夹层动脉瘤与缺血性卒中课件.ppt

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1、夹层动脉瘤与缺血性卒中,夹层动脉瘤与缺血性卒中,1,夹层动脉瘤与缺血性卒中夹层动脉瘤与缺血性卒中1,定义,夹层动脉瘤(dissecting aneurysm)又称动脉剥离(arter dissection),是血液进入动脉壁形成血肿或动脉壁内自发性血肿,使血管壁间剥离,导致动脉管腔狭窄或血管破裂。夹层动脉瘤好发于主动脉及大分支,约20%侵犯颅内外血管与脊髓血管,引起脑部或脊髓症状,夹层动脉瘤与缺血性卒中,2,定义 夹层动脉瘤(dissecting aneurysm)又,流行病学,Tumbull(1915年)首例报道脑夹层动脉瘤至今国内外已有千余例报道脑夹层动脉瘤人群年发病率约3/10万,2%的

2、缺血性卒中可能由本病引起*50岁以下的缺血性卒中约10%的是夹层动脉瘤所致*,*BesselmannM,VennemannB,LowensS,etal.Internal carotid artery dissectionJ.Neurology,2000,54:442.,夹层动脉瘤与缺血性卒中,3,流行病学Tumbull(1915年)首例报道脑夹层动脉瘤*B,病因与发病机制及病理,夹层动脉瘤与缺血性卒中,4,病因与发病机制及病理夹层动脉瘤与缺血性卒中4,病因,基础动脉病纤维肌肉发育不良动脉中层囊性变动脉内弹力层缺陷梅毒性动脉炎多发性结节性动脉炎烟雾病动脉畸形马凡综合征系统性红斑狼疮以及动脉硬化等

3、,夹层动脉瘤与缺血性卒中,5,病因基础动脉病夹层动脉瘤与缺血性卒中5,病因,高血压病轻微外伤,如颈部按摩推拿，过伸过曲及转头等动作,甚至咳嗽、呕吐、打喷嚏等也可引起椎动脉夹层 Chung YS,Han DH.Vertebrobasilar dissection:a possible role of Whiplash injury in its pathogenesisJ.Neurol Res,2002,24:129-138偏头痛Cephalalgia,2005, 25:575-580.,夹层动脉瘤与缺血性卒中,6,病因高血压病夹层动脉瘤与缺血性卒中6,病因,感染(如脑炎、脑膜炎等)口服避孕药遗

4、传,血浆同型半胱氨酸水平升高以及THFR纯合子(MTHFRTT)基因型表达可能是夹层动脉瘤发生的危险因素Med Hypotheses,2005,64:1007-1010Stroke,2002,33:664-669.N Engl JMed,2001,344:898-906.,夹层动脉瘤与缺血性卒中,7,病因感染(如脑炎、脑膜炎等)夹层动脉瘤与缺血性卒中7,病因,医源性因素,夹层动脉瘤与缺血性卒中,8,病因医源性因素夹层动脉瘤与缺血性卒中8,发病机制,管腔狭窄或闭塞可导致脑缺血症状,但动脉内皮破损处继发血栓形成,血栓片段脱落引起动脉栓塞则是缺血发生的更主要机制Stroke,2004,35:482-

5、485.动脉造影及外科手术可见管腔内易碎的血栓,或当管腔狭窄对血流动力学影响不大时即发生的缺血症状,也为远端动脉栓塞提供了间接证据,夹层动脉瘤与缺血性卒中,9,发病机制管腔狭窄或闭塞可导致脑缺血症状,但动脉内皮破损处继发,夹层动脉瘤与缺血性卒中,10,夹层动脉瘤与缺血性卒中10,病理,大体解剖常见动脉内膜下血肿,使内弹力板与中层分离,导致管腔狭窄少见血肿位于动脉外膜下层,引起动脉扩张(动脉瘤),如继续向外扩张并穿过外膜可引起蛛网膜下腔出血夹层动脉瘤还可累及脊髓前动脉而引起脊髓症状,夹层动脉瘤与缺血性卒中,11,病理大体解剖常见动脉内膜下血肿,使内弹力板与中层分离,导致管,病理,夹层动脉瘤近心端

6、常可见血管内膜与内弹力板的撕裂口,远心端可发现血管腔内穿破口镜下可见血肿位于内弹力板与中膜间,两者剥离并向对侧管壁移位,血管腔被挤成裂隙状或完全闭塞颅内夹层动脉瘤由于缺乏发育良好的外弹力膜,较易破裂,夹层动脉瘤与缺血性卒中,12,病理夹层动脉瘤近心端常可见血管内膜与内弹力板的撕裂口,远心端,夹层动脉瘤与缺血性卒中,13,夹层动脉瘤与缺血性卒中13,临床表现,夹层动脉瘤与缺血性卒中,14,临床表现夹层动脉瘤与缺血性卒中14,夹层动脉瘤与缺血性卒中,15,夹层动脉瘤与缺血性卒中15,夹层动脉瘤与缺血性卒中,16,夹层动脉瘤与缺血性卒中16,临床表现,多见于50岁以下年轻人,男性稍多,多数身体健康,

7、无卒中危险因素,常在某动脉区剧烈疼痛后出现相应神经功能缺失症状,临床表现因受累动脉而异。有人将夹层动脉瘤称为/健康青年人的脑梗死Neuropathology,2000,20:85290.,夹层动脉瘤与缺血性卒中,17,临床表现多见于50岁以下年轻人,男性稍多,多数身体健康,无卒,颈内动脉颅外段夹层动脉瘤,较常见典型表现突发剧烈头颈部疼痛,多为胀痛,可有同侧头皮触痛发病数小时至数日出现脑缺血症状,如偏瘫、失语、意识障碍以至昏迷,36天症状达高峰,急性起病者24h内病情可达高峰,甚至死亡40%50%的病例伴颈内动脉系统短暂性脑缺血发作(TIA)及同侧不完全Horner征,后者是沿颈内动脉壁走行的交

8、感神经纤维受累所致Neurologist,1997,3:104-119.,夹层动脉瘤与缺血性卒中,18,颈内动脉颅外段夹层动脉瘤较常见夹层动脉瘤与缺血性卒中18,颈内动脉颅外段夹层动脉瘤,25%的患者以搏动性耳鸣或主观性杂音为突出症状,偶见同侧脑神经麻痹,如舌下神经受损引起舌肌麻痹,也可累及舌咽神经,迷走神经,副神经和三叉神经等,通常是动脉外膜下夹层动脉瘤侵占颈部咽旁间隔所致表现颈部肿胀和闪光暗点等少见,也可为单侧颈部、面部或头部疼痛和眼交感神经麻痹,但无脑缺血症状,夹层动脉瘤与缺血性卒中,19,颈内动脉颅外段夹层动脉瘤25%的患者以搏动性耳鸣或主观性杂音,颈内动脉系统颅内段夹层动脉瘤,较少见

9、颈内动脉颅内段或大脑中动脉主干均可受累主要表现大脑半球缺血症状常先出现同侧严重头痛,预示动脉壁剥离有时以痫性发作或意识障碍起病,随即发生神经功能缺失数日内症状逐渐进展,可发展为完全性卒中,多数患者数日或数周内死亡,幸存者中半数遗留中、重度神经功能缺失约20%的患者发生蛛网膜下腔出血,夹层动脉瘤与缺血性卒中,20,颈内动脉系统颅内段夹层动脉瘤较少见夹层动脉瘤与缺血性卒中20,椎动脉颅外段夹层动脉瘤,较常见多与颈部按摩或扭转等动作有关椎动脉在C1、C2水平活动度最大,也最易受损典型表现突然发生后枕部严重疼痛继而出现枕叶、脑干和小脑等部位缺血症状,如晕眩、恶心、呕吐、眼震及共济失调等约1/3的患者发

10、生延髓背外侧综合征单侧椎动脉阻塞因对侧代偿,可不引起缺血症状,夹层动脉瘤与缺血性卒中,21,椎动脉颅外段夹层动脉瘤较常见夹层动脉瘤与缺血性卒中21,椎动脉颅内段夹层动脉瘤,少见约占颅内、外夹层动脉瘤的5%易发生蛛网膜下腔出血约1/3的患者出现脑干、小脑或大脑半球梗死1/10的患者为蛛网膜下腔出血合并脑梗死,偶可表现占位效应,压迫脑干和下位脑神经Neurosurgery,2002,51:9302937.,夹层动脉瘤与缺血性卒中,22,椎动脉颅内段夹层动脉瘤少见夹层动脉瘤与缺血性卒中22,基底动脉夹层动脉瘤,极少见可引起脑神经麻痹、交叉瘫或四肢瘫,甚至脑膜刺激征,严重者突发脑干缺血,可迅速死亡,也

11、可表现TIA、小灶性梗死和蛛网膜下腔出血等,夹层动脉瘤与缺血性卒中,23,基底动脉夹层动脉瘤极少见夹层动脉瘤与缺血性卒中23,脊髓前动脉夹层动脉瘤,累及脊髓前动脉引起脊髓缺血,患者常出现剧烈根痛或颈肩部疼痛。瘫痪多在疼痛出现后数小时达高峰,左右可不对称。早期为脊髓休克期,表现肌张力减低,腱反射消失等;休克期后出现病变节段周围性瘫,病变节段以下中枢性瘫,可伴尿!便功能障碍及分离性感觉障碍,夹层动脉瘤与缺血性卒中,24,脊髓前动脉夹层动脉瘤累及脊髓前动脉引起脊髓缺血,患者常出现剧,辅助检查,夹层动脉瘤与缺血性卒中,25,辅助检查夹层动脉瘤与缺血性卒中25,辅助检查,DSAMRI+MRACT+CTA

12、TCD,夹层动脉瘤与缺血性卒中,26,辅助检查DSA夹层动脉瘤与缺血性卒中26,DSA,数字减影血管造影术(DSA)是最可靠的诊断方法,但表现多样,同一患者在疾病不同时期可表现不同,夹层动脉瘤与缺血性卒中,27,DSA数字减影血管造影术(DSA)是最可靠的诊断方法,但表现,DSA,动脉不规则狭窄最常见,是较重要诊断依据,管腔呈不规则玫瑰花状(rosette sign)、线珠状(pearl and string sign)或呈波纹征(ripple sign),严重时呈线样征(string sign),也可见管腔完全闭塞Neurosurgery,1998,43:357-359.Stroke,199

13、7,28:370-374.J Neurosurg,1997,87:385-390.,夹层动脉瘤与缺血性卒中,28,DSA动脉不规则狭窄最常见,是较重要诊断依据,管腔呈不规则玫,DSA,双腔征(doublelumensign)极少见,是最典型且有诊断意义的表现,造影剂呈双重充盈,真腔(真正动脉管腔)与血管内膜下假腔同时充盈血管狭窄或完全闭塞,伴近端扩张及造影剂滞留可作为诊断的重要依据,因其他脑血管病变很少血管扩张与相邻部位狭窄或闭塞同时出现,也很少出现造影剂滞留Neurosurgery,1993,33:732-738.,夹层动脉瘤与缺血性卒中,29,DSA双腔征(doublelumensign)

14、极少见,是最典,DSA,其他少见征象包括内膜悬垂物(intimal flaps),常位于夹层近侧缘,还可见纤维肌肉发育不良、颈内动脉、大脑中动脉血流缓慢、栓塞引起远端或分支闭塞等。,夹层动脉瘤与缺血性卒中,30,DSA其他少见征象包括内膜悬垂物(intimal flaps,MRI,MRI检查可直接显示血管壁断面壁间血肿,可早期诊断,具有无创性、检出率高等优点,已成为诊断夹层动脉瘤的重要手段,但因无法发现微小病灶,且血流速度和出血时间对病灶信号影响较大,尚不可取代DSA,两者同时应用对诊断有互补作用AJR,2000,174:1137-114J Ultrasound Med,2000,19:263

15、-270.No To Shinkei,2002,54:2032211.,夹层动脉瘤与缺血性卒中,31,MRIMRI检查可直接显示血管壁断面壁间血肿,可早期诊断,具,MRI,壁间血肿:发病1周2个月T1加权像及质子像可见动脉壁呈新月状、曲线状、带状、点状或环状高信号(信号高低取决于出血时间及血肿大小),典型伴中心或偏心流空现象,称双腔征,属直接征象,可作为诊断确切依据No To Shinkei,2002,54:2032211.,夹层动脉瘤与缺血性卒中,32,MRI壁间血肿:发病1周2个月T1加权像及质子像可见动脉壁,MRI,T2加权像因脑脊液为高信号,较难辨认壁间血肿,应用增强的三维损坏性梯度回

16、波序列(3 dimensional spoiled gradient-recalled acquisition,3D-SPGR)扫描可使双腔检出率达87%Stroke,1997,28:370-374.,夹层动脉瘤与缺血性卒中,33,MRIT2加权像因脑脊液为高信号,较难辨认壁间血肿,应用增强,MRI,内膜悬垂物是动脉壁内膜夹层分离,T1、T2加权像和质子像可见高信号瓣状在血管腔中漂移,T2加权像更易见,夹层动脉瘤与缺血性卒中,34,MRI内膜悬垂物是动脉壁内膜夹层分离,T1、T2加权像和质子,MRA,磁共振血管造影(MRA)可无创性显示与传统血管造影相同的血管轮廓,对患者血管闭塞、线珠征、动脉

17、瘤样扩张和假性动脉瘤等有一定诊断价值,并可动态观察,但MRA不能发现小的夹层动脉瘤,不能精确显示狭窄程度,不能区分慢血流腔与壁间血肿,也不能显示双腔等特有征象。,夹层动脉瘤与缺血性卒中,35,MRA磁共振血管造影(MRA)可无创性显示与传统血管造影相同,CT,CT检查只能非特异显示颅内缺血性改变及蛛网膜下腔出血等,有报道动态螺旋CT血管造影,在检测颈内动脉夹层动脉瘤方面有高度灵敏性和特异性Stroke,1996,27:461-466.,夹层动脉瘤与缺血性卒中,36,CTCT检查只能非特异显示颅内缺血性改变及蛛网膜下腔出血等,TCD,经颅多普勒超声(TCD)可检测颈内动脉病变导致的颅内循环改变,

18、包括血流速度下降,侧支循环方式和远端栓子等,但检出夹层动脉瘤较差,夹层动脉瘤与缺血性卒中,37,TCD经颅多普勒超声(TCD)可检测颈内动脉病变导致的颅内循,诊断和鉴别诊断,夹层动脉瘤与缺血性卒中,38,诊断和鉴别诊断夹层动脉瘤与缺血性卒中38,诊断,夹层动脉瘤引起缺血性卒中临床表现缺乏特异性,诊断主要依据影像学所见脑缺血患者出现过度剧烈头痛或颈痛常为诊断线索40岁以下年轻患者,尤其婴幼儿急性脑卒中者应想到患本病可能,夹层动脉瘤与缺血性卒中,39,诊断夹层动脉瘤引起缺血性卒中临床表现缺乏特异性,诊断主要依据,诊断,临床确诊须根据DSA及MR等检查DSA显示双腔征、线珠征、血管完全闭塞伴近端扩张

19、、造影剂滞留等是可靠的诊断证据MRI的T1加权像发现动脉壁内血肿、T2加权像发现内膜悬垂物或增强3D2SPGR扫描提示动脉双腔或动脉壁及内膜强化即可诊断,夹层动脉瘤与缺血性卒中,40,诊断临床确诊须根据DSA及MR等检查夹层动脉瘤与缺血性卒中4,鉴别诊断,动脉粥样硬化性脑血栓形成动脉粥样硬化是缺血性卒中最常见的危险因素,多见于中老年人,常合并高血压病、糖尿病等,动脉造影表现单纯狭窄或闭塞,且狭窄则呈缓慢进展,很少在短时间内出现闭塞或恢复正常的戏剧性变化夹层动脉瘤则随壁间血肿吸收或增大,病变特征可消失、加重或由不典型变为典型其他动脉瘤夹层动脉瘤DSA显示管腔狭窄伴近端扩张,易误诊为囊状动脉瘤伴动

20、脉痉挛,但夹层动脉瘤血管狭窄不规则,而血管痉挛是规则的,夹层动脉瘤与缺血性卒中,41,鉴别诊断动脉粥样硬化性脑血栓形成夹层动脉瘤与缺血性卒中41,治疗,夹层动脉瘤与缺血性卒中,42,治疗夹层动脉瘤与缺血性卒中42,诊治流程,夹层动脉瘤与缺血性卒中,43,诊治流程夹层动脉瘤与缺血性卒中43,对症治疗,对仅有缺血症状、无蛛网膜下腔出血的患者,应避免引起血压及颅内压增高的诱因(如用力排便、咳嗽、喷嚏和情绪激动等),严重高血压210/130mmHg可适度降压,减少夹层动脉瘤扩张和蛛网膜下腔出血机会头痛时可用止痛药,保持通便可用缓泻剂等,夹层动脉瘤与缺血性卒中,44,对症治疗对仅有缺血症状、无蛛网膜下腔

21、出血的患者,应避免引起血,溶栓治疗,颈内动脉颅外段夹层动脉瘤患者发病6小时内可考虑动脉内溶栓,但须权衡出血风险DSA直视下超选择介入动脉溶栓,可超越病变部位直接作用于远端血栓,夹层动脉瘤与缺血性卒中,45,溶栓治疗颈内动脉颅外段夹层动脉瘤患者发病6小时内可考虑动脉内,抗凝及抗血小板治疗,颅外段夹层动脉瘤急性期首选肝素钠100mg加入0.9%生理盐水500ml静脉滴注,连用35天,后可用低分子肝素710天,继之以华法林口服维持抗凝禁忌患者可用抗血小板药。患者3个月时复查DSA决定下一步治疗。严重管腔不规则者可继续抗凝治疗,6个月时再复查DSA;轻度管腔不规则或管腔完全闭塞可用抗血小板药物。血管表

22、现正常也可用抗血小板药如脑缺血再发或出现局部神经压迫,可手术或血管内治疗,夹层动脉瘤与缺血性卒中,46,抗凝及抗血小板治疗颅外段夹层动脉瘤夹层动脉瘤与缺血性卒中46,抗凝及抗血小板治疗,颅内段夹层动脉瘤因较易发生蛛网膜下腔出血,抗凝要谨慎患者仅表现缺血症状,而无蛛网膜下腔出血可抗凝预防原位血栓扩展和动脉-动脉血栓栓塞。如临床病程和DSA提示复发的动脉-动脉栓塞或大的急性血栓,可早期使用肝素钠和华法林,并考虑外科或血管内闭塞手术,夹层动脉瘤与缺血性卒中,47,抗凝及抗血小板治疗颅内段夹层动脉瘤夹层动脉瘤与缺血性卒中47,外科及介入治疗,颈内动脉颅外段夹层动脉瘤病灶局限、手术易接近,内科治疗效果不

23、佳,或夹层动脉瘤逐渐增大引起进行性脑功能障碍时可考虑外科治疗常采用动脉瘤切除和颈动脉重建术,夹层动脉瘤与缺血性卒中,48,外科及介入治疗颈内动脉颅外段夹层动脉瘤夹层动脉瘤与缺血性卒中,外科及介入治疗,颈内动脉颅内段夹层动脉瘤可采用血管成形术,包括球囊扩张和放置支架如表现进行性血流动力学障碍,对适度扩容无反应,可考虑外科搭桥术,夹层动脉瘤与缺血性卒中,49,外科及介入治疗颈内动脉颅内段夹层动脉瘤夹层动脉瘤与缺血性卒中,外科及介入治疗,椎动脉夹层动脉瘤非优势侧椎动脉受累,因对侧常能充分代偿,可夹闭或采用弹簧圈、球囊等血管内介入治疗优势侧受累可行试验性球囊阻塞,如能很好耐受可施行闭塞术,夹层动脉瘤与

24、缺血性卒中,50,外科及介入治疗椎动脉夹层动脉瘤夹层动脉瘤与缺血性卒中50,预后,夹层动脉瘤与缺血性卒中,51,预后夹层动脉瘤与缺血性卒中51,预后,颅外段夹层动脉瘤预后较好,10年预期生存率为92%，70%80%的患者可恢复正常或遗留轻度神经功能缺失症状颅内动脉夹层动脉瘤致死率、致残率高, 75%的患者死亡,幸存者中半数遗留中、重度神经功能缺失,夹层动脉瘤与缺血性卒中,52,预后颅外段夹层动脉瘤预后较好,10年预期生存率为92%，70,病例讨论,夹层动脉瘤与缺血性卒中,53,病例讨论夹层动脉瘤与缺血性卒中53,CASE1,47岁男性患者，钓鱼过程中突发眩晕，立即送医院，当时查体仅仅存在眼球震

25、颤立即CT无异常发病后24小时突然头痛恶心呕吐复查CT提示双侧小脑半球梗死18小时后突发意识丧失，复查CT提示SAHDSA过程中死亡,Neurosurgery. 43(2):357-359, August 1998.,夹层动脉瘤与缺血性卒中,54,CASE147岁男性患者，钓鱼过程中突发眩晕，立即送医院，当,CASE1,A：anteroposterior view angiogram of the right vertebral artery, revealing an aneurysmal dilation of the proximal portion of the PICA, with

26、pearl-and-string sign. B： lateral view angiogram of the vertebral artery, depicting an irregular narrowing of the PICA,夹层动脉瘤与缺血性卒中,55,CASE1A：anteroposterior view an,尸体解剖,SAH双侧小脑半球肿胀小脑扁桃体疝右侧PICA近心端5mm处发现动脉瘤-不规则扩张，远端腊肠样改变左侧PICA腊肠样改变双侧PICA可以看到血栓形成，中层和外膜之间壁内血肿，没有发现夹层的入口,夹层动脉瘤与缺血性卒中,56,尸体解剖SAH夹层动脉瘤与缺血性卒中

27、56,病理,Photomicrographs of the PICAs(elastica van Giesons stain; original magnification, 20).A： massive intramural hemorrhage of the right PICA B, intramural hemorrhage of the left PICA (H, intramural hemorrhage;T, true lumen).,夹层动脉瘤与缺血性卒中,57,病理Photomicrographs of the PICA,CASE2,夹层动脉瘤与缺血性卒中,58,CASE2夹

28、层动脉瘤与缺血性卒中58,CASE3,夹层动脉瘤与缺血性卒中,59,CASE3夹层动脉瘤与缺血性卒中59,CASE3,夹层动脉瘤与缺血性卒中,60,CASE3夹层动脉瘤与缺血性卒中60,CASE3,夹层动脉瘤与缺血性卒中,61,CASE3夹层动脉瘤与缺血性卒中61,CASE3,夹层动脉瘤与缺血性卒中,62,CASE3夹层动脉瘤与缺血性卒中62,CASE4,夹层动脉瘤与缺血性卒中,63,CASE4夹层动脉瘤与缺血性卒中63,CASE5,夹层动脉瘤与缺血性卒中,64,CASE5夹层动脉瘤与缺血性卒中64,CASE5,夹层动脉瘤与缺血性卒中,65,CASE5夹层动脉瘤与缺血性卒中65,CASE5,夹

29、层动脉瘤与缺血性卒中,66,CASE5夹层动脉瘤与缺血性卒中66,CASE5,夹层动脉瘤与缺血性卒中,67,CASE5夹层动脉瘤与缺血性卒中67,CASE6,夹层动脉瘤与缺血性卒中,68,CASE6夹层动脉瘤与缺血性卒中68,夹层动脉瘤与缺血性卒中,69,夹层动脉瘤与缺血性卒中69,夹层动脉瘤与缺血性卒中,70,夹层动脉瘤与缺血性卒中70,夹层动脉瘤与缺血性卒中,71,夹层动脉瘤与缺血性卒中71,夹层动脉瘤与缺血性卒中,72,夹层动脉瘤与缺血性卒中72,夹层动脉瘤与缺血性卒中,73,夹层动脉瘤与缺血性卒中73,夹层动脉瘤与缺血性卒中,74,夹层动脉瘤与缺血性卒中74,夹层动脉瘤与缺血性卒中,7

30、5,夹层动脉瘤与缺血性卒中75,夹层动脉瘤与缺血性卒中,76,夹层动脉瘤与缺血性卒中76,夹层动脉瘤与缺血性卒中,77,夹层动脉瘤与缺血性卒中77,夹层动脉瘤与缺血性卒中,78,夹层动脉瘤与缺血性卒中78,Dissection of the ICA. a, Conventional angiography initially demonstrated a tapered stenosis of the ICA distal to the bifurcation. b, Baseline 2D TOF MRA obtained 2 days later revealed concordant e

31、vidence of a tapered stenosis. c, Follow-up 2D TOF MRA obtained 5 months later had normalized.,夹层动脉瘤与缺血性卒中,79,Dissection of the ICA. a, Conv,Dissection of the vertebral artery. a, Conventional angiography showed a well-defined dissection with a prominent intimal flap, mural hematoma, and luminal irr

32、egularity. b, Baseline 3D phase-contrast MRA showed a nonspecific flow abnormality in the midvertebral artery with associated luminal irregularity consistent with the diagnosis of dissection. c, Follow-up 3D phase-contrast MRA obtained 3 months later revealed a normal vertebral artery.,夹层动脉瘤与缺血性卒中,8

33、0,Dissection of the vertebral ar,夹层动脉瘤与缺血性卒中,81,夹层动脉瘤与缺血性卒中81,Left carotid dissection with tapered long stenosis on conventional angiography (top). The external diameter of the carotid artery is enlarged on helical CT (bottom), and the arterial lumen appears eccentric (arrow) because of the arterial

34、 wall thickening (mural hematoma; arrowhead). The level of the CT slice is indicated on the angiogram (arrow).,夹层动脉瘤与缺血性卒中,82,Left carotid dissection with t,Internal carotid artery (ICA) dissection with aneurysm at the upper portion of the right ICA on angiography (top) and helical CT findings (bott

35、om) showing both narrowed eccentric lumen (arrow) and aneurysm (arrowhead).,夹层动脉瘤与缺血性卒中,83,Internal carotid artery (ICA),Typical target CT picture of dissection of the left internal carotid artery associating an arterial wall thickening (straight arrow) and a narrowed eccentric lumen (arrowhead) sur

36、rounded by a thin annular contrast enhancement (curved arrow).,夹层动脉瘤与缺血性卒中,84,Typical target CT picture of d,Occlusive type dissection of the left internal carotid artery (ICA) on angiography (top) and helical CT (bottom) with increased external diameter (arrow) of the ICA compared with the contrala

37、teral site (arrowhead). The measurements were made just below the petrous bone.,夹层动脉瘤与缺血性卒中,85,Occlusive type dissection of t,夹层动脉瘤与缺血性卒中,86,夹层动脉瘤与缺血性卒中86,夹层动脉瘤与缺血性卒中,87,夹层动脉瘤与缺血性卒中87,夹层动脉瘤与缺血性卒中,88,夹层动脉瘤与缺血性卒中88,夹层动脉瘤与缺血性卒中,89,夹层动脉瘤与缺血性卒中89,夹层动脉瘤与缺血性卒中,90,夹层动脉瘤与缺血性卒中90,夹层动脉瘤与缺血性卒中,91,夹层动脉瘤与缺血性卒中91,

38、夹层动脉瘤与缺血性卒中,92,夹层动脉瘤与缺血性卒中92,a, T2-weighted axial MR images on day 7 after the initial ischemic attack show dilatation of both vertebral arteries (left greater than right). The linear high-intensity structures (arrows) demonstrate intimal flaps on both sides (double lumen). b, T1-weighted axial imag

39、es of the lower slice reveal intramural thrombus (arrow). c, MR angiogram taken on the same day shows fusiform dilatation of both vertebral arteries (arrows). d, Anteroposterior angiogram of the left vertebral artery performed on day 20 shows sausagelike swelling of the left vertebral artery (arrow)

40、. The basilar artery is poorly opacified (arrowhead). e, Angiogram performed on day 35 shows that the left vertebral artery has become more stenotic. The basilar artery is opacified very faintly (arrowhead). The fusiform dilatation did not change (arrow). The venous phase reveals retained contrast m

41、aterial (not shown). f, Nine months after the onset the left vertebral artery is totally occluded (arrow) at the origin of the posterior inferior cerebellar artery (arrowhead). The right vertebral artery still shows slight fusiform dilatation, through which the basilar artery is well demonstrated (n

42、ot shown).,夹层动脉瘤与缺血性卒中,93,a, T2-weighted axial MR images,a, MRI (proton image) shows a dilated right vertebral artery. An intimal flap (arrow) and the orifice are demonstrated. b, The aneurysm, which was demonstrated at the time of admission, is still evident after 2.5 years of follow-up (arrow). c, The persistent aneurysmal dilatation was successfully embolized with the use of an interlocking detachable coil (Target Therapeutics) (arrow).,夹层动脉瘤与缺血性卒中,94,a, MRI (proton image) shows a,听得让你辛苦了,夹层动脉瘤与缺血性卒中,95,听得让你辛苦了夹层动脉瘤与缺血性卒中95,