椎基底動脈擴(kuò)張延長癥(VBD)的影像學(xué)及臨床研究進(jìn)展

椎基底動脈擴(kuò)張延長癥（VBD）的影像學(xué)及臨床研究進(jìn)展大坪醫(yī)院放射科劉恒2014.06.24

椎基底動脈擴(kuò)張延長癥（vertebrobasilardolichoectasia，VBD）是指椎基底動脈的異常迂曲、擴(kuò)張和延長。概念1986年，Smoker等首次提出VBD的概念。2005年，Caplan對VBD的概念進(jìn)行了修訂。取代了既往“椎基底動脈系統(tǒng)迂曲”、“椎基底動脈延長擴(kuò)張”、“巨大延長的動脈瘤畸形、動脈變異及梭形動脈瘤”等術(shù)語。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.流行病學(xué)VBD在總體人群中的發(fā)生率為0.06%～5.8%，在卒中患者的發(fā)生率高達(dá)10%～12%。Pico等對466例VBD患者進(jìn)行的中位隨訪時間為5.3年的研究顯示:直徑＞4.3mm是卒中的高危因素；VBD也是致死性卒中的獨(dú)立危險因素;BA直徑每增加1.0mm，卒中的致死風(fēng)險增高1.23倍。PicoF,LabreucheJ,Gourfinkel-AnI,AmarencoP,InvestigatorsG.Basilararterydiameterand5-yearmortalityinpatientswithstroke.Stroke.2006;37:2342-2347.基底動脈(basilarartery，BA)由左右兩條椎動脈在腦橋下緣匯合而成向上行于腦橋基底溝中全長3cm，寬1.5—4mm

至約左右動眼神經(jīng)根之間分為左右大腦后動脈（鞍背平面上6mm內(nèi)，鞍上池下方）正常解剖1.基底動脈2.腦橋動脈3.左小腦后下動脈（PICA）4.右AICA-PICA干5.左小腦前下動脈（AICA）6.PICA半球支7.小腦上動脈（SCA）8.SCA的蚓支9.小腦上動脈半球支左側(cè)椎動脈造影前后位病因先天因素：血管肌纖維發(fā)育異常、動脈內(nèi)彈力層缺如、和（或）平滑肌層萎縮等后天因素：影響血管發(fā)育并引起血管壁破壞的疾病，如動脈粥樣硬化、動脈炎性病變等病理生理血管肌纖維結(jié)構(gòu)和功能異常內(nèi)彈力膜的廣泛缺陷及中膜網(wǎng)狀纖維的缺乏機(jī)械壓迫

腦脊液壓力增高血流動力學(xué)改變

血流變慢，狀態(tài)紊亂成功的VBD動物實(shí)驗(yàn)?zāi)Ｐ?，人活體組織結(jié)構(gòu)變化?受壓迫腦神經(jīng)、腦干等病理結(jié)構(gòu)和生理變化?血流對迂曲血管切應(yīng)力作用變化、流入和流出道血流狀態(tài)變化?組織血液灌注學(xué)和組織代謝學(xué)?臨床表現(xiàn)缺血性腦血管疾病出血性腦血管疾病壓迫和顱神經(jīng)損害癥狀

腦橋和延髓

面n.、三叉n.、聽n.、動眼n.腦積水

神經(jīng)腦干壓迫癥狀

神經(jīng)壓迫癥狀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．影像學(xué)檢查CT平掃：誤、漏診率高。DSA：有創(chuàng)。MRA：清晰。MS3D-CTA：首選。Ubogu、Zaidat：MRA診斷標(biāo)準(zhǔn)擴(kuò)張：BA直徑≥4.5mmVA直徑≥4mm(Passero、Rossi)延長：BA上段超過鞍上池或床突平面6mm以上，或BA長度＞29.5mm，VA顱內(nèi)段長度＞23.5mm迂曲：BA橫向偏離超過起始點(diǎn)至分叉之間垂直連線1mm或位置在鞍背或斜坡的旁正中至邊緣間以外，而VA任意一支偏離超過椎動脈顱內(nèi)入口到基底動脈起始點(diǎn)之間連線10mm為異常。UboguEE,ZaidatOO.Vertebrobasilardolichoectasiadiagnosedbymagneticresonanceangiographyandriskofstrokeanddeath.JNeurolNeurosurgPsychiatry.2004;75:22-26.Smoker:HRCT診斷標(biāo)準(zhǔn)BA分叉高于鞍上池或位置位于旁正中之外且直徑≥4.5mm定義為VBD。SmokerWR,CorbettJJ,GentryLR,KeyesWD,PriceMJ,McKuskerS..AJNRAmJNeuroradiol.1986;7:61-72.若高度評分≥2或位置評分≥2即為延長BA偏移分級BA延長（高度）分級鞍背以下：0鞍上池以下：1第三腦室層面：3BA高度分級評分第三腦室層面：3鞍上池層面：1正中線上：0

旁正中線與邊緣間：2BA偏移分級評分M，65，trigeminalneuralgiafor4months治療以對癥治療和腦保護(hù)治療為主內(nèi)科治療：抗凝、抗血小板聚集、降壓、降糖、調(diào)脂等控制危險因素以預(yù)防缺血性卒中的發(fā)生外科治療：微血管減壓復(fù)位術(shù)、腔內(nèi)血管重建術(shù)、動脈瘤夾閉術(shù)等。ArthurdeAzambujaPereiraFilho.Brainstem

compression

syndrome

caused

by

vertebrobasilardolichoectasia.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參考文獻(xiàn)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.Brainstem

compression

syndrome

caused

by

vertebrobasilardolichoectasia.ArqNeuropsiquiatr2008;66(2-B):408-41112.PasseroSG,CalchettiB,BartaliniS.IntracranialBleedinginpatientswithvertebrobasilardolichoectasiaStroke,2005,36：1421-1425．13.Amin-HanjaniS,DuX,ZhaoM,etal.Useofquantitativemagneticresonanceangiographytostratifystrokeriskinsymptomaticvertebrobasilardisease.Stroke,2005,36:1140-1145.14.WoltersFJ,RinkelGJ,VergouwenMD.Clinicalcourseandtreatmentofvertebrobasilardolichoectasia:asystematicreviewoftheliterature.NeurologicalResearch.2013;35(2):131–137.15.MangrumWI,HustonJIII,LinkMJ,WiebersDO,McClellandRL,ChristiansonTJ,etal.Enlargingvertebrobasilarnonsaccularintracranialaneurysms:frequency,predictors,andclinicaloutcomeofgrowth.JNeurosurg.2005;102(1):72–9.16.WolfeD,UboguEE,Fernandes-FilhoJA,ZaidatOO.Predictorsofclinicaloutcomeandmortalityinvertebrobasilardolichoectasiadiagnosedbymagneticresonanceangiography.JStrokeCerebrovascDis.2008;17(6):388–93.17.FlemmingKD,WiebersDO,BrownRDJr,LinkMJ,HustonJ3rd,McClellandRL,etal.Thenaturalhi