【摘要】：背景:后循環(huán)梗死的主要病理學(xué)基礎(chǔ)是動(dòng)脈粥樣硬化,但是隨著磁共振血管成像的廣泛應(yīng)用,發(fā)現(xiàn)后循環(huán)血管病變存在多樣性,遠(yuǎn)遠(yuǎn)超出既往單純的動(dòng)脈粥樣硬化危險(xiǎn)因素和血管病因。在正常人群和患者的磁共振血管成像檢查發(fā)現(xiàn),椎動(dòng)脈優(yōu)勢(shì)和基底動(dòng)脈彎曲是常見的血管變異,但是容易被臨床醫(yī)生忽視。臨床及影像醫(yī)師更多關(guān)注于血管的動(dòng)脈粥樣硬化和阻塞,而椎動(dòng)脈優(yōu)勢(shì)和基底動(dòng)脈彎曲可能參與后循環(huán)血管事件的發(fā)生和發(fā)展。椎動(dòng)脈優(yōu)勢(shì)及基底動(dòng)脈彎曲之間是否有關(guān)聯(lián),二者對(duì)后循環(huán)血液供應(yīng)的影響和確切機(jī)制也不清楚。暴露于血管危險(xiǎn)因素下的椎基底動(dòng)脈,是否會(huì)加大椎動(dòng)脈優(yōu)勢(shì)和基底動(dòng)脈彎曲,從而改變后循環(huán)的缺血,更易于發(fā)生后循環(huán)梗死尚不明確。目的:探討椎動(dòng)脈優(yōu)勢(shì)、基底動(dòng)脈彎曲與后循環(huán)梗死的關(guān)系。首先通過TCD來評(píng)估伴有椎動(dòng)脈優(yōu)勢(shì)的后循環(huán)梗死患者的血流動(dòng)力學(xué)變化;然后利用高場(chǎng)強(qiáng)核磁共振分析后循環(huán)梗死患者危險(xiǎn)因素;其次分析后循環(huán)不同部位梗死患者的椎動(dòng)脈優(yōu)勢(shì)與基底動(dòng)脈彎曲的關(guān)系;最后,結(jié)合血管危險(xiǎn)因素的暴露情況,分析椎動(dòng)脈優(yōu)勢(shì)和基底動(dòng)脈彎曲度和理論長(zhǎng)度之間的關(guān)系及其對(duì)后循環(huán)梗死患者的影響。拓寬對(duì)后循環(huán)血管評(píng)估結(jié)果的認(rèn)識(shí),加深對(duì)后循環(huán)缺血事件發(fā)生機(jī)制的認(rèn)識(shí),為后循環(huán)梗死患者的二級(jí)預(yù)防提供新的思路。對(duì)象與方法:本研究自2013年1月至2015年12月連續(xù)收集入住我院神經(jīng)內(nèi)科的急性后循環(huán)梗死患者,以及同時(shí)期住院的前循環(huán)梗死、頭暈和眩暈、頭痛患者,均有完整的頭顱核磁共振成像(MRI)、對(duì)比增強(qiáng)頸部核磁共振血管成像(CE-MRA)檢查資料,并且詳細(xì)記錄病史資料、相關(guān)量表及輔助檢查資料,尤其關(guān)注后循環(huán)血管狀態(tài)。數(shù)據(jù)處理分為4個(gè)部分。1、選取符合入組標(biāo)準(zhǔn)的急性后循環(huán)梗死患者82例。根據(jù)頭顱MRA檢查發(fā)現(xiàn)椎動(dòng)脈優(yōu)勢(shì)的患者作為研究組(44例),非椎動(dòng)脈優(yōu)勢(shì)的患者作為對(duì)照組(38例)。通過TCD觀察每個(gè)研究對(duì)象后循環(huán)供血?jiǎng)用}的血流動(dòng)力學(xué)和血流頻譜形態(tài)變化。2、選取資料完整并符合入組標(biāo)準(zhǔn)的前循環(huán)梗死組160例,后循環(huán)梗死組82例。對(duì)入選的患者進(jìn)行顱內(nèi)外血管MRA檢查及血管危險(xiǎn)因素篩查。把基底動(dòng)脈彎曲進(jìn)行分級(jí),采用多因素Logistic回歸分析尋找后循環(huán)梗死危險(xiǎn)因素。3、選取臨床表現(xiàn)為后循環(huán)梗死、頭暈和眩暈、頭痛等癥狀患者,根據(jù)MRA檢查結(jié)果分成椎動(dòng)脈優(yōu)勢(shì)組(86例)及非優(yōu)勢(shì)組(70例)。比較兩組間后循環(huán)各部位的梗死發(fā)生率以及基底動(dòng)脈彎曲的發(fā)生率,分析優(yōu)勢(shì)組各梗死部位后循環(huán)梗死側(cè)與椎動(dòng)脈優(yōu)勢(shì)側(cè)的關(guān)系,基底動(dòng)脈彎曲方向與椎動(dòng)脈優(yōu)勢(shì)側(cè)相關(guān)性,基底動(dòng)脈彎曲與后循環(huán)梗死的相關(guān)性。4、選取后循環(huán)梗死患者,根據(jù)MRA結(jié)果分為基底動(dòng)脈彎曲梗死組42例和基底動(dòng)脈無彎曲梗死組40例;同時(shí)期住院的基底動(dòng)脈彎曲無腦梗死的眩暈或頭痛患者38例為對(duì)照組。依MRA測(cè)量基底動(dòng)脈理論長(zhǎng)度(BAL)和基底動(dòng)脈彎曲長(zhǎng)度(BL)及基底動(dòng)脈直徑、雙側(cè)椎動(dòng)脈直徑,詳細(xì)記錄血管危險(xiǎn)因素暴露情況,比較三組之間血管危險(xiǎn)因素的差異。對(duì)后循環(huán)梗死患者危險(xiǎn)因素進(jìn)行單因素和多因素分析,把BL進(jìn)行分級(jí),探討其與后循環(huán)梗死的關(guān)系,并把雙側(cè)椎動(dòng)脈直徑差異進(jìn)行分級(jí),進(jìn)一步分析雙側(cè)椎動(dòng)脈直徑差異與BL和BAL之間的相關(guān)性。結(jié)果:1、椎動(dòng)脈優(yōu)勢(shì)組優(yōu)勢(shì)側(cè)椎動(dòng)脈Vs、Vd、Vm值均顯著高于非優(yōu)勢(shì)側(cè)以及非優(yōu)勢(shì)組左右兩側(cè)椎動(dòng)脈(P0.01)。優(yōu)勢(shì)組基底動(dòng)脈Vd和Vm值顯著低于非優(yōu)勢(shì)組(P0.05),PI和RI顯著高于非優(yōu)勢(shì)組(P0.01)。兩組大腦后動(dòng)脈同側(cè)的Vs、Vd、Vm、PI、RI值比較差別無顯著性意義(P0.05),優(yōu)勢(shì)組出現(xiàn)頻譜形態(tài)異常。2、后循環(huán)梗死組伴發(fā)冠心病史低于前循環(huán)梗死組,在吸煙率、伴發(fā)糖尿病史高于前循環(huán)梗死組,血LDL及Hb A1c水平也明顯高于前循環(huán)梗死組(P0.05),基底動(dòng)脈、椎動(dòng)脈狹窄程度以及椎動(dòng)脈優(yōu)勢(shì)和基底動(dòng)脈彎曲≥2級(jí)患者的比率明顯高于前循環(huán)梗死組(P0.01)。多因素Logistic回歸分析顯示,伴有糖尿病史(OR 4.02;95%CI1.80-9.01;P=0.002)、基底動(dòng)脈狹窄(OR 1.00;95%CI 1.02-1.05;P0.001)、基底動(dòng)脈彎曲≥2級(jí)(OR l.38;95%CI 1.01-1.06;P=0.009)是后循環(huán)梗死的危險(xiǎn)因素。3、85.1%(40/47)基底動(dòng)脈彎曲向椎動(dòng)脈優(yōu)勢(shì)對(duì)側(cè),基底動(dòng)脈彎曲方向與椎動(dòng)脈優(yōu)勢(shì)方向呈負(fù)相關(guān)性(r=㧟0.704,P0.0001),優(yōu)勢(shì)組后循環(huán)梗死的發(fā)生率明顯高于對(duì)照組(51.2%(44/86)vs.22.9%(16/70),χ2=13.063,P0.001)。兩組間在PICA區(qū)和BA區(qū)梗死發(fā)生率差異均有統(tǒng)計(jì)學(xué)意義,其余部位兩組間的發(fā)生率差異不顯著�；讋�(dòng)脈彎曲患者在PICA區(qū)和BA區(qū)梗死發(fā)生率與基底動(dòng)脈呈直線患者差異均有統(tǒng)計(jì)學(xué)意義,其余部位梗死的發(fā)生率差異不顯著。4、與基底動(dòng)脈無彎曲梗死患者血管危險(xiǎn)因素比較,年齡≥65歲、高血壓、糖尿病、高膽固醇血癥及高同型半胱氨酸血癥病史比例在基底動(dòng)脈彎曲組的優(yōu)勢(shì)比增加,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。和對(duì)照組比較,BAL和BL差異有統(tǒng)計(jì)學(xué)意義,年齡≥65歲、高血壓病、糖尿病及吸煙病史比例在基底動(dòng)脈彎曲組的優(yōu)勢(shì)比增加,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。年齡、高血壓病比例、糖尿病比例及右側(cè)椎動(dòng)脈直徑4個(gè)指標(biāo)在BL不同等級(jí)間比較差異有統(tǒng)計(jì)學(xué)意義(P0.05)。椎動(dòng)脈直徑差異與BL呈正相關(guān)性(r=0.769,P0.001),與BAL無相關(guān)性。進(jìn)行多因素分析后,基底動(dòng)脈彎曲長(zhǎng)度3級(jí)(BL3.71mm)是后循環(huán)梗死的重要預(yù)測(cè)因素(OR=3.274,95%CI 1.253-10.489,P0.05)。結(jié)論:1、椎動(dòng)脈優(yōu)勢(shì)患者優(yōu)勢(shì)側(cè)椎動(dòng)脈血流速度增快,非優(yōu)勢(shì)側(cè)血流速度減慢,遠(yuǎn)處基底動(dòng)脈血流速度減慢。椎動(dòng)脈優(yōu)勢(shì)患者出現(xiàn)腦血流動(dòng)力學(xué)改變,頻譜形態(tài)異常,TCD對(duì)評(píng)估PCI后循環(huán)血管變異具有一定的臨床價(jià)值。2、2型糖尿病、基底動(dòng)脈彎曲≥2級(jí)和基底動(dòng)脈狹窄可能是后循環(huán)梗死危險(xiǎn)因素。3、椎動(dòng)脈優(yōu)勢(shì)易于導(dǎo)致基底動(dòng)脈彎曲的發(fā)生,基底動(dòng)脈易向優(yōu)勢(shì)對(duì)側(cè)發(fā)生彎曲。椎動(dòng)脈優(yōu)勢(shì)容易發(fā)生PICA供血區(qū)及BA腦橋支供血區(qū)的梗死,PICA供血區(qū)梗死部位多發(fā)生在椎動(dòng)脈優(yōu)勢(shì)對(duì)側(cè),基底動(dòng)脈彎曲側(cè);而BA腦橋支供血區(qū)的梗死多發(fā)生在椎動(dòng)脈優(yōu)勢(shì)側(cè),即基底動(dòng)脈彎曲的對(duì)側(cè)。4、椎動(dòng)脈優(yōu)勢(shì)的存在與血管危險(xiǎn)因素暴露,增加基底動(dòng)脈彎曲的發(fā)生;雙側(cè)椎動(dòng)脈直徑差異與BL呈正相關(guān)性�；讋�(dòng)脈彎曲暴露在高齡、高血壓病、高膽固醇血癥及2型糖尿病等血管危險(xiǎn)因素下,增加后循環(huán)梗死發(fā)生的可能性。基底動(dòng)脈彎曲長(zhǎng)度3級(jí)(BL3.71mm)是后循環(huán)梗死的重要預(yù)測(cè)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.
【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2016
【分類號(hào)】：R743.3

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