颈动脉蹼相关性脑梗死的临床特点

Clinical characteristics of carotid web-related ischemic stroke

目的分析颈动脉蹼相关性脑梗死的临床特征和治疗方案,梳理颈动脉蹼相关性脑梗死的诊疗流程。方法对2018年1月至2022年9月就诊于首都医科大学宣武医院的6例颈动脉蹼相关性脑梗死患者的临床表现、头颅磁共振成像(MRI)、CT血管成像(CTA)/数字减影血管造影(DSA)、颈动脉超声检查、经颅彩色多普勒超声特点进行分析总结,并总结其治疗和随访情况。结果6例患者均为中青年,无传统脑血管病危险因素,男女比例2∶4。所有患者均有反复脑卒中发作,发病时美国国立卫生研究院卒中量表评分2~4分。头颅MRI显示5例患者大脑中动脉供血区域梗死,1例患者颅内无梗死灶。6例患者颈动脉蹼处血管均无明显狭窄。4例患者伴有同侧大脑中动脉狭窄或闭塞,1例患者于大脑中动脉发现微栓子信号,1例患者颅内动脉未见明显异常。6例患者均由脑颈血管超声初诊,经CTA/DSA确认5例,1例无异常发现。6例患者均接受颈动脉内膜切除术并做病理检查确诊。术后均规律抗血小板聚集、他汀类降脂治疗,随访0.5~5.2年,均无卒中再发。结论作为隐源性脑卒中的罕见病因,颈动脉蹼相关脑卒中的复发率较高。对于无传统脑血管病危险因素的卒中患者,反复出现颈内动脉系统栓塞性事件,应注重颈脑联合、综合血流动力学特点排查有无颈动脉蹼;颈脑血管超声联合其他影像学方法可以提高颈动脉蹼的检出率;单纯抗血小板聚集治疗不能有效预防卒中再发,对于确诊的颈动脉蹼相关性脑梗死患者可选择手术切除,并用颈脑血管超声评估治疗效果。

Objective To analyze the clinical characteristics and management strategy of carotid web(CW)-related stroke and improve the understanding of CW.Methods The clinical data of 6 patients with CW-related stroke treated at Xuanwu Hospital,Capital Medical University,from January 2018 to September 2022 were retrospectively analyzed.Relevant data included clinical manifestations,bronchial magnetic resonance imaging(MRI),CT angiography(CTA)/digital subtraction angiography(DSA),carotid ultrasonography,and transcranial color-coded Doppler sonography(TCCD).Treatments and follow-ups were also reported.Results All 6 patients were middle-aged or young,without traditional risk factors for cerebrovascular disease.The male-to-female ratio was 2∶4.All patients had recurrent strokes,with a score of 2-4 on the National Institutes of Health Stroke Scale at the time of onset.Head MRI showed 5 patients with cerebral infarction in the middle cerebral artery supply area;1 patient had no intracranial infarction.No significant stenosis of the vessels at the site of the CW was observed in any of the 6 patients.Four patients had ipsilateral stenosis or occlusion of the middle cerebral artery,1 patient had microembolic signals in the middle cerebral artery,and 1 patient had no significant abnormalities in the intracranial artery.All 6 patients were initially diagnosed by ultrasound.Diagnoses were confirmed by CTA/DSA in 5 cases;the other patient did not show any significant abnormalities.All 6 patients underwent a carotid endarterectomy after a pathological examination to confirm the diagnosis.Postoperatively,regular antiplatelet aggregation and statin lipid-lowering therapies were administered.A follow-up of 0.5 to 5.2 years showed no stroke recurrence in any patient.Conclusions CW-related stroke is a rare cause of cryptogenic stroke and has a high recurrence rate.For stroke patients who do not have traditional risk factors for cerebrovascular disease while repeatedly experiencing embolic events of the internal carotid artery system,attention should be paid to the combination of the carotid and cerebral arteries,and comprehensive hemodynamic characteristics should be checked for the presence of a CW.Carotid artery ultrasound and TCCD combined with other imaging methods can improve the detection rate of a CW.Simple antiplatelet aggregation therapy cannot effectively prevent stroke recurrence.For patients with confirmed CW-related cerebral infarction,surgical resection can be performed,and the treatment effect can be evaluated using ultrasonography.