1、夾層動(dòng)脈瘤與缺血性卒中夾層動(dòng)脈瘤與缺血性卒中1夾層動(dòng)脈瘤與缺血性卒中夾層動(dòng)脈瘤與缺血性卒中1定義 夾層動(dòng)脈瘤(dissecting aneurysm)又稱動(dòng)脈剝離(arter dissection),是血液進(jìn)入動(dòng)脈壁形成血腫或動(dòng)脈壁內(nèi)自發(fā)性血腫,使血管壁間剝離,導(dǎo)致動(dòng)脈管腔狹窄或血管破裂。夾層動(dòng)脈瘤好發(fā)于主動(dòng)脈及大分支,約20%侵犯顱內(nèi)外血管與脊髓血管,引起腦部或脊髓癥狀?yuàn)A層動(dòng)脈瘤與缺血性卒中2定義 夾層動(dòng)脈瘤(dissecting aneurysm)又流行病學(xué)Tumbull(1915年)首例報(bào)道腦夾層動(dòng)脈瘤至今國(guó)內(nèi)外已有千余例報(bào)道腦夾層動(dòng)脈瘤人群年發(fā)病率約3/10萬,2%的缺血性卒中可能由本

2、病引起*50歲以下的缺血性卒中約10%的是夾層動(dòng)脈瘤所致*BesselmannM,VennemannB,LowensS,etal.Internal carotid artery dissectionJ.Neurology,2000,54:442.夾層動(dòng)脈瘤與缺血性卒中3流行病學(xué)Tumbull(1915年)首例報(bào)道腦夾層動(dòng)脈瘤*B病因與發(fā)病機(jī)制及病理夾層動(dòng)脈瘤與缺血性卒中4病因與發(fā)病機(jī)制及病理夾層動(dòng)脈瘤與缺血性卒中4病因基礎(chǔ)動(dòng)脈病纖維肌肉發(fā)育不良動(dòng)脈中層囊性變動(dòng)脈內(nèi)彈力層缺陷梅毒性動(dòng)脈炎多發(fā)性結(jié)節(jié)性動(dòng)脈炎煙霧病動(dòng)脈畸形馬凡綜合征系統(tǒng)性紅斑狼瘡以及動(dòng)脈硬化等夾層動(dòng)脈瘤與缺血性卒中5病因基礎(chǔ)動(dòng)脈病夾

3、層動(dòng)脈瘤與缺血性卒中5病因高血壓病輕微外傷,如頸部按摩推拿，過伸過曲及轉(zhuǎn)頭等動(dòng)作,甚至咳嗽、嘔吐、打噴嚏等也可引起椎動(dòng)脈夾層 Chung YS,Han DH.Vertebrobasilar dissection:a possible role of Whiplash injury in its pathogenesisJ.Neurol Res,2002,24:129-138偏頭痛Cephalalgia,2005, 25:575-580.夾層動(dòng)脈瘤與缺血性卒中6病因高血壓病夾層動(dòng)脈瘤與缺血性卒中6病因感染(如腦炎、腦膜炎等)口服避孕藥遺傳,血漿同型半胱氨酸水平升高以及THFR純合子(MTHFRT

4、T)基因型表達(dá)可能是夾層動(dòng)脈瘤發(fā)生的危險(xiǎn)因素Med Hypotheses,2005,64:1007-1010Stroke,2002,33:664-669.N Engl JMed,2001,344:898-906.夾層動(dòng)脈瘤與缺血性卒中7病因感染(如腦炎、腦膜炎等)夾層動(dòng)脈瘤與缺血性卒中7病因醫(yī)源性因素夾層動(dòng)脈瘤與缺血性卒中8病因醫(yī)源性因素夾層動(dòng)脈瘤與缺血性卒中8發(fā)病機(jī)制管腔狹窄或閉塞可導(dǎo)致腦缺血癥狀,但動(dòng)脈內(nèi)皮破損處繼發(fā)血栓形成,血栓片段脫落引起動(dòng)脈栓塞則是缺血發(fā)生的更主要機(jī)制Stroke,2004,35:482-485.動(dòng)脈造影及外科手術(shù)可見管腔內(nèi)易碎的血栓,或當(dāng)管腔狹窄對(duì)血流動(dòng)力學(xué)影響不大

5、時(shí)即發(fā)生的缺血癥狀,也為遠(yuǎn)端動(dòng)脈栓塞提供了間接證據(jù)夾層動(dòng)脈瘤與缺血性卒中9發(fā)病機(jī)制管腔狹窄或閉塞可導(dǎo)致腦缺血癥狀,但動(dòng)脈內(nèi)皮破損處繼發(fā)夾層動(dòng)脈瘤與缺血性卒中10夾層動(dòng)脈瘤與缺血性卒中10病理大體解剖常見動(dòng)脈內(nèi)膜下血腫,使內(nèi)彈力板與中層分離,導(dǎo)致管腔狹窄少見血腫位于動(dòng)脈外膜下層,引起動(dòng)脈擴(kuò)張(動(dòng)脈瘤),如繼續(xù)向外擴(kuò)張并穿過外膜可引起蛛網(wǎng)膜下腔出血夾層動(dòng)脈瘤還可累及脊髓前動(dòng)脈而引起脊髓癥狀?yuàn)A層動(dòng)脈瘤與缺血性卒中11病理大體解剖常見動(dòng)脈內(nèi)膜下血腫,使內(nèi)彈力板與中層分離,導(dǎo)致管病理夾層動(dòng)脈瘤近心端?？梢娧軆?nèi)膜與內(nèi)彈力板的撕裂口,遠(yuǎn)心端可發(fā)現(xiàn)血管腔內(nèi)穿破口鏡下可見血腫位于內(nèi)彈力板與中膜間,兩者剝離并向

6、對(duì)側(cè)管壁移位,血管腔被擠成裂隙狀或完全閉塞顱內(nèi)夾層動(dòng)脈瘤由于缺乏發(fā)育良好的外彈力膜,較易破裂夾層動(dòng)脈瘤與缺血性卒中12病理夾層動(dòng)脈瘤近心端?？梢娧軆?nèi)膜與內(nèi)彈力板的撕裂口,遠(yuǎn)心端夾層動(dòng)脈瘤與缺血性卒中13夾層動(dòng)脈瘤與缺血性卒中13臨床表現(xiàn)夾層動(dòng)脈瘤與缺血性卒中14臨床表現(xiàn)夾層動(dòng)脈瘤與缺血性卒中14夾層動(dòng)脈瘤與缺血性卒中15夾層動(dòng)脈瘤與缺血性卒中15夾層動(dòng)脈瘤與缺血性卒中16夾層動(dòng)脈瘤與缺血性卒中16臨床表現(xiàn)多見于50歲以下年輕人,男性稍多,多數(shù)身體健康,無卒中危險(xiǎn)因素,常在某動(dòng)脈區(qū)劇烈疼痛后出現(xiàn)相應(yīng)神經(jīng)功能缺失癥狀,臨床表現(xiàn)因受累動(dòng)脈而異。有人將夾層動(dòng)脈瘤稱為/健康青年人的腦梗死Neuropa

7、thology,2000,20:85290.夾層動(dòng)脈瘤與缺血性卒中17臨床表現(xiàn)多見于50歲以下年輕人,男性稍多,多數(shù)身體健康,無卒頸內(nèi)動(dòng)脈顱外段夾層動(dòng)脈瘤較常見典型表現(xiàn)突發(fā)劇烈頭頸部疼痛,多為脹痛,可有同側(cè)頭皮觸痛發(fā)病數(shù)小時(shí)至數(shù)日出現(xiàn)腦缺血癥狀,如偏癱、失語、意識(shí)障礙以至昏迷,36天癥狀達(dá)高峰,急性起病者24h內(nèi)病情可達(dá)高峰,甚至死亡40%50%的病例伴頸內(nèi)動(dòng)脈系統(tǒng)短暫性腦缺血發(fā)作(TIA)及同側(cè)不完全Horner征,后者是沿頸內(nèi)動(dòng)脈壁走行的交感神經(jīng)纖維受累所致Neurologist,1997,3:104-119.夾層動(dòng)脈瘤與缺血性卒中18頸內(nèi)動(dòng)脈顱外段夾層動(dòng)脈瘤較常見夾層動(dòng)脈瘤與缺血性卒中1

8、8頸內(nèi)動(dòng)脈顱外段夾層動(dòng)脈瘤25%的患者以搏動(dòng)性耳鳴或主觀性雜音為突出癥狀,偶見同側(cè)腦神經(jīng)麻痹,如舌下神經(jīng)受損引起舌肌麻痹,也可累及舌咽神經(jīng),迷走神經(jīng),副神經(jīng)和三叉神經(jīng)等,通常是動(dòng)脈外膜下夾層動(dòng)脈瘤侵占頸部咽旁間隔所致表現(xiàn)頸部腫脹和閃光暗點(diǎn)等少見,也可為單側(cè)頸部、面部或頭部疼痛和眼交感神經(jīng)麻痹,但無腦缺血癥狀?yuàn)A層動(dòng)脈瘤與缺血性卒中19頸內(nèi)動(dòng)脈顱外段夾層動(dòng)脈瘤25%的患者以搏動(dòng)性耳鳴或主觀性雜音頸內(nèi)動(dòng)脈系統(tǒng)顱內(nèi)段夾層動(dòng)脈瘤較少見頸內(nèi)動(dòng)脈顱內(nèi)段或大腦中動(dòng)脈主干均可受累主要表現(xiàn)大腦半球缺血癥狀常先出現(xiàn)同側(cè)嚴(yán)重頭痛,預(yù)示動(dòng)脈壁剝離有時(shí)以癇性發(fā)作或意識(shí)障礙起病,隨即發(fā)生神經(jīng)功能缺失數(shù)日內(nèi)癥狀逐漸進(jìn)展,可發(fā)

9、展為完全性卒中,多數(shù)患者數(shù)日或數(shù)周內(nèi)死亡,幸存者中半數(shù)遺留中、重度神經(jīng)功能缺失約20%的患者發(fā)生蛛網(wǎng)膜下腔出血夾層動(dòng)脈瘤與缺血性卒中20頸內(nèi)動(dòng)脈系統(tǒng)顱內(nèi)段夾層動(dòng)脈瘤較少見夾層動(dòng)脈瘤與缺血性卒中20椎動(dòng)脈顱外段夾層動(dòng)脈瘤較常見多與頸部按摩或扭轉(zhuǎn)等動(dòng)作有關(guān)椎動(dòng)脈在C1、C2水平活動(dòng)度最大,也最易受損典型表現(xiàn)突然發(fā)生后枕部嚴(yán)重疼痛繼而出現(xiàn)枕葉、腦干和小腦等部位缺血癥狀,如暈眩、惡心、嘔吐、眼震及共濟(jì)失調(diào)等約1/3的患者發(fā)生延髓背外側(cè)綜合征單側(cè)椎動(dòng)脈阻塞因?qū)?cè)代償,可不引起缺血癥狀?yuàn)A層動(dòng)脈瘤與缺血性卒中21椎動(dòng)脈顱外段夾層動(dòng)脈瘤較常見夾層動(dòng)脈瘤與缺血性卒中21椎動(dòng)脈顱內(nèi)段夾層動(dòng)脈瘤少見約占顱內(nèi)、外夾層

10、動(dòng)脈瘤的5%易發(fā)生蛛網(wǎng)膜下腔出血約1/3的患者出現(xiàn)腦干、小腦或大腦半球梗死1/10的患者為蛛網(wǎng)膜下腔出血合并腦梗死,偶可表現(xiàn)占位效應(yīng),壓迫腦干和下位腦神經(jīng)Neurosurgery,2002,51:9302937.夾層動(dòng)脈瘤與缺血性卒中22椎動(dòng)脈顱內(nèi)段夾層動(dòng)脈瘤少見夾層動(dòng)脈瘤與缺血性卒中22基底動(dòng)脈夾層動(dòng)脈瘤極少見可引起腦神經(jīng)麻痹、交叉癱或四肢癱,甚至腦膜刺激征,嚴(yán)重者突發(fā)腦干缺血,可迅速死亡,也可表現(xiàn)TIA、小灶性梗死和蛛網(wǎng)膜下腔出血等夾層動(dòng)脈瘤與缺血性卒中23基底動(dòng)脈夾層動(dòng)脈瘤極少見夾層動(dòng)脈瘤與缺血性卒中23脊髓前動(dòng)脈夾層動(dòng)脈瘤累及脊髓前動(dòng)脈引起脊髓缺血,患者常出現(xiàn)劇烈根痛或頸肩部疼痛。癱瘓

11、多在疼痛出現(xiàn)后數(shù)小時(shí)達(dá)高峰,左右可不對(duì)稱。早期為脊髓休克期,表現(xiàn)肌張力減低,腱反射消失等;休克期后出現(xiàn)病變節(jié)段周圍性癱,病變節(jié)段以下中樞性癱,可伴尿!便功能障礙及分離性感覺障礙夾層動(dòng)脈瘤與缺血性卒中24脊髓前動(dòng)脈夾層動(dòng)脈瘤累及脊髓前動(dòng)脈引起脊髓缺血,患者常出現(xiàn)劇輔助檢查夾層動(dòng)脈瘤與缺血性卒中25輔助檢查夾層動(dòng)脈瘤與缺血性卒中25輔助檢查DSAMRI+MRACT+CTATCD夾層動(dòng)脈瘤與缺血性卒中26輔助檢查DSA夾層動(dòng)脈瘤與缺血性卒中26DSA數(shù)字減影血管造影術(shù)(DSA)是最可靠的診斷方法,但表現(xiàn)多樣,同一患者在疾病不同時(shí)期可表現(xiàn)不同夾層動(dòng)脈瘤與缺血性卒中27DSA數(shù)字減影血管造影術(shù)(DSA)

12、是最可靠的診斷方法,但表現(xiàn)DSA動(dòng)脈不規(guī)則狹窄最常見,是較重要診斷依據(jù),管腔呈不規(guī)則玫瑰花狀(rosette sign)、線珠狀(pearl and string sign)或呈波紋征(ripple sign),嚴(yán)重時(shí)呈線樣征(string sign),也可見管腔完全閉塞Neurosurgery,1998,43:357-359.Stroke,1997,28:370-374.J Neurosurg,1997,87:385-390.夾層動(dòng)脈瘤與缺血性卒中28DSA動(dòng)脈不規(guī)則狹窄最常見,是較重要診斷依據(jù),管腔呈不規(guī)則玫DSA雙腔征(doublelumensign)極少見,是最典型且有診斷意義的表現(xiàn),

13、造影劑呈雙重充盈,真腔(真正動(dòng)脈管腔)與血管內(nèi)膜下假腔同時(shí)充盈血管狹窄或完全閉塞,伴近端擴(kuò)張及造影劑滯留可作為診斷的重要依據(jù),因其他腦血管病變很少血管擴(kuò)張與相鄰部位狹窄或閉塞同時(shí)出現(xiàn),也很少出現(xiàn)造影劑滯留Neurosurgery,1993,33:732-738.夾層動(dòng)脈瘤與缺血性卒中29DSA雙腔征(doublelumensign)極少見,是最典DSA其他少見征象包括內(nèi)膜懸垂物(intimal flaps),常位于夾層近側(cè)緣,還可見纖維肌肉發(fā)育不良、頸內(nèi)動(dòng)脈、大腦中動(dòng)脈血流緩慢、栓塞引起遠(yuǎn)端或分支閉塞等。夾層動(dòng)脈瘤與缺血性卒中30DSA其他少見征象包括內(nèi)膜懸垂物(intimal flapsMR

14、IMRI檢查可直接顯示血管壁斷面壁間血腫,可早期診斷,具有無創(chuàng)性、檢出率高等優(yōu)點(diǎn),已成為診斷夾層動(dòng)脈瘤的重要手段,但因無法發(fā)現(xiàn)微小病灶,且血流速度和出血時(shí)間對(duì)病灶信號(hào)影響較大,尚不可取代DSA,兩者同時(shí)應(yīng)用對(duì)診斷有互補(bǔ)作用AJR,2000,174:1137-114J Ultrasound Med,2000,19:263-270.No To Shinkei,2002,54:2032211.夾層動(dòng)脈瘤與缺血性卒中31MRIMRI檢查可直接顯示血管壁斷面壁間血腫,可早期診斷,具M(jìn)RI壁間血腫:發(fā)病1周2個(gè)月T1加權(quán)像及質(zhì)子像可見動(dòng)脈壁呈新月狀、曲線狀、帶狀、點(diǎn)狀或環(huán)狀高信號(hào)(信號(hào)高低取決于出血時(shí)間及

15、血腫大小),典型伴中心或偏心流空現(xiàn)象,稱雙腔征,屬直接征象,可作為診斷確切依據(jù)No To Shinkei,2002,54:2032211.夾層動(dòng)脈瘤與缺血性卒中32MRI壁間血腫:發(fā)病1周2個(gè)月T1加權(quán)像及質(zhì)子像可見動(dòng)脈壁MRIT2加權(quán)像因腦脊液為高信號(hào),較難辨認(rèn)壁間血腫,應(yīng)用增強(qiáng)的三維損壞性梯度回波序列(3 dimensional spoiled gradient-recalled acquisition,3D-SPGR)掃描可使雙腔檢出率達(dá)87%Stroke,1997,28:370-374.夾層動(dòng)脈瘤與缺血性卒中33MRIT2加權(quán)像因腦脊液為高信號(hào),較難辨認(rèn)壁間血腫,應(yīng)用增強(qiáng)MRI內(nèi)膜懸垂

16、物是動(dòng)脈壁內(nèi)膜夾層分離,T1、T2加權(quán)像和質(zhì)子像可見高信號(hào)瓣?duì)钤谘芮恢衅?T2加權(quán)像更易見夾層動(dòng)脈瘤與缺血性卒中34MRI內(nèi)膜懸垂物是動(dòng)脈壁內(nèi)膜夾層分離,T1、T2加權(quán)像和質(zhì)子MRA磁共振血管造影(MRA)可無創(chuàng)性顯示與傳統(tǒng)血管造影相同的血管輪廓,對(duì)患者血管閉塞、線珠征、動(dòng)脈瘤樣擴(kuò)張和假性動(dòng)脈瘤等有一定診斷價(jià)值,并可動(dòng)態(tài)觀察,但MRA不能發(fā)現(xiàn)小的夾層動(dòng)脈瘤,不能精確顯示狹窄程度,不能區(qū)分慢血流腔與壁間血腫,也不能顯示雙腔等特有征象。夾層動(dòng)脈瘤與缺血性卒中35MRA磁共振血管造影(MRA)可無創(chuàng)性顯示與傳統(tǒng)血管造影相同CTCT檢查只能非特異顯示顱內(nèi)缺血性改變及蛛網(wǎng)膜下腔出血等,有報(bào)道動(dòng)態(tài)螺旋

17、CT血管造影,在檢測(cè)頸內(nèi)動(dòng)脈夾層動(dòng)脈瘤方面有高度靈敏性和特異性Stroke,1996,27:461-466.夾層動(dòng)脈瘤與缺血性卒中36CTCT檢查只能非特異顯示顱內(nèi)缺血性改變及蛛網(wǎng)膜下腔出血等,TCD經(jīng)顱多普勒超聲(TCD)可檢測(cè)頸內(nèi)動(dòng)脈病變導(dǎo)致的顱內(nèi)循環(huán)改變,包括血流速度下降,側(cè)支循環(huán)方式和遠(yuǎn)端栓子等,但檢出夾層動(dòng)脈瘤較差?yuàn)A層動(dòng)脈瘤與缺血性卒中37TCD經(jīng)顱多普勒超聲(TCD)可檢測(cè)頸內(nèi)動(dòng)脈病變導(dǎo)致的顱內(nèi)循診斷和鑒別診斷夾層動(dòng)脈瘤與缺血性卒中38診斷和鑒別診斷夾層動(dòng)脈瘤與缺血性卒中38診斷夾層動(dòng)脈瘤引起缺血性卒中臨床表現(xiàn)缺乏特異性,診斷主要依據(jù)影像學(xué)所見腦缺血患者出現(xiàn)過度劇烈頭痛或頸痛常為診

18、斷線索40歲以下年輕患者,尤其嬰幼兒急性腦卒中者應(yīng)想到患本病可能夾層動(dòng)脈瘤與缺血性卒中39診斷夾層動(dòng)脈瘤引起缺血性卒中臨床表現(xiàn)缺乏特異性,診斷主要依據(jù)診斷臨床確診須根據(jù)DSA及MR等檢查DSA顯示雙腔征、線珠征、血管完全閉塞伴近端擴(kuò)張、造影劑滯留等是可靠的診斷證據(jù)MRI的T1加權(quán)像發(fā)現(xiàn)動(dòng)脈壁內(nèi)血腫、T2加權(quán)像發(fā)現(xiàn)內(nèi)膜懸垂物或增強(qiáng)3D2SPGR掃描提示動(dòng)脈雙腔或動(dòng)脈壁及內(nèi)膜強(qiáng)化即可診斷夾層動(dòng)脈瘤與缺血性卒中40診斷臨床確診須根據(jù)DSA及MR等檢查夾層動(dòng)脈瘤與缺血性卒中4鑒別診斷動(dòng)脈粥樣硬化性腦血栓形成動(dòng)脈粥樣硬化是缺血性卒中最常見的危險(xiǎn)因素,多見于中老年人,常合并高血壓病、糖尿病等,動(dòng)脈造影表現(xiàn)

19、單純狹窄或閉塞,且狹窄則呈緩慢進(jìn)展,很少在短時(shí)間內(nèi)出現(xiàn)閉塞或恢復(fù)正常的戲劇性變化夾層動(dòng)脈瘤則隨壁間血腫吸收或增大,病變特征可消失、加重或由不典型變?yōu)榈湫推渌麆?dòng)脈瘤夾層動(dòng)脈瘤DSA顯示管腔狹窄伴近端擴(kuò)張,易誤診為囊狀動(dòng)脈瘤伴動(dòng)脈痙攣,但夾層動(dòng)脈瘤血管狹窄不規(guī)則,而血管痙攣是規(guī)則的夾層動(dòng)脈瘤與缺血性卒中41鑒別診斷動(dòng)脈粥樣硬化性腦血栓形成夾層動(dòng)脈瘤與缺血性卒中41治療夾層動(dòng)脈瘤與缺血性卒中42治療夾層動(dòng)脈瘤與缺血性卒中42診治流程夾層動(dòng)脈瘤與缺血性卒中43診治流程夾層動(dòng)脈瘤與缺血性卒中43對(duì)癥治療對(duì)僅有缺血癥狀、無蛛網(wǎng)膜下腔出血的患者,應(yīng)避免引起血壓及顱內(nèi)壓增高的誘因(如用力排便、咳嗽、噴嚏和情緒

20、激動(dòng)等),嚴(yán)重高血壓210/130mmHg可適度降壓,減少夾層動(dòng)脈瘤擴(kuò)張和蛛網(wǎng)膜下腔出血機(jī)會(huì)頭痛時(shí)可用止痛藥,保持通便可用緩瀉劑等夾層動(dòng)脈瘤與缺血性卒中44對(duì)癥治療對(duì)僅有缺血癥狀、無蛛網(wǎng)膜下腔出血的患者,應(yīng)避免引起血溶栓治療頸內(nèi)動(dòng)脈顱外段夾層動(dòng)脈瘤患者發(fā)病6小時(shí)內(nèi)可考慮動(dòng)脈內(nèi)溶栓,但須權(quán)衡出血風(fēng)險(xiǎn)DSA直視下超選擇介入動(dòng)脈溶栓,可超越病變部位直接作用于遠(yuǎn)端血栓夾層動(dòng)脈瘤與缺血性卒中45溶栓治療頸內(nèi)動(dòng)脈顱外段夾層動(dòng)脈瘤患者發(fā)病6小時(shí)內(nèi)可考慮動(dòng)脈內(nèi)抗凝及抗血小板治療顱外段夾層動(dòng)脈瘤急性期首選肝素鈉100mg加入0.9%生理鹽水500ml靜脈滴注,連用35天,后可用低分子肝素710天,繼之以華法林口

21、服維持抗凝禁忌患者可用抗血小板藥?；颊?個(gè)月時(shí)復(fù)查DSA決定下一步治療。嚴(yán)重管腔不規(guī)則者可繼續(xù)抗凝治療,6個(gè)月時(shí)再?gòu)?fù)查DSA;輕度管腔不規(guī)則或管腔完全閉塞可用抗血小板藥物。血管表現(xiàn)正常也可用抗血小板藥如腦缺血再發(fā)或出現(xiàn)局部神經(jīng)壓迫,可手術(shù)或血管內(nèi)治療夾層動(dòng)脈瘤與缺血性卒中46抗凝及抗血小板治療顱外段夾層動(dòng)脈瘤夾層動(dòng)脈瘤與缺血性卒中46抗凝及抗血小板治療顱內(nèi)段夾層動(dòng)脈瘤因較易發(fā)生蛛網(wǎng)膜下腔出血,抗凝要謹(jǐn)慎患者僅表現(xiàn)缺血癥狀,而無蛛網(wǎng)膜下腔出血可抗凝預(yù)防原位血栓擴(kuò)展和動(dòng)脈-動(dòng)脈血栓栓塞。如臨床病程和DSA提示復(fù)發(fā)的動(dòng)脈-動(dòng)脈栓塞或大的急性血栓,可早期使用肝素鈉和華法林,并考慮外科或血管內(nèi)閉塞手術(shù)夾

22、層動(dòng)脈瘤與缺血性卒中47抗凝及抗血小板治療顱內(nèi)段夾層動(dòng)脈瘤夾層動(dòng)脈瘤與缺血性卒中47外科及介入治療頸內(nèi)動(dòng)脈顱外段夾層動(dòng)脈瘤病灶局限、手術(shù)易接近,內(nèi)科治療效果不佳,或夾層動(dòng)脈瘤逐漸增大引起進(jìn)行性腦功能障礙時(shí)可考慮外科治療常采用動(dòng)脈瘤切除和頸動(dòng)脈重建術(shù)夾層動(dòng)脈瘤與缺血性卒中48外科及介入治療頸內(nèi)動(dòng)脈顱外段夾層動(dòng)脈瘤夾層動(dòng)脈瘤與缺血性卒中外科及介入治療頸內(nèi)動(dòng)脈顱內(nèi)段夾層動(dòng)脈瘤可采用血管成形術(shù),包括球囊擴(kuò)張和放置支架如表現(xiàn)進(jìn)行性血流動(dòng)力學(xué)障礙,對(duì)適度擴(kuò)容無反應(yīng),可考慮外科搭橋術(shù)夾層動(dòng)脈瘤與缺血性卒中49外科及介入治療頸內(nèi)動(dòng)脈顱內(nèi)段夾層動(dòng)脈瘤夾層動(dòng)脈瘤與缺血性卒中外科及介入治療椎動(dòng)脈夾層動(dòng)脈瘤非優(yōu)勢(shì)側(cè)椎

23、動(dòng)脈受累,因?qū)?cè)常能充分代償,可夾閉或采用彈簧圈、球囊等血管內(nèi)介入治療優(yōu)勢(shì)側(cè)受累可行試驗(yàn)性球囊阻塞,如能很好耐受可施行閉塞術(shù)夾層動(dòng)脈瘤與缺血性卒中50外科及介入治療椎動(dòng)脈夾層動(dòng)脈瘤夾層動(dòng)脈瘤與缺血性卒中50預(yù)后夾層動(dòng)脈瘤與缺血性卒中51預(yù)后夾層動(dòng)脈瘤與缺血性卒中51預(yù)后顱外段夾層動(dòng)脈瘤預(yù)后較好,10年預(yù)期生存率為92%，70%80%的患者可恢復(fù)正?；蜻z留輕度神經(jīng)功能缺失癥狀顱內(nèi)動(dòng)脈夾層動(dòng)脈瘤致死率、致殘率高, 75%的患者死亡,幸存者中半數(shù)遺留中、重度神經(jīng)功能缺失夾層動(dòng)脈瘤與缺血性卒中52預(yù)后顱外段夾層動(dòng)脈瘤預(yù)后較好,10年預(yù)期生存率為92%，70病例討論夾層動(dòng)脈瘤與缺血性卒中53病例討論夾層

24、動(dòng)脈瘤與缺血性卒中53CASE147歲男性患者，釣魚過程中突發(fā)眩暈，立即送醫(yī)院，當(dāng)時(shí)查體僅僅存在眼球震顫立即CT無異常發(fā)病后24小時(shí)突然頭痛惡心嘔吐復(fù)查CT提示雙側(cè)小腦半球梗死18小時(shí)后突發(fā)意識(shí)喪失，復(fù)查CT提示SAHDSA過程中死亡Neurosurgery. 43(2):357-359, August 1998.夾層動(dòng)脈瘤與缺血性卒中54CASE147歲男性患者，釣魚過程中突發(fā)眩暈，立即送醫(yī)院，當(dāng)CASE1A：anteroposterior view angiogram of the right vertebral artery, revealing an aneurysmal dilati

25、on of the proximal portion of the PICA, with pearl-and-string sign. B： lateral view angiogram of the vertebral artery, depicting an irregular narrowing of the PICA 夾層動(dòng)脈瘤與缺血性卒中55CASE1A：anteroposterior view an尸體解剖SAH雙側(cè)小腦半球腫脹小腦扁桃體疝右側(cè)PICA近心端5mm處發(fā)現(xiàn)動(dòng)脈瘤-不規(guī)則擴(kuò)張，遠(yuǎn)端臘腸樣改變左側(cè)PICA臘腸樣改變雙側(cè)PICA可以看到血栓形成，中層和外膜之間壁內(nèi)血腫，沒有

26、發(fā)現(xiàn)夾層的入口夾層動(dòng)脈瘤與缺血性卒中56尸體解剖SAH夾層動(dòng)脈瘤與缺血性卒中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). 夾層動(dòng)脈瘤與缺血性卒中57病理Photomicrographs of th

27、e PICACASE2夾層動(dòng)脈瘤與缺血性卒中58CASE2夾層動(dòng)脈瘤與缺血性卒中58CASE3夾層動(dòng)脈瘤與缺血性卒中59CASE3夾層動(dòng)脈瘤與缺血性卒中59CASE3夾層動(dòng)脈瘤與缺血性卒中60CASE3夾層動(dòng)脈瘤與缺血性卒中60CASE3夾層動(dòng)脈瘤與缺血性卒中61CASE3夾層動(dòng)脈瘤與缺血性卒中61CASE3夾層動(dòng)脈瘤與缺血性卒中62CASE3夾層動(dòng)脈瘤與缺血性卒中62CASE4夾層動(dòng)脈瘤與缺血性卒中63CASE4夾層動(dòng)脈瘤與缺血性卒中63CASE5夾層動(dòng)脈瘤與缺血性卒中64CASE5夾層動(dòng)脈瘤與缺血性卒中64CASE5夾層動(dòng)脈瘤與缺血性卒中65CASE5夾層動(dòng)脈瘤與缺血性卒中65CASE5夾

28、層動(dòng)脈瘤與缺血性卒中66CASE5夾層動(dòng)脈瘤與缺血性卒中66CASE5夾層動(dòng)脈瘤與缺血性卒中67CASE5夾層動(dòng)脈瘤與缺血性卒中67CASE6夾層動(dòng)脈瘤與缺血性卒中68CASE6夾層動(dòng)脈瘤與缺血性卒中68夾層動(dòng)脈瘤與缺血性卒中69夾層動(dòng)脈瘤與缺血性卒中69夾層動(dòng)脈瘤與缺血性卒中70夾層動(dòng)脈瘤與缺血性卒中70夾層動(dòng)脈瘤與缺血性卒中71夾層動(dòng)脈瘤與缺血性卒中71夾層動(dòng)脈瘤與缺血性卒中72夾層動(dòng)脈瘤與缺血性卒中72夾層動(dòng)脈瘤與缺血性卒中73夾層動(dòng)脈瘤與缺血性卒中73夾層動(dòng)脈瘤與缺血性卒中74夾層動(dòng)脈瘤與缺血性卒中74夾層動(dòng)脈瘤與缺血性卒中75夾層動(dòng)脈瘤與缺血性卒中75夾層動(dòng)脈瘤與缺血性卒中76夾層動(dòng)

29、脈瘤與缺血性卒中76夾層動(dòng)脈瘤與缺血性卒中77夾層動(dòng)脈瘤與缺血性卒中77夾層動(dòng)脈瘤與缺血性卒中78夾層動(dòng)脈瘤與缺血性卒中78Dissection 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 evidence of a tapered stenosis. c, Follow-

30、up 2D TOF MRA obtained 5 months later had normalized. 夾層動(dòng)脈瘤與缺血性卒中79Dissection of the ICA. a, ConvDissection of the vertebral artery. a, Conventional angiography showed a well-defined dissection with a prominent intimal flap, mural hematoma, and luminal irregularity. b, Baseline 3D phase-contrast MRA

31、 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. 夾層動(dòng)脈瘤與缺血性卒中80Dissection of the vertebral ar夾層動(dòng)脈瘤與缺血性卒中81夾

32、層動(dòng)脈瘤與缺血性卒中81Left 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 wall thickening (mural hematoma; arrowhead). The

33、level of the CT slice is indicated on the angiogram (arrow). 夾層動(dòng)脈瘤與缺血性卒中82Left carotid dissection with tInternal carotid artery (ICA) dissection with aneurysm at the upper portion of the right ICA on angiography (top) and helical CT findings (bottom) showing both narrowed eccentric lumen (arrow) and

34、 aneurysm (arrowhead). 夾層動(dòng)脈瘤與缺血性卒中83Internal 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) surrounded by a thin annular contrast enhancement (curved

35、arrow). 夾層動(dòng)脈瘤與缺血性卒中84Typical target CT picture of dOcclusive 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 contralateral site (arrowhead). The measurements were made just be

36、low the petrous bone. 夾層動(dòng)脈瘤與缺血性卒中85Occlusive type dissection of t夾層動(dòng)脈瘤與缺血性卒中86夾層動(dòng)脈瘤與缺血性卒中86夾層動(dòng)脈瘤與缺血性卒中87夾層動(dòng)脈瘤與缺血性卒中87夾層動(dòng)脈瘤與缺血性卒中88夾層動(dòng)脈瘤與缺血性卒中88夾層動(dòng)脈瘤與缺血性卒中89夾層動(dòng)脈瘤與缺血性卒中89夾層動(dòng)脈瘤與缺血性卒中90夾層動(dòng)脈瘤與缺血性卒中90夾層動(dòng)脈瘤與缺血性卒中91夾層動(dòng)脈瘤與缺血性卒中91夾層動(dòng)脈瘤與缺血性卒中92夾層動(dòng)脈瘤與缺血性卒中92a, T2-weighted axial MR images on day 7 after the ini

37、tial 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 images 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 an