症状性颈内动脉狭窄患者侧支循环与卒中再发

The cerebral collateral circulation and the ischemic stroke's recurrence in patients with symptomatic internal carotid stenosis

目的：颈内动脉（internal carotid artery，ICA）狭窄是缺血性卒中的高危因素，动脉狭窄程度虽然是影响血流动力学的重要因素，但是侧支循环对狭窄动脉供血区域脑灌注有非常重要的影响．利用经颅多普勒（transcrani-al Doppler，TCD）以及核磁共振成像（magnetic resonance imaging，MRI）的液体衰减反转恢复序列（fluidattenuated in-version recovery，FLAIR），来研究缺血性卒中伴有ICA严重狭窄患者的侧支循环情况，探讨侧支循环与其卒中再发的关系．方法：57例予以内科药物治疗的ICA严重狭窄首发非心源性缺血性卒中患者，采用TCD评定侧支循环等级，按照“无、Willis环前循环、Willis环后循环、颈外动脉（external carotid artery，ECA）系统、局部新生血管代偿”评分，每种途径为1分，总分0～4分．根据MRI-FLAIR上患侧大脑中动脉远端高信号血管影（distal hyperintense ves-sel，DHV）多少，分为0、1、2分．将患者在TCD和FLIAR上侧支循环分数分为无（0分）、差（12分）、中等（3～4分）及良好（5～6分）．记录患者临床资料并电话或门诊随访一年，观察其有无卒中再发，比较侧支循环上分级程度与一年内卒中再发的关系．结果：57例患者中27例一年内再发卒中．TCD和FLAIR侧支循环评分一年再发卒中风险分别为：无（3/3，100％）、差（3/9，33.3％）、中等（17/30，56.7％）、良好（4/15，26.7％）．经Fisher确切概率检验，发现TCD联合MRI-FLAIR进行侧支循环评分，不同分值在脑卒中复发率上有明显差异（P＝0.049）．结论：重度ICA狭窄缺血性卒中一年内再发卒中风险高，TCD联合MRI-FLAIR可以用来评定该类患者的侧支循环，侧支循环程度与一年内卒中再发有密切相关．

Aim：Stenosis of the internal carotid artery （ICA）is the high risk factor of ischemic stroke.The severity of carotid arteriostenosis is the important factor that affects the haemodynamics,but the cerebral collateral circulation has very considerable influence on the cerebral perfusion of stenosis ar-terial blood-supply regions.TCD（transcranial Doppler）and MRI-FLAIR （magnetic resonance imaging, fluidattenuated inversion recovery）were used to study the collateral circulation in the ischemic stroke pa-tients with the severe ICA stenosis,and analyzed the relationship between the merits of the cerebral col-lateral circulation and the recurrence of the stroke.Methods：Fifty seveven patients with severe ICA ste-nosis who were first diagnosed as ischemic stroke were collected.According to the compensation path of“non,anterior circulation of the willis circle,posterior circulation of the willis circle,external carotid ar-tery （ECA）system,local new vessels”to assess the level of the cerebral collateral circulation in TCD, we rated their amount on a score of 0 to 4,Non for 0 score,each of the others for 1 score.According to the quantity of the affected side MCA（middle cerebral artery）s distal hyperintense vessel（DHV）on MRI-FLAIR,we rated them on a score of“0,1 ,2”.And then we graded the collateral circulation of“non（0 score）,poor（1 -2 score）,average（3-4 score）and excellent（5 -6 score）”according to the patients score of their cerebral collateral circulation on TCD and FLIAR.We collected the patients clinical data and visited the patients 1 year followed-up,to analyze the relationship between the cerebral collateral cir-culation and the stroke recurrence.Results：Twenty seven cases had recurred cerebral ischemic stroke within 1 year.The risk of the cerebral ischemic strokes recurrence within 1 year,which with the cerebral collateral circulations grade of TCD and FLAIR were non（3/3,1 00%）,poor（3/9,33.3%）,average （1 7/30,56.7%）and excellent（4/1 5,26.7%）respectively.Analyzed by Fisher Exact Test,we found there was significant difference between the score of the cerebral collateral circulation and the recurrence rate of cerebral ischemic stroke （P=0.049 ）.Conclusion：The ischemic stroke patients with the severe ICA stenosis have a high risk of stroke recurrence.TCD combined with MRI-FLAIR can be used to grade the patients cerebral collateral circulation.There is a close relationship between the cerebral collateral circulation condition and the recurrence of ischemic stroke.