本文選題：椎動脈V1段　切入點：動脈狹窄　出處：《蘭州大學》2007年碩士論文

【摘要】： 目的：缺血性卒中大約有1／4的患者累及后循環(huán)或椎基底循環(huán)。動脈粥樣硬化性狹窄可發(fā)生在椎基底動脈全程，但以椎動脈V1段為多見，在顱外腦血管狹窄患者中，25％～40％發(fā)生在椎動脈V1段。本研究旨在：1．通過尸體解剖椎動脈V1段，觀察正常椎動脈的開口部位以及進入橫突孔的位置，分別測量椎動脈開口的外徑及椎動脈V1段的長度，為椎動脈V1段支架置入提供指導性數據。2．觀察頸椎橫突孔的形狀，測量橫突孔的矢狀徑與橫徑的長度，為椎動脈V1段狹窄的支架置入提供解剖學依據。3．通過全腦血管造影篩選有癥狀的椎動脈V1段狹窄(狹窄率≥50％)并接受支架成形術治療的患者，進行支架大小的統計，用頸部彩色多譜勒測定的方法，對支架治療前后椎動脈V1段的狹窄率與血流動力學的變化進行比較，從而為由于椎動脈V1段狹窄引起的腦供血不足的血管內臨床治療提供依據。　　 方法：1．對9具尸體雙側椎動脈V1段(n=18)進行解剖，從頸前方由淺入深逐層解剖胸鎖乳突肌區(qū)和頸根部，游離椎動脈的起源血管，觀察椎動脈開口的部位及進入橫突孔的位置及血管的走行特征，測量(精確度0.02mm)椎動脈開口的外徑以及椎動脈V1段的長度。　　 2．測量頸椎C1—C7橫突孔的橫徑及矢狀徑�！　� 3．通過全腦血管造影篩選有椎動脈供血不足癥狀的椎動脈V1段狹窄(狹窄率≥50％)，并接受支架成形術治療的患者35例，對36枚(1例為兩側支架置入)3種類型支架進行大小的統計，通過彩色多普勒血流顯像(Color Doppler flow imaging，CDFI)測算實施支架前、后椎動脈V1段的狹窄率，支架前、后椎動脈V1段、間隙段收縮期峰值流速(Peak systolic Velocity，PVS)以及椎間隙段的博動指數(Pulsatile index，PI)，進行統計學處理。　　 結果：1、椎動脈起始的部位：左側發(fā)自鎖骨下動脈第一段上后壁有7例(77.8％)呈垂直上行(90°)穿橫突孔，發(fā)自鎖骨下動脈第一段上前壁2例(22.2％)；右側發(fā)自鎖骨下動脈第一段上后壁6例(66.7％)呈垂直上行，發(fā)自鎖骨下動脈第一段上前壁3例(33.3％)。 2、椎動脈V1段的長度與開口的外徑：長度(mm)：左側37.8±4.9，右側36.4±5.7；外徑(mm)：左側曲行組4.72±0.37(n=3，33.3％)，，左側直行組4.25±0.135(n=6，66.7％)；右側曲行組4.35±0.41(n=4，44.4％)，右側直行組3.95±0.38(n=5，55.6％)。 3、雙側椎動脈穿橫突孔的位置：左側椎動脈7例(77.8％)穿C6橫突孔，變異2例(22.2％)其中1例穿C5橫突孔，另1例穿C4橫突孔：右側椎動脈8例穿C6橫突孔(88.9％)，變異只有1例(11％)為穿C5橫突孔。 4、頸椎橫突孔的形狀及其橫徑與矢狀徑：頸椎橫突孔的形狀大體可分為圓形、縱橢圓形、橫橢圓形，不規(guī)則形四種，不論左側或右側C1、C2橫突孔均以縱橢圓形為主，C3—C7以橫橢圓形為主，橫突孔的橫徑(mm)多數以C4為最大(6.4±0.8)，C7為最小(5.3±1.7)：矢徑(mm)以C1為最大6.8±1.0)，C7為最小(4.1±1.2)。 5、椎動脈V1段狹窄支架置入前后狹窄率與血流動力學的改變：35名患者36支椎動脈V1段狹窄狹窄率=50％，其中雙側狹窄6例，一側狹窄對側閉塞12例，單側椎動脈V1段狹窄17例。9側使用Bxsonic(5×20mm)支架，6側為AVEgfx(BX，4×20 mm)支架，21側使用Firebird(4×18mm)支架。支架置入術前、后椎動脈V1段內徑分別為：1.3±0.4 mm與2.7±0.7 mm(p＜0.001)；狹窄率從64±9％降至23±17％(p＜0.001)，術前收縮期血流峰植(PSV)的異常高流速242±102cm／s，術后降至87±45cm／s(P＜0.001)。術前患側椎動脈椎間隙段的搏動指數(PI)值為0.77±019，健側為0.96±0.17(P=0.011)�！　� 結論：1、椎動脈V1以近似90°起源于鎖骨下動脈的第一段，椎動脈起點變異較少，一般起源于鎖骨下動脈的上后壁，在鎖骨下動脈上起始處的方位呈向后上方集中的趨勢，是鎖骨下動脈的最大一個分支。 2、右側椎動脈V1段開口外徑相對左側較細；左側椎動脈V1段開口外徑曲行組小于直行組，雙側椎動脈V1段的長度曲行組與直行組差異無顯著性。 3、椎動脈V1段動脈未見分支。 4、椎動脈穿經第6頸椎橫突孔(雙側平均為88.3％)上行，左側椎動脈穿橫突孔部位變異2例(22.2％)，1例穿C5橫突孔，另1例穿C4橫突孔；右側椎動脈穿橫突孔部位變異只有1例(11％)為穿C5橫突孔。 5、頸6橫突孔不論是矢狀徑還是橫徑均大于椎動脈V1段的外徑。 6、椎動脈V1段走行過程中少有變異，但是在進入橫突孔前無明顯分支且缺乏骨性結構的限制，所以適合血管內介入治療，且通過椎動脈V1段狹窄支架前后狹窄率及血流動力學指標的變化，說明椎動脈V1段狹窄的血管內治療是安全有效的。
[Abstract]:Objective: ischemic stroke is about 1 / 4 of the patients with posterior circulation or vertebrobasilar circulation. Atherosclerotic stenosis can occur in vertebrobasilar artery course, but in V1 segment of vertebral artery was more common in patients with extracranial arterial stenosis, 25% to 40% occurred in the V1 vertebral artery. The purpose of this study is to: 1. the autopsy of V1 segment of vertebral artery, the opening part of the vertebral artery and to observe the normal position into the transverse foramen, vertebral artery were measured and the diameter of the vertebral artery V1 segment length, provide guidance and data.2. observation of cervical transverse foramen in the shape of V1 segment of vertebral artery stenting, sagittal length measurement of transverse foramen the diameter and transverse diameter, and provide anatomic basis.3. through cerebral angiography of vertebral artery were symptomatic V1 stenosis of vertebral artery stenosis (V1 stent stenosis rate greater than 50%) and underwent stent angioplasty for the treatment of patients in Statistics for the stent size, determination method of neck color Doppler, compare the changes of stenosis rate and hemodynamics of vertebral artery before and after stent in the treatment of V1 segment, which is due to the V1 segment of vertebral artery stenosis caused by insufficient blood supply to the brain blood vessels provide the basis for clinical treatment.
Methods: 1. of the 9 bodies of bilateral vertebral artery V1 segment (n=18) were dissected by dissecting the sternocleidomastoid muscle and neck root from anterior vertebral artery blood vessel free from the shallower to the deeper, the origin, characteristics of vertebral artery were observed along the site and into the transverse foramen and position measurement accuracy (blood vessels. 0.02mm) vertebral artery diameter and vertebral artery V1 segment length.
2. the transverse diameter and sagittal diameter of the C1 - C7 transverse process of the cervical spine were measured.
V1 segment of vertebral artery by cerebral angiography were 3. vertebral artery insufficiency symptomatic stenosis (stenosis rate greater than 50%), and 35 cases were treated with stenting, of 36 cases (1 cases of stent implantation on both sides) 3 types of stent size statistics, by color Doppler flow imaging (Color Doppler flow imaging, CDFI) estimates support before the restenosis rate after V1 segment of vertebral artery stenting before and after the V1 segment of vertebral artery, gap of systolic peak velocity (Peak systolic, Velocity, PVS) and intervertebral segment of the pulsatile index (Pulsatile, index, PI) were statistically analyzed.
Results: 1 vertebral artery position: left from the wall of the first section after subclavian artery in 7 cases (77.8%) in a vertical upward (90 degrees) in the transverse foramen, from the first part of the subclavian artery anterior wall in 2 cases (22.2%); the right from the first wall section after subclavian artery in 6 cases (66.7%) in a vertical upward, from the first part of the subclavian artery anterior wall in 3 cases (33.3%).
2, vertebral artery V1 segment length with the opening of the outer diameter: length (mm): the left side of the 37.8 + 4.9, 36.4 + 5.7 on the right side; the diameter (mm): left crooked group 4.72 + 0.37 (n=3,33.3%), left straight group 4.25 + 0.135 (n=6,66.7%); right crooked group 4.35 + 0.41 (n=4,44.4%), right straight group 3.95 + 0.38 (n=5,55.6%).
3, bilateral vertebral artery puncture through transverse foramen: 7 cases (77.8%) of the left vertebral artery, 77.8% cases wore C6 transverse foramen, 2 cases (22.2%) were variant, 1 cases wore C5 transverse foramen, and 1 cases wore C4 transverse foramen. 8 cases of right vertebral artery wore C6 transverse foramen (88.9%), and only 1 cases (11%) wore C5 transverse foramen.
4, the shape of the transverse cervical transverse foramen diameter and sagittal diameter: cervical transverse foramen shape can be divided into round, oval, ellipse, irregular shape four, regardless of the left or right C1, C2 transverse foramen were mainly oval, C3 - C7 to cross ellipse transverse foramen diameter (mm) most of the C4 is the largest (6.4 + 0.8), C7 (5.3 + 1.7): minimum radius (mm) to C1 is the largest of 6.8 + 1), C7 was the smallest (4.1 + 1.2).
5, V1 segment of vertebral artery stenosis before and after stent stenosis and hemodynamic change: 35 patients with 36 vertebral artery V1 segment stenosis rate of =50%, including bilateral stenosis in 6 cases, one side of the narrow side occlusion in 12 cases, unilateral vertebral artery V1 segment stenosis in 17 cases of.9 side Bxsonic (5 * 20mm). Frame, 6 side AVEgfx (BX, 4 * 20 mm) stent, 21 side using the Firebird (4 x 18mm). Stent stenting before and after the V1 segment of vertebral artery diameter were 1.3 + 0.4 and 2.7 + 0.7 mm mm (P < 0.001); stenosis rate from 64 + 9% to 23 + 17% (P < 0.001), preoperative systolic peak velocity (PSV) of the abnormally high 242 + 102CM / s, postoperative to 87 + 45cm / S (P < 0.001). The patients with intervertebral segment of vertebral artery pulsatility index (PI) value was 0.77 + 019, contralateral 0.96 + 0.17 (P=0.011).
Conclusion: 1, the first segment of vertebral artery V1 with approximate 90 degrees originated from the subclavian artery, vertebral artery starting point less variation generally originated from subclavian artery on the posterior wall of the subclavian artery in the initial position is on the back above the central tendency, is one of the biggest branch of the subclavian artery.
2, the outer diameter of V1 segment of the right vertebral artery is smaller than that of the left side. The V1 segment opening diameter of the left vertebral artery is smaller than that of the straight line group. There is no significant difference in the length of bilateral vertebral artery V1 segment between the straight line group and the straight line group.
3, there was no branch of the V1 segment of the vertebral artery.
4, vertebral artery penetrated through the transverse foramen of sixth cervical vertebra (bilateral average 88.3%). 2 cases (22.2%) had transversal foramen position in the left vertebral artery, 1 cases wore C5 transverse foramen, and 1 cases wore C4 transverse foramen. Only 1 cases (11%) of the right vertebral artery crossing the transverse foramen were C5 transverse foramen.
5, both the sagittal and transverse diameter of the 6 transverse foramen of the neck were greater than the outer diameter of the V1 segment of the vertebral artery.
6, the course of the V1 artery with little variation, but into the transverse foramen without significant branches and bony structure, so it is suitable for endovascular therapy, and the changes of V1 segment of vertebral artery stenosis stent stenosis rate and hemodynamics, indicating V1 segment of vertebral artery stenosis treatment is safe and effective.

【學位授予單位】：蘭州大學
【學位級別】：碩士
【學位授予年份】：2007
【分類號】：R322

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