【摘要】：背景 腦血管疾病已成為我國首位的疾病死亡原因，其中腦梗死占全部腦血管疾病的80%左右，而后循環(huán)腦梗死約占所有腦梗死的20%，較前循環(huán)腦梗死少見。后循環(huán)為延髓、腦橋、中腦、小腦及枕葉等重要基本生命中樞所在區(qū)域供血，該供血區(qū)一旦出現(xiàn)腦梗死后，將引起嚴重的神經(jīng)功能缺損，臨床癥狀一般較重，病情兇險，其致殘率、病死率均較高。但與前循環(huán)頸內(nèi)動脈剝脫術(shù)及支架植入術(shù)研究相比，，目前對后循環(huán)腦梗死的二級預防措施相對有限，所以對后循環(huán)腦梗死危險因素的研究非常必要。腦梗死的危險因素很多，簡單地分類可包括可控制危險因素和不可控制危險因素；其常見的可控制危險因素包括高血壓病、糖尿病、高脂血癥、抽煙等，而腦血管發(fā)育不全被認為是不可控制的危險因素之一；有文獻報道，椎動脈發(fā)育不全(Vertebral arteryhypoplasia，VAH)可能是后循環(huán)腦梗死的獨立危險因素之一。但通過數(shù)字減影血管造影術(shù)(digital subtraction angiography，DSA)評估椎動脈發(fā)育不全來研究椎動脈發(fā)育不全與后循環(huán)腦梗死相關(guān)性的研究尚未見報道。 目的探討DSA對椎動脈發(fā)育不全的診斷價值，椎動脈發(fā)育不全是否是后循環(huán)腦梗死的獨立危險因素之一。初步探討椎動脈發(fā)育不全與再發(fā)后循環(huán)腦梗死的關(guān)系。 方法1、收集2003年01月至2008年12月在我科連續(xù)行全腦血管造影檢查的1135例腦梗死患者，根據(jù)患者顱腦MRI或CT結(jié)果分為前后循環(huán)腦梗死組兩組。其中前循環(huán)腦梗死組724例；后循環(huán)梗死組411例。同時收集兩組患者的年齡、性別、吸煙、高血壓病、糖尿病、高脂血癥等腦梗死常見危險因素情況。根據(jù)DSA表現(xiàn)：本研究將VAH分5型，其中Ⅰ型；一側(cè)椎動脈全程纖細，管徑小于2.5mm，或與對側(cè)椎動脈比值小于1/1.7。Ⅱ型:雙側(cè)椎動脈顱外段管徑大于2.5mm，但一側(cè)參與基底動脈供血段明顯纖細，管徑是對側(cè)的1/1.7以下。Ⅲ型：一側(cè)椎動脈未參與基底動脈供血，止于小腦后下動脈，而另一側(cè)椎動脈管徑大于2.5mm。Ⅳ型:一側(cè)椎動脈先天不發(fā)育，另一側(cè)椎動脈管徑大于2.5mm。Ⅴ型:雙側(cè)椎動脈發(fā)育不全，即雙側(cè)椎動脈均表現(xiàn)為Ⅰ型(和)或Ⅲ型(和)或Ⅳ型的情況。同時觀察患者后交通動脈(posterior communicating artery，PCoA)的開放情況。統(tǒng)計分析前后循環(huán)腦梗死組兩組患者VAH的差別，以及VAH患者和非VAH患者中PCoA開放情況的差別。 2、收集2003年01月至2008年12月在我科行全腦血管造影檢查的初發(fā)后循環(huán)腦梗死患者因再發(fā)后循環(huán)腦梗死再次入院就診情況；未再次就診患者進行電話隨訪其在是否再次發(fā)生后循環(huán)腦梗死，同時收集患者的年齡、性別、吸煙、高血壓病、糖尿病、高脂血癥等腦梗死常見危險因素。終點事件為再次發(fā)生后循環(huán)腦梗死或患者死亡。比較兩組患者中常見腦梗死危險因素及VAH的差別。 數(shù)據(jù)統(tǒng)計應用SPSS13.0軟件，分析兩組組間的各個指標是否存在統(tǒng)計學差異。 結(jié)果 1、1135例腦梗死患者中，診斷前循環(huán)腦梗死724例，后循環(huán)腦梗死411例。后循環(huán)腦梗死組患者平均年齡(59.97±10.84歲)較前循環(huán)腦梗死組患者(61.48±9.69歲)小，但差異無明顯統(tǒng)計學意義(p=0.21)。后循環(huán)腦梗死中男性(72.46%)較女性多見，與前循環(huán)組比較，差異無明顯統(tǒng)計學意義(p=0.42)。兩組患者中腦梗死常見危險因素，如吸煙(p=0.47)、高血壓病(p=0.75)、糖尿病(p=0.92)、高脂血癥(p=0.68)差異均沒有統(tǒng)計學意義。兩組患者共262例診斷VAH，其中前循環(huán)腦梗死組診斷VAH122例(16.85%)，后循環(huán)腦梗死組VAH140例(34.06%)。VAH患者發(fā)生后循環(huán)腦梗死的危險是前循環(huán)腦梗死組的2.75倍(OR=2.75，95%CI：1.60～3.58；p＜0.05)。VAH以右側(cè)最常見(61.07%)，左側(cè)占(27.86%)，雙側(cè)最少見(11.07%)。5型VAH以Ⅰ型最常見(41.60%)，Ⅲ型次之(22.14%)，Ⅳ型、Ⅴ型各占16.03%及11.07%，Ⅱ型最少見(9.16%)。VAH組患者95例(36.26%)后交通動脈開放，非VAH組患者119例(13.79%)后交通動脈開放，VAH組患者后交通動脈開放較非VAH組患者明顯增多，差異有統(tǒng)計學意義(p＜0.05)。 2、隨訪結(jié)果：隨訪2003年01月至2008年12月在我科行全腦血管造影檢查的347例初發(fā)后循環(huán)腦梗死患者中，其中45人因未留電話號碼、39人因電話號碼變更而失訪。實際隨訪到263例(35人已死亡)。其中因再發(fā)后循環(huán)腦梗死再次住我院67人(6人死亡，納入統(tǒng)計)，電話隨訪196人(29人死亡，其中15人死因不詳，6人死于癌癥，4死于腦梗死后遺癥，4人再發(fā)腦梗死后死亡-再發(fā)腦梗死部位不詳，29人均不納入統(tǒng)計)。因此最終納入234例患者資料進行統(tǒng)計分析，年齡43-78歲(57.32±11.12歲)，臨床診斷再發(fā)后循環(huán)腦梗死124例。分析性別、年齡、高血壓、糖尿病、高脂血癥、吸煙、VAH與再發(fā)后循環(huán)腦梗死關(guān)系，單因素分析結(jié)果顯示：年齡＞65歲、高血壓病史、糖尿病史、VAH是再發(fā)后循環(huán)腦梗死有意義的影響因素(P＜0.05)，經(jīng)過多因素logistic回歸分析得出：年齡＞65歲、高血壓病史、糖尿病史及VAH四個因素為再發(fā)后循環(huán)腦梗死的危險因素(p值＜0.05)。 結(jié)論 (1) DSA能明確診斷各型VAH，并能明確后交通動脈開放情況，對VAH的診斷有重要的臨床意義。 (2)VAH可能是后循環(huán)腦梗死的危險因素之一。 (3)VAH患者更易再發(fā)后循環(huán)腦梗死。
[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.
【學位授予單位】：第三軍醫(yī)大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R743.3

【參考文獻】

相關(guān)期刊論文 前10條

1 黃小欽,賈建平;短暫性腦缺血患者頸動脈粥樣硬化及相關(guān)危險因素分析[J];北京醫(yī)學;2005年02期

2 楊玉輝,呂衡發(fā),劉景臣,高忠禮;椎動脈V1段的形態(tài)學特點及其臨床意義[J];吉林大學學報(醫(yī)學版);2004年05期

3 席剛明;岳炫燁;葉飛;胡發(fā)云;鮑玉華;莊鳳娟;聶森;;中樞性眩暈患者的92例數(shù)字減影全腦血管造影結(jié)果分析[J];第二軍醫(yī)大學學報;2007年03期

4 是明啟;王玉洲;張小喜;;DSA診斷的椎動脈發(fā)育不良60例臨床分析[J];河南醫(yī)學研究;2011年04期

5 王力力;華揚;凌晨;段春;賈凌云;;應用血管超聲分析椎動脈管徑發(fā)育不良與眩暈的關(guān)系[J];中國腦血管病雜志;2009年08期

6 侯紅玲;閆福嶺;;椎動脈優(yōu)勢及其研究進展[J];現(xiàn)代醫(yī)學;2010年04期

7 邢成名,劉學升,盧幸明,李軍,張敏;椎基底動脈供血不足患者的血管異常分析(英文)[J];中國臨床康復;2004年25期

8 金潔;胡英嗣;;椎動脈優(yōu)勢與腦梗死關(guān)系的臨床分析[J];心腦血管病防治;2012年01期

9 陳莉;呂發(fā)金;姚開情;李劍秋;勒都曉蘭;;后交通動脈開放與椎動脈顱內(nèi)段發(fā)育間關(guān)系的MRA研究[J];中國臨床解剖學雜志;2012年02期

10 申敬順;韓杰;王瑩;陳佼;楊志強;;多層螺旋CT血管成像在椎基底動脈短暫性腦缺血發(fā)作診斷中的價值[J];卒中與神經(jīng)疾病;2006年02期

本文編號：2143542