20140624 椎基底动脉扩张延长症(VBD)的影像学及临床研究进展

椎基底动脉扩张延长症（VBD）的影像学及临床研究进展大坪医院放射科刘恒2014.06.24椎基底动脉扩张延长症（vertebrobasilardolichoectasia，VBD）是指椎基底动脉的异常迂曲、扩张和延长。概念•1986年，Smoker等首次提出VBD的概念。•2005年，Caplan对VBD的概念进行了修订。取代了既往“椎基底动脉系统迂曲”、“椎基底动脉延长扩张”、“巨大延长的动脉瘤畸形、动脉变异及梭形动脉瘤”等术语。1.SmokerWR,CorbettJJ,GentryLR,KeyesWD,PriceMJ,McKuskerS.High-resolutioncomputedtomographyofthebasilarartery:2.Vertebrobasilardolichoectasia:clinical-pathologiccorrelationandreview.AJNRAmJNeuroradiol.1986;7:61-72.2.2.SavitzSI,CaplanLR.Vertebrobasilardisease.NEnglJMed.2005;352:2618-2626.流行病学•VBD在总体人群中的发生率为0.06%～5.8%，在卒中患者的发生率高达10%～12%。•Pico等对466例VBD患者进行的中位随访时间为5.3年的研究显示:•直径＞4.3mm是卒中的高危因素；•VBD也是致死性卒中的独立危险因素;•BA直径每增加1.0mm，卒中的致死风险增高1.23倍。PicoF,LabreucheJ,Gourfinkel-AnI,AmarencoP,InvestigatorsG.Basilararterydiameterand5-yearmortalityinpatientswithstroke.Stroke.2006;37:2342-2347.基底动脉(basilarartery，BA)•由左右两条椎动脉在脑桥下缘汇合而成•向上行于脑桥基底沟中•全长3cm，宽1.5—4mm•至约左右动眼神经根之间分为左右大脑后动脉（鞍背平面上6mm内，鞍上池下方）正常解剖1.基底动脉2.脑桥动脉3.左小脑后下动脉（PICA）4.右AICA-PICA干5.左小脑前下动脉（AICA）6.PICA半球支7.小脑上动脉（SCA）8.SCA的蚓支9.小脑上动脉半球支左侧椎动脉造影前后位病因•先天因素：血管肌纤维发育异常、动脉内弹力层缺如、和（或）平滑肌层萎缩等•后天因素：影响血管发育并引起血管壁破坏的疾病，如动脉粥样硬化、动脉炎性病变等病理生理•血管肌纤维结构和功能异常内弹力膜的广泛缺陷及中膜网状纤维的缺乏•机械压迫脑脊液压力增高•血流动力学改变血流变慢，状态紊乱•成功的VBD动物实验模型，人活体组织结构变化?•受压迫脑神经、脑干等病理结构和生理变化?•血流对迂曲血管切应力作用变化、流入和流出道血流状态变化?•组织血液灌注学和组织代谢学?临床表现•缺血性脑血管疾病•出血性脑血管疾病•压迫和颅神经损害症状脑桥和延髓面n.、三叉n.、听n.、动眼n.•脑积水神经脑干压迫症状神经压迫症状63，MCamposWK,GuastiAA,daSilvaBF,GuastiJA.TrigeminalNeuralgiaduetoVertebrobasilarDolichoectasia.CaseRepNeurolMed.2012;2012:367304.69，M，aleftsidefacialspasmfor5years.KangJH,KangDW,ChungSS,ChangJW.Theeffectofmicrovasculardecompressionforhemifacialspasmcausedbyvertebrobasilardolichoectasia.JKoreanNeurosurgSoc.2012;52:85-91.73，MTanLA,MoftakharR,LopesDK.Treatmentofarupturedvertebrobasilarfusiformaneurysmusingpipelineembolizationdevice.JCerebrovascEndovascNeurosurg.2013;15:30-33.KimCH,SonYJ,PaekSH,etal.Clinicalanalysisofvertebrobasilardissection.ActaNeurochir(Wien).2006;148:395-404.59，M，severeheadache,withoutneurologicaldeficitPasseroSG,CalchettiB,BartaliniS．IntracranialBleedinginpatientswithvertebrobasilardolichoectasiaStroke,2005,36：1421-1425．影像学检查•CT平扫：误、漏诊率高。•DSA：有创。•MRA：清晰。•MS3D-CTA：首选。Ubogu、Zaidat：MRA诊断标准•扩张：BA直径≥4.5mmVA直径≥4mm(Passero、Rossi)•延长：BA上段超过鞍上池或床突平面6mm以上，或BA长度＞29.5mm，VA颅内段长度＞23.5mm•迂曲：BA横向偏离超过起始点至分叉之间垂直连线1mm或位置在鞍背或斜坡的旁正中至边缘间以外，而VA任意一支偏离超过椎动脉颅内入口到基底动脉起始点之间连线10mm为异常。UboguEE,ZaidatOO.Vertebrobasilardolichoectasiadiagnosedbymagneticresonanceangiographyandriskofstrokeanddeath.JNeurolNeurosurgPsychiatry.2004;75:22-26.Smoker:HRCT诊断标准BA分叉高于鞍上池或位置位于旁正中之外且直径≥4.5mm定义为VBD。SmokerWR,CorbettJJ,GentryLR,KeyesWD,PriceMJ,McKuskerS..AJNRAmJNeuroradiol.1986;7:61-72.若高度评分≥2或位置评分≥2即为延长BA偏移分级BA延长（高度）分级鞍背以下：0鞍上池以下：1第三脑室层面：3BA高度分级评分第三脑室层面：3鞍上池层面：1正中线上：0旁正中线与边缘间：2BA偏移分级评分M，65，trigeminalneuralgiafor4months治疗•以对症治疗和脑保护治疗为主•内科治疗：抗凝、抗血小板聚集、降压、降糖、调脂等控制危险因素以预防缺血性卒中的发生•外科治疗：微血管减压复位术、腔内血管重建术、动脉瘤夹闭术等。ArthurdeAzambujaPereiraFilho.Brainstemcompressionsyndromecausedbyvertebrobasilardolichoectasia.ArqNeuropsiquiatr2008;66(2-B):408-411microvascularrepositioningtechnique.M.O.,medullaoblongata;P,posteriorinferiorcerebellarartery;V.A.,Vertebralartery;XII,hypoglossalnerve;X,vagusnerve.M，48percutaneoustransluminalangioplastyembolizationofintracranialaneurysmKimCH,SonYJ,PaekSH,etal.Clinicalanalysisofvertebrobasilardissection.ActaNeurochir(Wien).2006;148:395-404.Post-embolization参考文献•1.SmokerWR,CorbettJJ,GentryLR,KeyesWD,PriceMJ,McKuskerS.High-resolutioncomputedtomographyofthebasilarartery:2.Vertebrobasilardolichoectasia:clinical-pathologiccorrelationandreview.AJNRAmJNeuroradiol.1986;7:61-72.•2.SavitzSI,CaplanLR.Vertebrobasilardisease.NEnglJMed.2005;352:2618-2626.•3.PicoF,LabreucheJ,Gourfinkel-AnI,AmarencoP,InvestigatorsG.Basilararterydiameterand5-yearmortalityinpatientswithstroke.Stroke.2006;37:2342-2347.•4.UboguEE,ZaidatOO.Vertebrobasilardolichoectasiadiagnosedbymagneticresonanceangiographyandriskofstrokeanddeath:acohortstudy.JNeurolNeurosurgPsychiatry.2004;75:22-26.•5.LinYW,ChenCH,LaiML.Thedilemmaoftreatingvertebrobasilardolichoectasia.ClinPract.2012;2:e84.•6.KimBM,KimSH,KimDI,etal.Outcomesandprognosticfactorsofintracranialunrupturedvertebrobasilararterydissection.Neurology.2011;76:1735-1741.•7.KimCH,SonYJ,PaekSH,etal.Clinicalanalysisofvertebrobasilardissection.ActaNeurochir(Wien).2006;148:395-404.•8.TanLA,MoftakharR,LopesDK.Treatmentofarupturedvertebrobasilarfusiformaneurysmusingpipelineembolizationdevice.JCerebrovascEndovascNeurosurg.2013;15:30-33.•9.CamposWK,GuastiAA,daSilvaBF,GuastiJA.TrigeminalNeuralgiaduetoVertebrobasilarDolichoectasia.CaseRepNeurolMed.2012;2012:367304.•10.KangJH,KangDW,ChungSS,ChangJW.Theeffectofmicrovasculardecompressionforhemifacialspasmcausedbyvertebrobasilardolichoectasia.JKoreanNeurosurgSoc.2012;52:85-91.•11.ArthurdeAzambujaPereiraFilho.Brainstemcompressionsyndromecausedbyvertebrobasilardolichoectasia.ArqNeuropsiquiatr2008;66(2-B):408-411•12.PasseroSG,CalchettiB,BartaliniS.IntracranialBleedinginpatientswithvertebrobasilardolichoectasiaStroke,2005,36：1421-1425．•13.Amin-HanjaniS,DuX,ZhaoM,etal.Useofquantitativemagneticresonance