梗死的关系。方法1、收集2003年01月至2008年12月在我科连续行全脑血管造影检查的1135例脑梗死患者，根据患者颅脑MRI或CT结果分为前后循环脑梗死组两组。其中前循环脑梗死组724例；后循环梗死组411例。同时收集两组患者的年龄、性别、吸烟、高血压病、糖尿病、高脂血症等脑梗死常见危险因素情况。根据DSA表现：本研究将VAH分5型，其中Ⅰ型；一侧椎动脉全程纤细，管径小于2.5mm，或与对侧椎动脉比值小于1/1.7。Ⅱ型:双侧椎动脉颅外段管径大于2.5mm，但一侧参与基底动脉供血段明显纤细，管径是对侧的1/1.7以下。Ⅲ型：一侧椎动脉未参与基底动脉供血，止于小脑后下动脉，而另一侧椎动脉管径大于2.5mm。Ⅳ型:一侧椎动脉先天不发育，另一侧椎动脉管径大于2.5mm。Ⅴ型:双侧椎动脉发育不全，即双侧椎动脉均表现为Ⅰ型(和)或Ⅲ型(和)或Ⅳ型的情况。同时观察患者后交通动脉(posterior communicating artery，PCoA)的开放情况。统计分析前后循环脑梗死组两组患者VAH的差别，以及VAH患者和非VAH患者中PCoA开放情况的差别。 2、收集2003年01月至2008年12月在我科行全脑血管造影检查的初发后循环脑梗死患者因再发后循环脑梗死再次入院就诊情况；未再次就诊患者进行电话随访其在是否再次发生后循环脑梗死，同时收集患者的年龄、性别、吸烟、高血压病、糖尿病、高脂血症等脑梗死常见危险因素。终点事件为再次发生后循环脑梗死或患者死亡。比较两组患者中常见脑梗死危险因素及VAH的差别。数据统计应用SPSS13.0软件，分析两组组间的各个指标是否存在统计学差异。结果 1、1135例脑梗死患者中，诊断前循环脑梗死724例，后循环脑梗死411例。后循环脑梗死组患者平均年龄(59.97±10.84岁)较前循环脑梗死组患者(61.48±9.69岁)小，但差异无明显统计学意义(p=0.21)。后循环脑梗死中男性(72.46%)较女性多见，与前循环组比较，差异无明显统计学意义(p=0.42)。两组患者中脑梗死常见危险因素，如吸烟(p=0.47)、高血压病(p=0.75)、糖尿病(p=0.92)、高脂血症(p=0.68)差异均没有统计学意义。两组患者共262例诊断VAH，其中前循环脑梗死组诊断VAH122例(16.85%)，后循环脑梗死组VAH140例(34.06%)。VAH患者发生后循环脑梗死的危险是前循环脑梗死组的2.75倍(OR=2.75，95%CI：1.60～3.58；p＜0.05)。VAH以右侧最常见(61.07%)，左侧占(27.86%)，双侧最少见(11.07%)。5型VAH以Ⅰ型最常见(41.60%)，Ⅲ型次之(22.14%)，Ⅳ型、Ⅴ型各占16.03%及11.07%，Ⅱ型最少见(9.16%)。VAH组患者95例(36.26%)后交通动脉开放，非VAH组患者119例(13.79%)后交通动脉开放，VAH组患者后交通动脉开放较非VAH组患者明显增多，差异有统计学意义(p＜0.05)。 2、随访结果：随访2003年01月至2008年12月在我科行全脑血管造影检查的347例初发后循环脑梗死患者中，其中45人因未留电话号码、39人因电话号码变更而失访。实际随访到263例(35人已死亡)。其中因再发后循环脑梗死再次住我院67人(6人死亡，纳入统计)，电话随访196人(29人死亡，其中15人死因不详，6人死于癌症，4死于脑梗死后遗症，4人再发脑梗死后死亡-再发脑梗死部位不详，29人均不纳入统计)。因此最终纳入234例患者资料进行统计分析，年龄43-78岁(57.32±11.12岁)，临床诊断再发后循环脑梗死124例。分析性别、年龄、高血压、糖尿病、高脂血症、吸烟、VAH与再发后循环脑梗死关系，单因素分析结果显示：年龄＞65岁、高血压病史、糖尿病史、VAH是再发后循环脑梗死有意义的影响因素(P＜0.05)，经过多因素logistic回归分析得出：年龄＞65岁、高血压病史、糖尿病史及VAH四个因素为再发后循环脑梗死的危险因素(p值＜0.05)。结论 (1) DSA能明确诊断各型VAH，并能明确后交通动脉开放情况，对VAH的诊断有重要的临床意义。 (2)VAH可能是后循环脑梗死的危险因素之一。 (3)VAH患者更易再发后循环脑梗死。
[Abstract]:background
Cerebrovascular disease has become the leading cause of death in our country, of which cerebral infarction accounts for about 80% of all cerebrovascular diseases, and the latter is about 20% of all cerebral infarction, which is less than that of the anterior circulation cerebral infarction. The posterior circulation is the medulla oblongata, the pontine, the middle brain, the cerebellum and the occipital lobe should supply the blood in the region of the vital center, once the blood supply area is located. After the occurrence of cerebral infarction, it will cause serious nerve function defect, the clinical symptoms are heavy, the disease is dangerous, the rate of disability and the mortality rate are high. But compared with the study of the anterior circulation internal carotid artery exfoliation and stent implantation, the two stage prevention measures for the posterior circulation cerebral infarction are relatively limited, so the risk factors of the posterior circulation cerebral infarction are studied. It is very necessary. There are many risk factors for cerebral infarction. Simple classification can include controllable risk factors and non controlled risk factors; the common control risk factors include hypertension, diabetes, hyperlipidemia, smoking and so on, and cerebral vascular dysplasia is considered as one of the non control risk factors; there are literature reports, vertebra Vertebral arteryhypoplasia (VAH) may be one of the independent risk factors for posterior circulation cerebral infarction. However, the study of the correlation between vertebral artery dysplasia and posterior circulation cerebral infarction by digital subtraction angiography (digital subtraction angiography, DSA) to evaluate vertebral artery dysplasia is not yet reported.
Objective to investigate the value of DSA in the diagnosis of vertebral artery dysplasia, and whether vertebral artery dysplasia is one of the independent risk factors for posterior circulation cerebral infarction.
Method 1, 1135 patients with cerebral infarction were collected from 01 months to December 2008 2003 in our department. According to the results of MRI or CT, the patients were divided into two groups of anterior and posterior circulation cerebral infarction group, including 724 cases of anterior circulation cerebral infarction and 411 cases of posterior circulation infarction. At the same time, the age, sex, smoking, hypertension of two groups of patients were collected. The common risk factors of cerebral infarction such as diabetes and hyperlipidemia. According to the DSA findings, VAH is divided into 5 types, including type I, one side of the vertebral artery is fine, the diameter is less than 2.5mm, or the ratio of the contralateral vertebral artery is less than 1/1.7. II: the diameter of the extracranial segment of the bilateral vertebral artery is larger than that of 2.5mm, but the blood supply segment of the basilar artery is obviously slender in the side. The diameter of the opposite side was below 1/1.7. Type III: one side of the vertebral artery did not participate in the basilar artery blood supply and stopped at the posterior inferior cerebellar artery. The other side of the vertebral artery was larger than the 2.5mm. IV type: one side of the vertebral artery was not developed and the other vertebral artery was larger than the 2.5mm. V type: bilateral vertebral artery was not developed, that is, both vertebral arteries were type I (and). Type III (and) or type IV conditions. At the same time, the opening of posterior communicating artery (PCoA) was also observed. The difference in VAH between the two groups of cerebral infarction groups before and after the cyclic cerebral infarction, and the difference of PCoA opening in VAH patients and non VAH patients were statistically analyzed.
2, from 01 months to December 2008 2003, the patients with cerebral infarction of the first recurrent cerebral infarction were readmitted to the hospital for recurrent cerebral infarction after recurrent cerebral angiography. The patients were followed up by telephone follow-up after the recurrence of recurrent cerebral infarction, and the age, sex, smoking, hypertension, sugar, and sugar were collected. Common risk factors for cerebral infarction, such as urinary and hyperlipidemia. The end event was recurrent cerebral infarction or death after the recurrence. The risk factors of cerebral infarction and the difference of VAH were compared in the two groups.
SPSS13.0 software was used to analyze the statistical differences between the two groups.
Result
Of the 11135 patients with cerebral infarction, 724 cases were circulatory cerebral infarction before diagnosis and 411 cases of posterior circulation cerebral infarction. The average age of the patients in the posterior circulation cerebral infarction group (59.97 + 10.84 years old) was smaller than that of the anterior circulatory cerebral infarction group (61.48 + 9.69 years), but the difference was not significant (p=0.21). The male (72.46%) in the posterior circulation cerebral infarction was more common than the female, and the anterior circulation group was more common than the anterior circulation group. The difference was not statistically significant (p=0.42). The common risk factors of cerebral infarction in the two groups, such as smoking (p=0.47), hypertension (p=0.75), diabetes (p=0.92) and hyperlipidemia (p=0.68) were not statistically significant. Two groups of patients were diagnosed as VAH, of which the anterior circulation cerebral infarction group was diagnosed as VAH122 cases (16.85%) and posterior circulation cerebral infarction. Group VAH140 (34.06%).VAH patients with recurrent cerebral infarction were 2.75 times as dangerous as those in the anterior circulation cerebral infarction group (OR=2.75,95%CI:1.60 to 3.58; P < 0.05),.VAH was the most common (61.07%), left (27.86%), and the most rare (11.07%).5 VAH was the most common (41.60%), type III (22.14%), type IV, and type V in 16.03% and 11.07%. The most rare (9.16%) group (9.16%) patients in group II (36.26%) were open after 95 (36.26%), and 119 (13.79%) of non VAH patients were open, and the number of arterial opening in group VAH was significantly increased than that in group VAH (P < 0.05).
2, follow up: from 01 months to December 2008 2003 to December 2008, 347 cases of primary recurrent cerebral infarction were found in our department of total cerebral angiography, of which 45 had no telephone number and 39 were lost because of the change of telephone number. 263 cases (35 people died) were followed up. Among them, 67 people died of recurrent cerebral infarction (6 people died). 196 people were followed up by telephone (29 deaths, of which 15 were unknown, 6 died of cancer, 4 died of sequelae of cerebral infarction, 4 died of cerebral infarction, 4 had cerebral infarction and 29 per capita were not included). Therefore, the data of 234 patients were included in the statistical analysis of the age 43-78 (57.32 + 11.12 years) and clinical diagnosis. 124 cases of recurrent cerebral infarction were analyzed. The relationship between sex, age, hypertension, diabetes, hyperlipidemia, smoking, VAH and recurrent cerebral infarction was analyzed. The results of single factor analysis showed that age > 65 years old, hypertension history, diabetes history, and VAH were significant influencing factors of recurrent cerebral infarction (P < 0.05), after multiple factor Logistic regression analysis It was concluded that age > 65 years old, history of hypertension, diabetes mellitus and VAH were risk factors for recurrent cerebral infarction (p < 0.05).
conclusion
(1) DSA can clearly diagnose all types of VAH and the opening of posterior communicating artery, which is of great clinical significance in the diagnosis of VAH.
(2) VAH may be one of the risk factors of posterior circulation cerebral infarction.
(3) patients with VAH are more prone to recurrent cerebral infarction.
【学位授予单位】：第三军医大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R743.3

【参考文献】