颈动脉盗血综合征的临床及影像特点分析

发布时间：2018-10-13 07:09

【摘要】：[目的]1、有关颈动脉盗血综合征的临床报道较少,病例类型单一,临床表现复杂多变,临床症状与血管病变不相符,诊断率低。分析颈动脉盗血综合征的临床及影像学特点,为其临床诊断提供参考。2、分析颈动脉盗血综合征的侧支循环建立与代偿方式评估颈动脉盗血综合征患者的预后。3、颈动脉内膜剥除术及颈动脉支架植入术是治疗颈动脉盗血综合征患者的两种主要治疗方法,通过分析两种治疗方法,评估颈动脉盗血综合征患者的循环改善程度,为治疗提供依据。[方法]1、搜集2016年3月～2017年3月在昆明医科大学第二附属医院住院治疗的颈动脉盗血综合征患者11例。2、收集所有研究对象的临床资料,包括病史采集及危险因素分析,如性别、年龄、吸烟、饮酒、高血压病、糖尿病、高脂血症、高同型半胱氨酸血症、脑卒中史等。于入院第二天晨起空腹取静脉血,测定空腹血糖、血脂、同型半胱氨酸、肝肾功能等。3、住院期间对11例患者均进行颈部血管彩超或经颅多普勒、头颅CTA或MRA、数字减影血管造影等检查。4、在证实为颈动脉盗血综合征后,其中9例患者在住院期间行颈动脉内膜剥除术或颈动脉内支架植入术,2例仅药物保守治疗。5、对11例患者进行出院后3个月、6个月和1年时间的随访。随访内容包括:(1).mRs量表评估;(2).是否发生缺血性脑血管事件;(3).卒中二级预防药物服用情况;(4).血管危险因素管理情况。[结果]1、共纳入11例颈动脉盗血综合征患者,其中男性7例(63.6%),女性4例(36.4%),年龄57-79岁,平均年龄(62.5±4.2)岁,均存在脑血管病相关危险因素:吸烟史6例(54.5%),饮酒史2例(18.2%),高血压9例(81.8%),糖尿病3例(27.3%),高脂血症8例(72.7%),高同型半胱氨酸血症10例(90.9%),脑卒中病史3例(27.3%)。2、11例受试者中,颈内动脉闭塞2例(18.2%),颈内动脉重度狭窄9例(81.8%)。单侧颈内动脉病变7例(63.6%),其中1例为闭塞,6例为重度狭窄(其中1例因夹层导致);双侧颈内动脉病变4例(36.4%)(其中1例为双侧闭塞,其他3例为一侧重度狭窄、一侧中度狭窄)。3、颈动脉盗血综合征的主要临床表现为分水岭梗死或短暂性脑缺血发作。本病例中,后循环短暂性脑缺血发作5例(45.5%),后循环脑梗死2例(18.2%),前循环短暂性脑缺血发作2例(18.2%),前循环脑梗死2例(18.2%);数字减影血管造影显示:发生病变的颈内动脉和颈总动脉共18支,13支累及颈内动脉起始段;11例受检者均有侧支循环建立,一级侧支循环11例(100%),二级侧支循环4例(36.4%),三级侧支循环1例(9.1%);ASITN评分0-2级的1例(9.1%),3级的4例(36.4%),4级的6例(54.5%);前交通动脉开放4例(36.4%),后交通动脉开放6例(54.5%),前后交通动脉同时开放1例(9.1%)。4、11例患者均在危险因素管理的基础上进行药物治疗,其中9例重度狭窄患者行手术治疗,5例行颈动脉支架植入术,4例行颈动脉内膜剥除术,2例闭塞患者仅给予药物保守治疗。所有患者均在出院后3个月、6个月、1年时间进行随访,2例行颈动脉支架植入术的患者出院后不同时期出现卒中样症状,其中1例因自行停服抗血小板聚集、他汀类药物治疗,1个月后出现反复前循环短暂性脑缺血发作;1例在常规用药的前提下,出院后6个月仍出现卒中样症状。4例行颈动脉内膜剥除术的患者,术后1年进行随访,均未发生卒中。2例颈动脉闭塞患者出院后仍有间断头晕发作,多次复查头颅MRI提示:多发腔隙性脑梗塞。[结论]1、颈动脉盗血综合征患者的颈内动脉病变多位于颅外段,临床上多表现为前、后循环短暂性脑缺血发作或分水岭梗死,临床表现与病变血管不一致。由于颈动脉的严重狭窄或闭塞,侧支循环的代偿起着重要作用,数字减影血管造影是其确诊方法;2、低灌注可能是颈动脉盗血综合征的发病机制,颈动脉支架植入术或颈动脉内膜剥除术是目前颈动脉盗血综合征的有效治疗手段;短期内颈动脉盗血综合征患者行颈动脉支架植入术与颈动脉内膜剥除术预后均较好,而远期效果颈动脉内膜剥除术可能优于颈动脉支架植入术;3、对于颈动脉闭塞的颈动脉盗血综合征患者,药物保守治疗效果欠佳,血管再通术能否成为颈内动脉闭塞的最佳治疗方案,仍需进一步研究。
[Abstract]:[Objective] 1. There are fewer clinical reports about carotid artery steal syndrome, the case type is single, the clinical manifestation is changeable, the clinical symptoms are not consistent with the vascular disease, and the diagnosis rate is low. To analyze the clinical and imaging characteristics of carotid artery steal syndrome and provide reference for its clinical diagnosis. Carotid endarterectomy and carotid artery stent implantation are two main treatment methods for patients with carotid artery steal syndrome.[Methods] 1. Collect 11 cases of carotid artery steal syndrome hospitalized in the Second Affiliated Hospital of Kunming Medical University from March 2016 to March 2017. 2. Collect clinical data of all subjects, including medical history collection and risk factors analysis, such as sex, age, smoking, drinking, Hypertension, diabetes, hyperlipidemia, hyperhomocysteinemia, history of stroke, etc. fasting blood glucose, blood lipid, homocysteine and liver and kidney function were measured on the morning after admission to the hospital. In the hospitalization period, 11 patients were examined with color Doppler ultrasound or cranial Doppler, cranial CTA or MRA, digital subtraction angiography and so on. Nine patients underwent carotid endarterectomy or carotid endoluminal stent implantation during hospitalization and 2 were only conservative. 5. Follow-up of 3 months, 6 months and 1 year after discharge was performed in 11 patients. Follow-up includes: (1). mRS scale assessment; (2). Whether ischemic cerebrovascular events have occurred; (3). Secondary prevention of stroke in stroke; (4). Management of vascular risk factors.[Results] Among 11 patients with carotid artery steal syndrome, 7 of them (63.6%), 4 women (36. 4%), aged 57-79 years, mean age (65.2. 5, 4.2), were associated with cerebrovascular diseases: 6 cases (54. 5%) of smoking history. There were 2 cases (18. 2%) of drinking history, 9 cases of hypertension (81.8%), 3 cases of diabetes (27. 3%), 8 cases of hyperlipidemia (72.7%), 10 cases of hyperhomocysteinemia (90.9%), 3 cases of cerebral stroke (27. 3%). Among 11 subjects, 2 cases (18.2%) were occluded by internal carotid artery. There were 9 cases of severe stenosis of internal carotid artery (81.8%). There were 7 cases (63.6%) of unilateral internal carotid artery disease, of which 1 case was occlusion, 6 cases were severe stenosis (1 case was caused by dissection); 4 cases (36. 4%) of double-sided internal carotid artery disease (1 case was double-sided occlusion, 3 others were severe stenosis on one side, one side was moderately narrow). 3, The main clinical manifestations of carotid steal syndrome are watershed infarction or transient ischemic attack. In this case, 5 cases (44.5%) of transient ischemic attack, 2 cases (18.2%) of post-circulating cerebral infarction, 2 cases of transient ischemic attack (18.2%), 2 cases of anterior circulation cerebral infarction (18.2%), 2 cases of anterior circulation cerebral infarction (18.2%), and digital subtraction angiography showed that: There were 18 branches of internal carotid artery and total carotid artery, 13 of which involved the initial segment of internal carotid artery; 11 subjects had side branch circulation, 11 cases (100%) of primary side branch, 4 cases (36. 4%) of secondary side branch and 1 case (97.1%) of tertiary side branch. One case (97.1%) of ASITN score of 0-2, 4 cases (36. 4%) of grade 3, 6 cases (54. 5%) of grade 4, 4 cases (34.4%) of open traffic artery, 6 cases (54. 5%) open posterior communicating artery, 1 case (92.1%) open at the same time of anterior and posterior communicating artery, all of 11 patients were treated with drugs on the basis of risk factor management. Among them, 9 patients with severe stenosis underwent surgical treatment, 5 cases of carotid artery stent implantation, 4 cases of carotid endarterectomy, 2 patients with occlusive disease only given the conservative treatment. All patients were followed up for 3 months, 6 months, 1 year after discharge, 2 patients with carotid artery stent implantation developed stroke-like symptoms at different times of discharge, of which 1 case had anti-platelet aggregation due to self-stop. Statins were treated for 1 month post-recurrent transient ischemic attack; 1 had stroke-like symptoms in 6 months after discharge on the basis of conventional medication. 4 patients with carotid endarterectomy were followed up for 1 year, No stroke occurred in 2 cases of carotid artery occlusion. 2 cases of carotid artery occlusion still had intermittent giddiness and multiple reexamination of cranial MRI revealed: multiple lacunar cerebral infarction.[Conclusion] 1. The internal carotid artery lesions of the patients with carotid artery steal syndrome are located in the extracranial segment, and the clinical manifestations are anterior and posterior circulation transient ischemic attack or watershed infarction, and the clinical manifestations are inconsistent with the diseased vessels. due to the severe stenosis or occlusion of the carotid artery, the compensation of collateral circulation plays an important role, and the digital subtraction angiography is a definite diagnosis method; 2, the low perfusion may be the pathogenesis of the carotid steal syndrome, Carotid stent implantation or carotid endarterectomy is an effective method for the treatment of carotid artery steal syndrome at present. The prognosis of carotid artery stent implantation and carotid endarterectomy is better in the short term. But long-term effect carotid endarterectomy may be superior to carotid artery stent implantation; 3. For patients with carotid artery occlusion with carotid artery occlusion, the conservative treatment effect of drugs is poor, and vascular restenosis can become the best treatment plan for internal carotid artery occlusion, and further study is still needed.
【学位授予单位】：昆明医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3

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