椎动脉夹层致缺血性卒中5例报道及文献复习

Ischemic Stroke Caused by Vertebral Artery Dissection:a Report of 5 Cases and Literature Review

目的:结合病例及文献,分析椎动脉夹层(VAD)所致缺血性卒中的临床表现和影像学特点,并探讨其治疗和转归。方法:报道我院收治的5例VAD致缺血性卒中病例,并结合文献进行回顾性分析。结果:5例患者均出现头晕或眩晕,2例有颈部剧烈活动诱因,起病时有后颈部、枕部疼痛。头核磁(MRI)示枕叶皮质、底节区、丘脑、小脑及延髓背外侧梗死灶;头磁共振血管成像(MRA)/CT血管成像(CTA)示椎动脉扩张、狭窄及闭塞;数字减影血管造影(DSA)检查显示VAD,出现闭塞、狭窄,2例合并基底动脉狭窄;高分辨磁共振(HR-MRI)示椎动脉壁间血肿、夹层瓣及管壁强化、增厚等表现。5例患者均行抗栓治疗。随访3~6个月,2例血管完全再通,5例均未出现卒中复发。搜索既往报道的1972例VAD患者数据,最常见表现依次为头晕/眩晕、头痛、颈痛;椎动脉颅外段夹层所致脑梗死较为常见,短暂性脑缺血发作和颅内段夹层所致蛛网膜下腔出血相对少见;大多数患者预后良好。结论:无动脉粥样硬化危险因素的中青年患者,突发头晕、颈枕部疼痛等症状时需考虑VAD可能;仔细询问病史、进一步行HR-MRI检查是发现VAD的有效手段;及早诊治通常预后良好。

Objective:To analyze the clinical manifestations and imaging features of ischemic stroke caused by vertebral artery dissection(VAD),and discuss its treatment and outcome.Methods:Five cases of ischemic stroke caused by VAD were reported and the relevant literature were reviewed.Results:Dizziness/vertigo were the main onset symptoms for all the subjects.Two cases had inducement of violent neck movement and had pain in the back neck and occiput at the onset.Head MRI showed lesions in occipital cortex,basal ganglia,thalamus,cerebellum and dorsolateral medulla oblongata.Head MRA/CTA demonstrated dilation,stenosis and occlusion of the vertebral artery.All patients had VAD in DSA with occlusion or stenosis,and 2 cases combined with basilar artery stenosis.HR MRI showed intermural hematoma,dissection valve,and vessel wall enhancement and thickening.Five cases were treated with antithrombotic therapy.After follow-up 3 to 6 months,two patients had recanalization and no one had stroke recurrence.We collected data of 1972 cases of VAD from the MEDLINE.The most common symptoms were dizziness/vertigo,headache,and neck pain in order.Stroke was common,especially with extracranial dissections,whereas transient ischemic attack and subarachnoid hemorrhage(SAH)were uncommon.SAH were only with intracranial dissections.Most patients have a good outcome.Conclusion:The possibility of VDA should be considered in the cases of young and middle-aged patients with sudden dizziness,occipital or posterior cervical pain and without obvious risk factors for atherosclerosis.Careful medical history enquiry and further HR-MRI examinations are effective means to discover VAD.Patients diagnosed and treated early have good prognosis.