视网膜中央动脉阻塞患者血管神经眼科特征

Clinical characteristics of vascular neuro-ophthalmology in patients with central retinal artery occlusion

目的观察视网膜中央动脉阻塞(CRAO)患者血管神经眼科的临床特征。方法单中心、前瞻性临床研究。2018年1月至2020年12月于西安市第一医院神经眼科病区收治的CRAO患者49例49只眼纳入研究。收集患者人口学特征、血管危险因素、发病特点、颈内动脉血管数字减影血管造影(DSA)影像特征、治疗方式、与治疗相关不良事件及出院1个月随访血管事件等资料。所有患者均行视力、头颅CT和或磁共振成像检查。同时行颈内动脉血管DSA检查35例;头颈部CT血管造影检查14例。将颈内动脉颅外段解剖变异分为纡曲、折曲、盘曲;主动脉弓分为Ⅰ型、Ⅱ型、Ⅲ型、牛型。行静脉溶栓、动脉溶栓、保守治疗。治疗后随访时间1个月。功能性视觉定义为视力≥20/100。血管事件为随访期间发生卒中、心血管事件、死亡和新生血管青光眼。结果49例49只眼中,男性40例40只眼(81.6%,40/49),女性9例9只眼(18.4%,9/49);平均年龄(60.7±12.9)岁。合并高血压、2型糖尿病、脑血管疾病分别为33、17、16例;既往有吸烟史、牙齿脱落病史分别为27、34例。服用降血压、降血糖、抗血小板聚集/抗凝、降血脂药物治疗分别为15、5、8、5例。发病前有一过性黑矇11例,醒后发现CRAO 17例。合并患侧脑组织梗死软化灶33例(67.3%,33/49)。行DSA检查的35例,患侧颈内动脉狭窄率70%~99%、100%分别为3(8.6%,3/35)、4(11.4%,4/35)例。患侧眼动脉起源于颈外动脉5例(14.3%,5/35)例。颈内动脉颅外段解剖变异纡曲、折曲分别为17(54.8%,17/31)、2(6.5%,2/31)例。主动脉弓Ⅱ型、Ⅲ型、牛型分别为15(42.9%,15/35)、6(17.1%,6/35)、2(5.7%,2/35)例。行静脉溶栓、动脉溶栓治疗分别为13、29例。发生治疗中并发症2例;治疗后症状波动3例,影像学无症状新发梗死灶10例。行抗血小板聚集/抗凝和降血脂药物治疗48例。出院及治疗后1个月时,恢复功能性视觉分别为7、17例。治疗后1个月,因心肌梗死死亡1例;发生新生血管青光眼2例。结论CRAO患者合并血管危险因素和患侧颈内动脉异常比例较高;采用静脉溶栓和(或)动脉溶栓治疗及卒中二级预防后预后相对较好。

Objective To investigate the clinical characteristics of vascular neuro-ophthalmology in patients with central retinal artery occlusion(CRAO).Methods A single-center,prospective clinical study.From January 2018 to December 2020,49 eyes of 49 CRAO patients of The Neuro-ophthalmology Department of Xi'an First Hospital were included in the study.Data on patient demographic characteristics,vascular risk factors,disease characteristics,digital subtraction angiography(DSA)imaging characteristics of internal carotid arteries,treatment,treatment-related adverse events,and 1-month follow-up vascular events were collected.All patiens were examined by visual acuity,head CT and or magnetic resonance imaging.At the same time,35 cases of internal carotid artery vascular DSA were examined;14 cases of head and neck CT angiography were examined.The anatomical variation of the extracranial segment of the internal carotid artery was divided into tortuous,tortuous,and coiled;the aortic arch was divided into typeⅠ,typeⅡ,typeⅢ,and bovine type.Intravenous thrombolysis,arterial thrombolysis,conservative treatment were performed.The follow-up time was1 month after treatment.Functional vision was defined as vision≥20/100.Vascular events were strokes,cardiovascular events,deaths and neovascular glaucoma during follow-up.Results Among 49 eyes of 49 cases,40 eyes were male(81.6%,40/49),and 9 eyes were female(18.4%,9/49);the average age was 60.7±12.9 years.There were 33,17,and 16 cases with hypertension,type 2 diabetes,and cerebrovascular disease,respectively;27 and 34 cases had a history of smoking and tooth loss,respectively.Taking antihypertensive,hypoglycemic,antiplatelet aggregation/anticoagulation,and hypolipidemic drugs were 15,5,8,and 5 patients,respectively.There were 11 cases of transient amaurosis before the onset,and 17 cases of CRAO after waking up.There were 33 cases(67.3%,33/49)with infarction of the affected side of the brain tissue.DSA was performed in 35 cases,and the stenosis rate of the internal carotid artery on the affected side was 70%-99%and 100%were 3(8.6%,3/35)and 4(11.4%,4/35)cases,respectively.The ophthalmic artery on the affected side originated from the external carotid artery in 5 cases(14.3%,5/35).There were 17(54.8%,17/31)and 2(6.5%,2/31)cases of tortuousity and kinking in the extracranial segment of the internal carotid artery.There were 15(42.9%,15/35),6(17.1%,6/35),and 2(5.7%,2/35)cases of aortic arch typeⅡ,typeⅢ,and bovine type,respectively.Intravenous thrombolysis and arterial thrombolysis were performed in 13 and 29 cases,respectively.Complications occurred in 2 cases during treatment;3 cases of symptoms fluctuated after treatment,and 10 cases of asymptomatic new infarcts occurred in imaging studies.Forty-eight cases were treated with antiplatelet aggregation/anticoagulation and hypolipidemic treatment.At discharge and 1 month after treatment,the recovery of functional vision was 7 and 17 cases,respectively.One month after treatment,1 case died because myocardial infarction;2 cases of neovascular glaucoma occurred.Conclusion The proportion of CRAO patients with vascular risk factors and internal carotid artery abnormalities on the affected side is relatively high;the prognosis is relatively good after intravenous thrombolysis and/or arterial thrombolysis and secondary stroke prevention.