颈动脉多普勒超声对锁骨下动脉窃血综合征与后循环缺血的评估

Evaluation of subclavian steal syndrome and posterior circulation ischemia by carotid Doppler ultrasonography

目的探讨锁骨下动脉中-重度狭窄或闭塞时,颈动脉多普勒超声(CDU)对患侧椎动脉窃血类型与后循环缺血关系的评估。方法回顾性纳入2017年1月至2020年7月于苏州大学附属第一医院脑卒中中心,经CDU及数字减影血管造影(DSA)证实的锁骨下动脉中-重度狭窄或闭塞患者共163例,所有患者均行头颅磁共振成像(MRI)检查及美国卫生研究院卒中量表(NIHSS)评分。根据CDU检查的患侧椎动脉窃血类型,将163例患者分为Ⅰ型(隐匿型窃血)51例,Ⅱ型(部分型窃血)70例和Ⅲ型(完全型窃血)42例。CDU评估窃血类型并与DSA对照;分析锁骨下动脉不同程度狭窄与椎动脉窃血类型的相关性以及不同椎动脉窃血类型患者的脑梗死发生率。结果CDU与DSA评估椎动脉窃血类型比较:Ⅰ型(51例vs 0例);Ⅱ型(70例vs 53例);Ⅲ型(42例vs 42例)。锁骨下动脉不同程度狭窄与椎动脉窃血类型的关系:46例锁骨下动脉中度狭窄患者中,CDU评估Ⅰ型窃血36例(78.3%,36/46);Ⅱ型窃血10例(21.7%,10/46);Ⅲ型窃血0例。83例锁骨下动脉重度狭窄患者中,CDU评估Ⅰ型窃血15例(18.1%,15/83);Ⅱ型窃血60例(72.3%,60/83);Ⅲ型窃血8例(9.6%,8/83)。34例锁骨下动脉闭塞患者中,CDU评估均为Ⅲ型窃血。锁骨下动脉狭窄程度与椎动脉窃血类型呈正相关(rs=0.802,P<0.001)。CDU评估的不同窃血类型与后循环缺血的关系:Ⅰ型患者均表现为短暂性脑缺血发作(TIA),脑梗死发生率为0(0/51),NIHSS评分均<10分;Ⅱ型患者脑梗死发生率为28.6%(20/70),NIHSS评分≥10分者占4.3%(3/70);Ⅲ型患者脑梗死发生率为52.4%(22/42),NIHSS评分≥10分者占16.7%(7/42)。Ⅰ~Ⅲ型患者脑梗死发生率逐渐升高,差异有统计学意义(H=33.337,P<0.001)。结论随着患侧椎动脉窃血类型进展,其脑梗死发生率逐渐升高,CDU能够早期、无创、实时动态、准确评估锁骨下动脉窃血综合征,为临床个体化治疗提供依据。

Objective To evaluate the relationship between the type of vertebral artery steal and posterior circulation ischemia by carotid Doppler ultrasonography(CDU)in the case of moderate to severe subclavian artery stenosis or occlusion.Methods A total of 163 patients with moderate to severe subclavian artery stenosis or occlusion confirmed by CDU and digital subtraction angiography(DSA)at the Stroke Center of the First Affiliated Hospital of Soochow University from January 2017 to July 2020 were retrospectively enrolled.All patients underwent cranial magnetic resonance imaging(MRI)and National Institute of Health Stroke Scale(NIHSS)score evaluation.According to the type of vertebral artery steal on the affected side of patients examined by CDU,163 patients were divided into typeⅠ(latent type;51 cases),typeⅡ(partial type;70 cases),and typeⅢ(complete type;42 cases)cases.CDU was used to assess the type of blood steal and compared with DSA findings to analyze the correlation between different degrees of subclavian artery stenosis and the type of vertebral artery steal,and the incidence of cerebral infarction in patients with different types of vertebral artery steal.Results The results of CDU and DSA in evaluating the types of vertebral artery steal were:typeⅠ(51 vs 0);typeⅡ(70 vs 53);typeⅢ(42 vs 42).Among 46 patients with moderate subclavian artery stenosis,36(78.3%,36/46),10(21.7%,10/46),and 0 were evaluated by CDU as having typeⅠ,typeⅡ,and typeⅢblood steal,respectively.Among 83 patients with severe stenosis of SA,15(18.1%,15/83),60(72.3%,60/83),and 8(9.6%,8/83)were evaluated by CDU as having typeⅠ,typeⅡ,and typeⅢblood steal,respectively.All 34 patients with SA occlusion were evaluated by CDU as having typeⅢblood steal.The degree of subclavian artery stenosis was not completely consistent,but positively correlated,with the type of vertebral artery steal(rs=0.802,P<0.001).All patients with typeⅠshowed transient ischemic attack(TIA),the incidence of cerebral infarction was 0(0/51),and the NIHSS score was<10.The incidence of cerebral infarction in typeⅡpatients was 28.6%(20/70),and those with an NIHSS score≥10 accounted for 4.3%(3/70).The incidence of cerebral infarction in typeⅢpatients was 52.4%(22/42),and those with an NIHSS score≥10 accounted for 16.7%(7/42).There was a significant difference in the incidence of cerebral infarction in typeⅠ~Ⅲpatients(H=33.337,P<0.001).Conclusion With the development of the type of blood steal from the affected vertebral artery,the incidence of cerebral infarction gradually increases.CDU allows for early,noninvasive,real-time,dynamical,and accurate evaluation of subclavian artery blood steal syndrome,so as to provide a basis for clinical individualized treatment.