卵圆孔未闭分流量、解剖特点与隐源性脑卒中影像学特点的相关性

Correlations between shunt flow,anatomical features of patent foramen ovale and imaging characteristics of cryptogenic stroke

目的探讨卵圆孔未闭(Patent foramen oval,PFO)分流量、解剖特点与隐源性脑卒中(Cryptogenic stroke,CS)影像学特点的相关性。方法收集2012年8月-2020年12月在大连市中心医院神经内科住院的急性隐源性脑卒中患者110例,所有患者进行头部弥散成像(Diffuse weighted imaging,DWI)、磁共振成像(Magnetic resonance imaging,MRI)、磁共振血管成像(Magnetic resonance angiography,MRA)或头颈部CT血管成像(Computed tomography angiography,CTA)、动态心电图、颈动脉超声及心脏超声等检查排除其他病因;分别根据经颅多普勒超声发泡试验(Contrast-enhanced transcranial doppler,cTCD)阳性分型、cTCD确定右向左分流(Right-to-left shunt,RLS)量及经食道超声(transesophageal echocardiography,TEE)检查的PFO不同解剖特点,即行cTCD确定RLS量和PFO分型,TEE检查确定存在PFO及观察并测量其解剖结构,分析隐源性脑卒中的病灶分布、部位及数量是否有差异。结果共入组110例,男64例(58.1%),平均年龄(42±11)岁,根据cTCD常规阳性和Valsalva动作阳性将PFO分为固有型组(53例)和潜在型组(57例),2组性别、年龄、高血压病、糖尿病、脑卒中或TIA病史及ROPE评分均无明显差异(P>0.05)。cTCD显示RLS中小量组(栓子量≤25个)50例(45.5%),大量组60例(54.5%)。TEE检查静息状态下PFO直径(1.5±1.1)mm,PFO的平均长度(9.4±2.7)mm,长隧道型(PFO长度>8 mm)52例(47.2%),有过隔血流78例(70.9%)。头DWI显示梗死灶累及前循环供血区49例(44.5%),后循环供血区36例(32.7%),前后循环供血区25例(22.7%),单侧72例(65.4%),双侧38例(34.5%),皮层15例(13.6%),皮层下14例(12.7%),深部16例(14.5%),皮层+皮层下41例(37.2%),皮层、皮层下+深部24例(21.8%),单一梗死51例(46.3%),多发梗死59例(53.6%)。PFO固有型组(53例)和PFO潜在型组(57例)脑梗死灶分布、部位和数量均无明显差异(P>0.05),PFO固有型组患者脑梗死灶多见于半卵圆、侧脑室旁21例(39.6%);PFO潜在型组患者的脑梗死灶多见于脑干、小脑23例(40.3%)。中小量RLS组(栓子量≤25个,50例)和大量RLS组(栓子量>25个,60例)脑梗死灶分布、部位和数量均无明显差异(P>0.05)。长隧道型(>8 mm,52例)和非长隧道型(≤8 mm,26例)脑梗死灶分布、部位和数量均无明显差异(P>0.05)。无过隔血流(32例)和有过隔血流(78例)脑梗死灶分布、部位和数量均无明显差异(P>0.05)。小PFO(PFO直径<2 mm)组(54例)和中大PFO(PFO直径≥2 mm)组(24例)梗死灶分布(P=0.006)和梗死灶数量(P=0.027)均有明显差异;小PFO组患者脑梗死灶常见于前循环供血区(48.1%)、单侧(72.2%)及单一梗死灶(55.5%);中大PFO组患者脑梗死灶以前后循环供血区(41.6%)、双侧(58.3%)、多发梗死灶(70.8%)多见。结论小PFO组的脑梗死灶在影像学上分布以前循环供血区、单侧、单一病灶多见;中大PFO组的脑梗死灶以前后循环供血区、双侧、多发梗死灶多见;PFO大小与PFO相关的隐源性脑卒中梗死灶的分布及数量有关。PFO固有型患者的脑梗死灶多见于前循环供血区,其中梗死部位以皮层下多见;PFO潜在型患者的脑梗死灶多见于后循环供血区。

Objective To investigate the correlations between shunt flow,anatomical features of patent foramen ovale and imaging characteristics of cryptogenic stroke(CS).Methods A total of 110 patients with acute CS who were hospitalized in the Department of Neurology of Dalian Central Hospital from August 2012 to December 2020 were collected.All patients underwent head DWI,MRI,MRA or head and neck CTA,dynamic electrocardiography,carotid ultrasound,and cardiac ultrasound to exclude other causes.Contrast-enhanced transcranial Doppler(cTCD)was performed to determine the amount of right-to-left shunt(RLS)and the type of PFO.Transesophageal echocardiography(TEE)was conducted to determine the presence of PFO,and its anatomical structure was observed and measured.Results A total of 110 patients were enrolled,including 64 males(58.1%)with an average age of 42±11 years.PFO was divided into the intrinsic group(n=53)and latent group(n=57)according to the positive cTCD and positive Valsalva action.No significant differences were found in gender,age,hypertension,diabetes,stroke or TIA history,and ROPE score between the two groups(P>0.05).cTCD showed that 50 patients(45.5%)had a small-medium amount of RLS(embolus≤25)and 60 patients(54.5%)had a large amount of RLS.TEE revealed that the diameter of PFO was 1.5±1.1 mm and the average length of PFO was 9.4±2.7 mm under resting state.There were 52 patients(47.2%)with long tunnel type(PFO length>8 mm)and 78 patients(70.9%)having septal blood flow.Head DWI displayed that the infarction involved the anterior circulation in 49 patients(44.5%),posterior circulation in 36 patients(32.7%),anterior and posterior circulation in 25 patients(22.7%),unilateral circulation in 72 patients(65.4%),bilateral circulation in 38 patients(34.5%),cortical circulation in 15 patients(13.6%),subcortical circulation in 14 patients(12.7%),deep circulation in 16 patients(14.5%),cortical+subcortical circulation in 41 patients(37.2%),cortical,subcortical+deep circulation in 24 patients(21.8%),single infarction in 51 patients(46.3%),and multiple infarction in 59 patients(53.6%).The distribution,location,and number of cerebral infarction(CI)lesions presented no statistical differences between the intrinsic PFO group and the latent PFO group(P>0.05).The CI lesions in the intrinsic PFO group were more common in the semiovale and lateral ventricle(n=21,39.6%),and those in the latent PFO group were more common in the brainstem and cerebellum(n=23).There were no statistical differences in the distribution,location,or the number of CI lesions between the small-medium RLS amount group(embolus≤25,n=50)and the large RLS amount group(embolus>25,n=60)(P>0.05).The distribution,location,and the number of CI lesions showed no statistical differences between the long tunnel type(>8 mm,n=52)and the non-long tunnel type(≤8 mm,n=26)(P>0.05).No statistical differences were found in the distribution,location,or number of CI lesions between the non-septal blood flow group(n=32),and septal blood flow group(n=78)(P>0.05).The small PFO group(diameter<2 mm,n=54)and the medium-large PFO group(diameter≥2 mm,n=24)showed statistical significance in the distribution(P=0.006)and number(P=0.027)of CI lesions.In the small PFO group,CI lesions in the anterior circulation(41.6%),unilateral(72.2%)and single(55.5%)lesions were more common.In the medium-large PFO group,CI lesions in the anterior-posterior circulation(41.6%),bilateral(58.3%),and multiple(70.8%)lesions were more common.Conclusion In the small PFO group,CI lesions are mostly distributed in the anterior circulation blood supply area,unilateral and single lesions,while in the medium-large PFO group,CI lesions are mostly distributed in the anterior-posterior circulation blood supply area,bilateral and multiplelesions.The size of PFO is correlated with the distribution and number of infarction lesions in PFO-related CS.The CI lesions of patients with intrinsic PFO are mostly in the anterior circulation blood supply area,and the infarction is mostly distributed in the subcortex.CI lesions in the posterior circulation blood supply area are more common in patients with latent PFO.