椎动脉优势和基底动脉弯曲对后循环梗死的关联研究

发布时间：2018-09-10 10:10

【摘要】：背景:后循环梗死的主要病理学基础是动脉粥样硬化,但是随着磁共振血管成像的广泛应用,发现后循环血管病变存在多样性,远远超出既往单纯的动脉粥样硬化危险因素和血管病因。在正常人群和患者的磁共振血管成像检查发现,椎动脉优势和基底动脉弯曲是常见的血管变异,但是容易被临床医生忽视。临床及影像医师更多关注于血管的动脉粥样硬化和阻塞,而椎动脉优势和基底动脉弯曲可能参与后循环血管事件的发生和发展。椎动脉优势及基底动脉弯曲之间是否有关联,二者对后循环血液供应的影响和确切机制也不清楚。暴露于血管危险因素下的椎基底动脉,是否会加大椎动脉优势和基底动脉弯曲,从而改变后循环的缺血,更易于发生后循环梗死尚不明确。目的:探讨椎动脉优势、基底动脉弯曲与后循环梗死的关系。首先通过TCD来评估伴有椎动脉优势的后循环梗死患者的血流动力学变化;然后利用高场强核磁共振分析后循环梗死患者危险因素;其次分析后循环不同部位梗死患者的椎动脉优势与基底动脉弯曲的关系;最后,结合血管危险因素的暴露情况,分析椎动脉优势和基底动脉弯曲度和理论长度之间的关系及其对后循环梗死患者的影响。拓宽对后循环血管评估结果的认识,加深对后循环缺血事件发生机制的认识,为后循环梗死患者的二级预防提供新的思路。对象与方法:本研究自2013年1月至2015年12月连续收集入住我院神经内科的急性后循环梗死患者,以及同时期住院的前循环梗死、头晕和眩晕、头痛患者,均有完整的头颅核磁共振成像(MRI)、对比增强颈部核磁共振血管成像(CE-MRA)检查资料,并且详细记录病史资料、相关量表及辅助检查资料,尤其关注后循环血管状态。数据处理分为4个部分。1、选取符合入组标准的急性后循环梗死患者82例。根据头颅MRA检查发现椎动脉优势的患者作为研究组(44例),非椎动脉优势的患者作为对照组(38例)。通过TCD观察每个研究对象后循环供血动脉的血流动力学和血流频谱形态变化。2、选取资料完整并符合入组标准的前循环梗死组160例,后循环梗死组82例。对入选的患者进行颅内外血管MRA检查及血管危险因素筛查。把基底动脉弯曲进行分级,采用多因素Logistic回归分析寻找后循环梗死危险因素。3、选取临床表现为后循环梗死、头晕和眩晕、头痛等症状患者,根据MRA检查结果分成椎动脉优势组(86例)及非优势组(70例)。比较两组间后循环各部位的梗死发生率以及基底动脉弯曲的发生率,分析优势组各梗死部位后循环梗死侧与椎动脉优势侧的关系,基底动脉弯曲方向与椎动脉优势侧相关性,基底动脉弯曲与后循环梗死的相关性。4、选取后循环梗死患者,根据MRA结果分为基底动脉弯曲梗死组42例和基底动脉无弯曲梗死组40例;同时期住院的基底动脉弯曲无脑梗死的眩晕或头痛患者38例为对照组。依MRA测量基底动脉理论长度(BAL)和基底动脉弯曲长度(BL)及基底动脉直径、双侧椎动脉直径,详细记录血管危险因素暴露情况,比较三组之间血管危险因素的差异。对后循环梗死患者危险因素进行单因素和多因素分析,把BL进行分级,探讨其与后循环梗死的关系,并把双侧椎动脉直径差异进行分级,进一步分析双侧椎动脉直径差异与BL和BAL之间的相关性。结果:1、椎动脉优势组优势侧椎动脉Vs、Vd、Vm值均显著高于非优势侧以及非优势组左右两侧椎动脉(P0.01)。优势组基底动脉Vd和Vm值显著低于非优势组(P0.05),PI和RI显著高于非优势组(P0.01)。两组大脑后动脉同侧的Vs、Vd、Vm、PI、RI值比较差别无显著性意义(P0.05),优势组出现频谱形态异常。2、后循环梗死组伴发冠心病史低于前循环梗死组,在吸烟率、伴发糖尿病史高于前循环梗死组,血LDL及Hb A1c水平也明显高于前循环梗死组(P0.05),基底动脉、椎动脉狭窄程度以及椎动脉优势和基底动脉弯曲≥2级患者的比率明显高于前循环梗死组(P0.01)。多因素Logistic回归分析显示,伴有糖尿病史(OR 4.02;95%CI1.80-9.01;P=0.002)、基底动脉狭窄(OR 1.00;95%CI 1.02-1.05;P0.001)、基底动脉弯曲≥2级(OR l.38;95%CI 1.01-1.06;P=0.009)是后循环梗死的危险因素。3、85.1%(40/47)基底动脉弯曲向椎动脉优势对侧,基底动脉弯曲方向与椎动脉优势方向呈负相关性(r=㧟0.704,P0.0001),优势组后循环梗死的发生率明显高于对照组(51.2%(44/86)vs.22.9%(16/70),χ2=13.063,P0.001)。两组间在PICA区和BA区梗死发生率差异均有统计学意义,其余部位两组间的发生率差异不显著。基底动脉弯曲患者在PICA区和BA区梗死发生率与基底动脉呈直线患者差异均有统计学意义,其余部位梗死的发生率差异不显著。4、与基底动脉无弯曲梗死患者血管危险因素比较,年龄≥65岁、高血压、糖尿病、高胆固醇血症及高同型半胱氨酸血症病史比例在基底动脉弯曲组的优势比增加,差异有统计学意义(P0.05)。和对照组比较,BAL和BL差异有统计学意义,年龄≥65岁、高血压病、糖尿病及吸烟病史比例在基底动脉弯曲组的优势比增加,差异有统计学意义(P0.05)。年龄、高血压病比例、糖尿病比例及右侧椎动脉直径4个指标在BL不同等级间比较差异有统计学意义(P0.05)。椎动脉直径差异与BL呈正相关性(r=0.769,P0.001),与BAL无相关性。进行多因素分析后,基底动脉弯曲长度3级(BL3.71mm)是后循环梗死的重要预测因素(OR=3.274,95%CI 1.253-10.489,P0.05)。结论:1、椎动脉优势患者优势侧椎动脉血流速度增快,非优势侧血流速度减慢,远处基底动脉血流速度减慢。椎动脉优势患者出现脑血流动力学改变,频谱形态异常,TCD对评估PCI后循环血管变异具有一定的临床价值。2、2型糖尿病、基底动脉弯曲≥2级和基底动脉狭窄可能是后循环梗死危险因素。3、椎动脉优势易于导致基底动脉弯曲的发生,基底动脉易向优势对侧发生弯曲。椎动脉优势容易发生PICA供血区及BA脑桥支供血区的梗死,PICA供血区梗死部位多发生在椎动脉优势对侧,基底动脉弯曲侧;而BA脑桥支供血区的梗死多发生在椎动脉优势侧,即基底动脉弯曲的对侧。4、椎动脉优势的存在与血管危险因素暴露,增加基底动脉弯曲的发生;双侧椎动脉直径差异与BL呈正相关性。基底动脉弯曲暴露在高龄、高血压病、高胆固醇血症及2型糖尿病等血管危险因素下,增加后循环梗死发生的可能性。基底动脉弯曲长度3级(BL3.71mm)是后循环梗死的重要预测因素。
[Abstract]:BACKGROUND: The main pathological basis of posterior circulation infarction is atherosclerosis, but with the wide application of magnetic resonance angiography (MRA), it has been found that there is diversity of posterior circulation vascular lesions, which is far beyond the past simple atherosclerosis risk factors and vascular etiology. Arterial dominance and basilar artery curvature are common vascular variations, but are easily overlooked by clinicians. Clinicians and radiologists pay more attention to vascular atherosclerosis and obstruction. Vertebral dominance and basilar artery curvature may be involved in the occurrence and development of posterior circulation vascular events. It is not clear whether exposure to vascular risk factors increases vertebral artery dominance and basilar artery curvature, thereby altering posterior circulation ischemia, which is more likely to lead to posterior circulation infarction. The relationship between curvature and posterior circulation infarction was evaluated by TCD. The hemodynamic changes in patients with posterior circulation infarction accompanied by vertebral artery dominance were assessed. The risk factors of posterior circulation infarction were analyzed by high-field magnetic resonance imaging. Then, the relationship between vertebral artery superiority, basilar artery curvature and theoretical length and its influence on patients with posterior circulation infarction were analyzed in combination with the exposure of vascular risk factors. Objectives and Methods: From January 2013 to December 2015, all patients with acute posterior circulation infarction, as well as patients with anterior circulation infarction, dizziness, dizziness and headache who were hospitalized at the same time, had complete head magnetic resonance imaging (MRI) and contrast-enhanced cervical magnetic resonance angiography (CE-MR). Data processing was divided into four parts. 1. 82 patients with acute posterior circulation infarction were selected. Patients with vertebral artery superiority were selected as study group (44 cases) and non-vertebral artery superiority was found by cranial MRA. Patients were taken as control group (38 cases). The hemodynamics and blood spectrum morphology of the posterior circulation artery were observed by TCD. 2. 160 cases of anterior circulation infarction group and 82 cases of posterior circulation infarction group were selected. Intracranial and extracranial vascular MRA examination and vascular risk factors screening were performed. The basilar artery curvature was graded and the risk factors of posterior circulation infarction were analyzed by multivariate logistic regression. 3. The patients with clinical symptoms such as posterior circulation infarction, dizziness and headache were divided into vertebral artery dominant group (86 cases) and non-dominant group (70 cases) according to the results of MRA. The incidence of infarction and the incidence of basilar artery curvature were analyzed. The relationship between the superior side of vertebral artery and the inferior side of posterior circulation was analyzed. The correlation between the direction of basilar artery curvature and the superior side of vertebral artery, and the correlation between basilar artery curvature and posterior circulation infarction was analyzed. There were 42 patients with flexure infarction and 40 patients with basilar artery inflexion-free infarction, 38 patients with vertigo or headache without basilar artery inflexion who were hospitalized at the same time as control group. The risk factors of posterior circulation infarction were analyzed by univariate and multivariate analysis, the relationship between BL and posterior circulation infarction was classified, and the diameter difference of bilateral vertebral artery was classified, and the correlation between the diameter difference of bilateral vertebral artery and BL and BAL was further analyzed. Results: 1. Vs, Vd, Vm of dominant vertebral artery were significantly higher than those of non-dominant vertebral artery and left and right vertebral artery in non-dominant vertebral artery group (P 0.01). Vd and Vm of basilar artery in dominant group were significantly lower than those of non-dominant group (P 0.05), PI and RI were significantly higher than those of non-dominant group (P 0.01). Sexual significance (P 0.05), the dominant group showed abnormal spectral shape. 2. The history of coronary heart disease in the posterior circulation infarction group was lower than that in the anterior circulation infarction group. The smoking rate, the history of diabetes mellitus were higher than that in the anterior circulation infarction group. The levels of LDL and Hb A1c in the blood were also significantly higher than those in the anterior circulation infarction group (P 0.05), the degree of stenosis of basilar artery, vertebral artery and basilar artery Multivariate logistic regression analysis showed that history of diabetes mellitus (OR 4.02; 95% CI 1.80-9.01; P = 0.002), basilar artery stenosis (OR 1.00; 95% CI 1.02-1.05; P 0.001), basilar artery curvature (>2) (OR 1.38; 95% CI 1.01-1.06; P = 0.009) were risk factors for posterior circulation infarction. The incidence of posterior circulation infarction in the dominant group was significantly higher than that in the control group (51.2% (44/86) vs. 22.9% (16/70), _2 = 13.063, P 0.001). There was a significant difference in the incidence of infarction between the PICA and BA regions. The incidence of basilar artery infarction in patients with basilar artery curvature in PICA and BA areas was significantly different from that in patients with basilar artery curvature. The incidence of other parts of the infarction was not significantly different. 4. Compared with the risk factors of basilar artery curvature-free infarction, the age of patients with basilar artery curvature (>6) Compared with the control group, BAL and BL were significantly different. Age (> 65 years), hypertension, diabetes mellitus, diabetes mellitus and smoking were significantly different in the basilar artery curvature group. There were significant differences in age, hypertension, diabetes and right vertebral artery diameter among different grades of BL (P 0.05). There was positive correlation between vertebral artery diameter and BL (r = 0.769, P 0.001), but no correlation with BAL. The curvature length 3 (BL3.71mm) was an important predictor of posterior circulation infarction (OR = 3.274, 95% CI 1.253-10.489, P 0.05). Conclusion: 1. The blood flow velocity of dominant vertebral artery increased, that of non-dominant vertebral artery decreased, and that of distant basilar artery decreased in patients with vertebral artery dominance. Abnormalities, TCD has a certain clinical value in assessing vascular variability after PCI. 2, type 2 diabetes mellitus, basilar artery curvature (> 2) and basilar artery stenosis may be risk factors for posterior circulation infarction. 3. Vertebral artery dominance is prone to cause basilar artery curvature, and basilar artery is prone to curvature. In CA and BA blood supply areas, the infarction sites of PICA blood supply areas mostly occurred on the opposite side of vertebral artery superiority and the curved side of basilar artery, while the infarction sites of BA blood supply areas mostly occurred on the opposite side of vertebral artery superiority, that is, the curved side of basilar artery. 4. The presence of vertebral artery superiority and exposure of vascular risk factors increase the curvature of basilar artery. Basilar artery curvature exposure to vascular risk factors such as age, hypertension, hypercholesterolemia, and type 2 diabetes increases the likelihood of posterior circulation infarction. Basilar artery curvature 3 (BL3.71 mm) is an important predictor of posterior circulation infarction.
【学位授予单位】：苏州大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R743.3

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