颈内动脉颅外段严重狭窄和闭塞所致脑梗死病灶分布模式特征分析

Characteristic analysis of severe stenosis and occlusion of extracranial internal carotid artery caused the distribution patterns of cerebral infarction lesion

目的分析颈内动脉颅外段（extracranialinternalcarotidartery，EICA）严重狭窄和闭塞所致脑梗死的病灶分布模式，进而探讨两者导致脑梗死机制的差异，为个体化防治策略提供依据。方法回顾性分析61例EICA粥样硬化性严重狭窄（狭窄程度70％～99％）或闭塞所致急性脑梗死患者的临床和影像学资料，根据狭窄程度分为狭窄组（n=31）和闭塞组（n=30），比较两组脑梗死病灶分布模式。根据EICA病变侧大脑中动脉（middlecerebralartery，MCA）磁共振血管成像（magneticresonanceangiogaplay，MRA）分为侧支循环代偿良好组（n＝31）和不良组（n＝26），比较两组脑梗死病灶分布模式。结果侧支循环不良组高血压患者比例显著高于侧支循环良好组（22／26对18／31，P=0．042）。闭塞组多发性梗死患者比例显著高于狭窄组（15／30对7／31，P=0．026），单发性梗死患者比例显著低于狭窄组（15／30对24／31，P=0．026），大范围皮质梗死患者比例显著高于狭窄组（7／30对1／31，P=0．026）。在单发性梗死患者中，闭塞组分水岭梗死（border—zoneinfarct，BZI）患者比例显著高于狭窄组（8／15对5／24，P=0．036），皮质分支动脉供血区梗死（corticalinfarct，CI）患者比例显著低于狭窄组（15／24对4／15，P=0．048）；侧支循环不良组BZI患者比例显著高于侧支循环良好组（8／15对4／22，P=0．036），CI患者比例显著低于侧支循环良好组（4／15对14／22，P=0．045）。闭塞组大穿支动脉供血区梗死（11／30对3／31，P=0．016）和BZI（20／30对10／31，P=0．010）患者比例显著高于狭窄组，BZI患者中梗死仅累及内部分水岭区域的患者比例显著高于狭窄组（15／30对6／31，P=0．016）。侧支循环不良组BZI患者比例显著高于侧支循环良好组（19／26对9／31，P=0．001），BZI患者中梗死仅累及内部分水岭区域患者比例显著高于侧支循环良好组（14／26对6／31，P=0．011）。侧支循环不良组Willis前环不完整患者比例显著高于侧支循环良好组（19／26对8／31，P=0．001）。结论EICA严重狭窄和闭塞所致脑梗死的病灶分布模式存在差异，提示两者致脑梗死机制不同。EICA严重闭塞性病变患者MRA所示病变侧MCA显影信号变化可能是判断侧支循环状态的潜在替代指标，但需用血流灌注定量测定的研究手段加以检验。

Objective To analyze the severe extracranial internal carotid artery （EICA） stenosis and occlusion caused the distribution patterns of cerebral infarction lesion and then to investigate the differences of stenosis and occlusion caused mechanisms of cerebral infarction in order to provide the basis for individual prevention and treatment strategies. Methods The clinical and imaging data of 61 patients with atherosclerotic severe EICA stenosis （70-99%） or occlusion caused acute cerebral infarction were analyzed retrospectively. They were divided into stenosis group （n =31） and occlusion group （n =30） according to the degree of stenosis. The distribution patterns of infarct lesion of both groups were compared. They were divided into good （n =31） and poor （n =26） collateral flow compensation groups according to the middle cerebral artery （MCA） and magnetic resonance angiography （MRA） on the lesion sides of EICA. The distribution patterns of the infarct lesion in both groups were compared. Results The proportion of the patients with hypertension in the poor collateral flow compensation group was significantly higher than that in the good collateral flow compensation group （22/26 vs. 18/31, P =0. 042）. The proportion of the patients with multiple cerebral infarction in the occlusion group was sigfificantly higher than that in the stenosis group （15/30 vs. 24/31, P =0. 026）, and the proportion of the patients with single cerebral infarction was sigdficantly lower than that in the stenosis group （15/30 vs. 7/31, P =0. 026）. The proportion of the patients with large cortical infarction was sigoificantly higher than that in the stenosis group （7/30 vs. 1/31, P = 0. 026）. Among the patients with single cerebral infarction, the proportion of the patients with border-zone infarct （BZI） in the occlusion group was significantly higher than that in the stenosis group （8/15 vs. 5/24, P = 0. 036）, and the proportion of the patients with cortical infarct （CI） was significantly lower than that in the stenosis group （15/24 vs. 4/15, P =0. 048）. The proportion of the patients with BZI in the poor collateral flow compensation group was sigoificantly higher than that in the good collateral flow compensation group （8/15vs. 4/22, P = 0. 036）, and the proportion of the patients with CI was significantly lower than that in the good collateral flow compensation group （4/15 vs. 14/22, P =0. 045）. The proportions of the patients with large perforating artery infarct （11/30 vs. 3/31, P=0. 016） and BZI （20/30 vs. 10/31, P = 0. 010） in the occlusion group were sifnificantly higher than those in the stenosis group, and among the patients with BZI, the proportion of the infarction involving only the patients with internal border zone was sigoificantly higher than that in the,,stenosis group （15/30 vs. 6/31, P = 0. 016）. The proportion of the patients with BZI in the poor collateral flow compensation group was significantly higher than that in the good collateral flow compensation group （19/26 vs. 9/31, P =0. 001）, and among the patients with BZI, the proportion of the infarction involving only the patients with internal border zone was sigfificantly higher than that in the good collateral flow compensation group （14/26 vs. 6/31, P = 0. 011）. The proportion of the patients with incomplete anterior circle of Willis in the poor collateral flow compensation group was significantly higher than that in the good collateral flow compensation group （19/26 vs. 8/31, P =0. 001）.Conclusions The lesion distribution patterns of cerebral infarction caused by severe EICA stenosis and occlusion are different, and it suggests that the cerebral infarction mechanisms caused by both are different. In patients with severe EICA occlusive disease, MRA showed that the developing sigoal change at the lesion sides of MCA may be a potential surrogate index for identifying the state of collateral circulation, but it needs to use the research means of quantitative determination of blood perfusion to verify.