脑血管夹层诊断与治疗

第三军医大学第一附属医院神经内科 重庆市缺血性卒中介入诊治研究所 陈康宁

Epidemiologic Features
2.5-3/10,000/year in the United States and France Large hospital, the incidence of spontaneous vertebral-artery dissection can be estimated at 1~1.5/100,000/year Account for only about 2% of all ischemic strokes and for 10~25% of young and middle-aged patients There is a distinct peak in the fifth decade of life Women are on average about five years younger than men at the time of the dissection

Epidemiologic Features
extracranial segments of the vertebral arteries are much more likely to undergo dissection greater mobility of the extracranial internal carotid and vertebral arteries May be injured by contact with bony structures, such as the cervical vertebrae or the styloid process.

Pathogenesis
Genetic Factors ：
Structural defect of the arterial wall, such as Ehlers–Danlos syndrome type IV, Marfan's syndrome Family histories FMD are found in about 15% of patients Ultrastructural abnormalities of dermal connective-tissue components have been detected in two thirds of patients

Pathogenesis
Environmental Factors ：
"bottoms-up dissection" "beauty-parlor stroke." hyperextension or rotation of the neck include practicing yoga, painting a ceiling, coughing, vomiting, sneezing, the receipt of anesthesia, and the act of resuscitation. Chiropractic manipulation of the neck A recent history of a respiratory tract infection common risk factors for vascular disease, such as tobacco use, hypertension, and the use of oral contraceptives

200例颈-椎动脉夹层患者的临床表现
ICAD（163） headache ischemia Horner’s syndrome asymptomatic 117（72%） 103（63%） 60（37%） 8（5%） 10（20%） VAD（50） 35（70%） 32（64%）

颈部血管夹层的影像学
MRI：夹层的血肿/血栓，增强更加明显 ： DSA 动脉不规则狭窄、管腔呈不规则玫瑰花状、线珠状、呈波纹 征、呈线样征、管腔完全闭塞 双腔征：造影剂呈双重充盈 血管狭窄或完全闭塞，伴近端扩张及造影剂滞留 血管扩张与相邻部位狭窄或闭塞 其他少见征象包括内膜悬垂物

Prognosis
Death rate<5%, and about 3/4 of patients who have had a stroke make a good functional recovery Headache associated with dissection resolves within a week in about 90% of patients, but in a few patients it can persist for many years The risk of a recurrent dissection in an initially unaffected artery is about 2% during the first month but then decreases to a rate of only about 1% per year

Treatment
anticoagulation with intravenous heparin followed by oral warfarin has been recommended for all patients with acute dissections continue anticoagulant therapy for three more months if luminal irregularities are found Surgical or endovascular treatment should be reserved for patients who have persistent symptoms of ischemia despite adequate anticoagulation.