Vertebral Artery Dissection

椎动脉夹层
  • 文章类型: Case Reports
    在年轻患者中,缺血性卒中是椎动脉夹层(VAD)的罕见结果。椎骨的损伤可以突然发生或由于创伤而发生。没有公认的诊断和治疗建议,大多数模糊的症状和延迟的表现提供了严重的诊断问题。虽然建议采用抗凝或抗血小板治疗的医疗管理,尚无成功的双重疗法的记录.虽然外伤性夹层是45岁以下人群后脑循环卒中的常见原因,但与自发性夹层相比,自发性VAD已得到充分报道,通常使用抗凝治疗。VAD可导致致命的并发症,如基底区梗死,即使它通常是无症状的。这是一例37岁男性,在双侧VAD后出现后循环中风,没有颈部外伤的证据,也没有可检测的原因提示自发病因。
    In young patients, ischemic stroke is an uncommon result of vertebral artery dissection (VAD). Damage to the vertebrae can occur suddenly or as a result of trauma. There are no generally recognized recommendations for diagnosis and treatment, and the majority of vague symptoms and delayed presentation provide a significant diagnostic problem. While medical management with anticoagulant or antiplatelet therapy is advised, no successful dual therapy has been documented. Although traumatic dissection is a more frequent cause of posterior cerebral circulation stroke in people under 45 years of age than spontaneous dissection, spontaneous VAD is well-reported and usually treated with anticoagulation. VAD can result in fatal complications such as basilar area infarction, even though it is often asymptomatic. Here is a case of a 37-year-old male who presented with a posterior circulation stroke after bilateral VAD with no evidence of trauma to the neck and no detectable cause suggesting spontaneous etiology.
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  • 文章类型: Journal Article
    背景:椎动脉夹层(VAD)的及时诊断和治疗对于预防中风至关重要。使用多普勒超声检查进行栓子检测研究(EDS)是一种新兴的方法,已被提出用于预测中风风险并指导后续治疗。关于这种新兴模式在后循环中的预测价值的数据有限。本研究旨在评估栓子检测研究(EDS)在预测VAD患者住院卒中中的预测价值,并确定相关的危险因素。患者在2009年1月至2018年1月之间招募。
    方法:我们对在我们机构接受EDS的104例连续VAD患者进行了回顾性分析。患者接受了经颅超声检查以检测微栓子,此后进行了临床和影像学随访,以了解中风的证据。
    结果:共有104例自发性患者(58%),我们的分析包括创伤性(39%)或医源性(4%)VAD.与创伤性VAD相比,自发性VAD患者的卒中发生率更高(p<0.001)。17例患者(16%)检出微栓子,包括18.3%的自发VAD,12.5%的创伤性VAD,和25%的医源性VAD。61例患者(59%)患有后循环卒中,然而,微栓子的检测与卒中事件之间没有显着关联(60%的无微栓子患者与53%的患者在EDS期间HITS≥1;p=0.6)。同样,在任何发生迟发性卒中的患者中均未发现微栓子.
    结论:在我们对VAD患者的单机构回顾性分析中,在EDS上检测到微栓子与卒中无关,也不能预测延迟卒中.此外,与创伤性VAD相比,自发性VAD患者的卒中风险可能更高.
    BACKGROUND: Prompt diagnosis and treatment of vertebral artery dissection (VAD) is critical for preventing stroke. The use of emboli detection studies (EDS) using Doppler ultrasonography is an emerging method that has been proposed to predict stroke risk and guide subsequent treatment. Limited data exists on the predictive value of this emerging modality in the posterior circulation. This study aims to assess the predictive value of emboli detection studies (EDS) in forecasting inpatient stroke in VAD patients and identify associated risk factors. Patients were recruited between January 2009 and January 2018.
    METHODS: We performed a retrospective analysis of 104 consecutive patients with VAD who underwent EDS at our institution. Patients underwent transcranial ultrasonography for detection of microemboli and were followed clinically and radiographically thereafter for evidence of stroke.
    RESULTS: A total of 104 patients with spontaneous (58 %), traumatic (39 %) or iatrogenic (4 %) VAD were included in our analysis. Stroke occurred more frequently in patients with spontaneous VAD compared to traumatic VAD (p < 0.001). Microemboli were detected in 17 patients (16 %), including 18.3 % of spontaneous VAD, 12.5 % of traumatic VAD, and 25 % of iatrogenic VAD. 61 patients (59 %) suffered a posterior circulation stroke, however there was no significant association between detection of microemboli and stroke events (60 % of patients without microemboli vs. 53 % of patients with ≥ 1 HITS during EDS; p = 0.6). Similarly, no microemboli were detected in any of the patients who went on to develop a delayed stroke.
    CONCLUSIONS: In our single-institution retrospective analysis of patients with VAD, the detection of microemboli on EDS was not associated with stroke nor was it predictive of delayed stroke. Additionally, patients with spontaneous VAD may be at higher risk for stroke compared to traumatic VAD.
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  • 文章类型: English Abstract
    背景:颈动脉夹层(CAD)是年轻人缺血性卒中(CVA)的主要原因。中风的危险因素和与CAD的时间关系没有很好的表征。我们也没有允许了解中风风险的临床放射学分类。
    目的:描述CAD患者ACVi的相关因素和时间性。
    方法:我们进行了一项前瞻性研究,包括18岁以上的患者,2009年8月至2017年6月期间因颈动脉和/或椎体CAD住院。临床和放射学诊断为CAD病例;当影像学研究显示梗塞时,诊断为ACVi。Borgess分类用于在放射学上表征CAD。对于相关性研究,我们使用单变量和多变量逻辑回归分析.
    结果:我们分析了163例182例CAD患者(60%椎体和40%颈动脉)。68例患者中有28例(41.2%)同时出现夹层和缺血症状。68例患者中有60例(88%)在第一周出现缺血症状。CAD:BorgessIB型(p=0.001;OR:4.1;CI:1.8-9.3),男性(p<0.001;OR:0.2;CI:0.06-0.8)与缺血性卒中和口服避孕药显著相关(p=0.02;OR:0.2;CI:0.06-0.8).
    结论:与CAD相关的卒中频率相对较低。它与解剖动脉的类型无关。它主要不与CAD同时发生并且在第一周内发生。发生中风的主要相关因素是动脉闭塞(BorgessIB型).1,8-9,3),男性(p<0.001;OR:0.2;CI:0.06-0.8)和口服避孕药(p=0.02;OR:0.2;CI:0.06-0.8)。
    BACKGROUND: Cervical artery dissections (CAD) are the leading cause of ischemic stroke (CVA) in young people. The risk factors for stroke and the temporal relationship with CAD are not well characterized. Nor do we have a clinical-radiological classification that allows knowing the risk of stroke.
    OBJECTIVE: To describe the associated factors and temporality of ACVi in patients with CAD.
    METHODS: We performed a prospective study that included patients over 18 years of age, hospitalized for carotid and/or vertebral CAD between August 2009 and June 2017. CAD cases were diagnosed clinically and radiologically; ACVi was diagnosed when the imaging study demonstrated infarction. The Borgess Classification was used to characterize the CAD radiologically. For correlation studies, we used univariate and multivariate logistic regression analyses.
    RESULTS: We analyzed 163 patients with 182 CAD (60% vertebral and 40% carotid). 28 of 68 patients (41.2%) simultaneously had symptoms of dissection and ischemia. 60 of 68 patients (88%) presented symptoms of ischemia during the first week. CAD: Borgess type IB (p = 0.001; OR: 4.1; CI: 1.8-9.3), male (p < 0.001; OR: 0.2; CI: 0.06- 0.8) were significantly associated with ischemic strokes and oral contraceptives (p = 0.02; OR: 0.2; CI: 0.06-0.8).
    CONCLUSIONS: Stroke associated with CAD has a relatively low frequency. It is not related to the type of dissected artery. It mainly occurs not simultaneously with CAD and within the first week. The main associated factor for developing a stroke is arterial occlusion (Borgess type IB).1,8-9,3), male sex (p < 0.001; OR: 0.2; CI: 0.06-0.8) and oral contraceptives (p = 0.02; OR: 0.2; CI: 0.06-0.8).
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  • 文章类型: Case Reports

    如果严重的颈脊髓损伤或严重的颈椎骨折,已确认半脱位或脱位,20-40%的病例有椎动脉夹层或闭塞。这些可能是无症状的,但除了颈髓和颈神经根症状外还能引起额外的神经损伤。椎动脉夹层可由直接损伤引起,刺伤或枪伤.间接椎动脉夹层可与半脱位同时发生,脱位,或复杂的颈椎骨折。CTA是选择的检查程序。在许多情况下,数字亚动血管造影检查和,如有必要,神经介入治疗必须先于开腹神经外科手术。在我们的报告中,在第一个病人中,C.VI椎骨完全脱位导致单侧椎动脉2段夹层闭塞,在我们的第二个病人身上,刺伤导致椎动脉直接压缩和夹层。在任何情况下,椎动脉闭塞均未引起神经系统症状。在我们两个案例中,在神经外科手术前,在椎动脉损伤水平进行母体血管闭塞.


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    If severe cervical spinal cord injury or severe cervical vertebral fracture, subluxation or luxation is confirmed, 20-40% of the cases have vertebral artery dissection or occlusion. These can be asymptomatic, but can cause additional neurological damage in addition to cervical myelon and cervical nerve root symptoms. Vertebral artery dissection can be caused by direct injuries, stab wounds or gunshot wounds. Indirect vertebral artery dissection can occur at the same time as subluxation, luxation, or complex fractures of the cervical vertebra. CTA is the examination procedure of choice. In many cases, digital subtaction angiography examination and, if necessary, neurointerventional treatment must precede open neurosurgery. In our report, in the first patient, complete luxation of the C.VI vertebra caused unilateral vertebral artery 2-segment dissection-occlusion, while in our second patient, a stab injury caused direct vertebral artery compression and dissection. The occlusion of the vertebral artery did not cause neurological symptoms in any of the cases. In both of our cases, parent vessel occlusion was performed at the level of the vertebral artery injury before the neurosurgical operation.

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    Ha súlyos nyaki gerincvelő-sérülést vagy súlyos nyaki csigolyatörést, subluxatiót vagy luxatiót igazolunk, akkor 20–40%-ban arteria vertebralis dissectio vagy okklúzió áll fenn. Ez lehet tünetmentes, de okozhat a nyaki myelon- és nyaki ideggyöktünetek mellett további neurológiai károsodásokat is. Az arteria vertebralis dissectio kialakulhat direkt sérülés által, szúrásos vagy lőtt sérülések esetén. Indirekt arteria vertebralis dissectio jöhet létre nyaki csigolya-subluxatióval, luxatióval vagy komplex csigolyatöréssel egy időben. CT-angiográfia az elsőként választandó vizsgálóeljárás. Számos esetben digitális szubsztrakciós angiográfia vizsgálatnak, illetve szükség esetén neurointervenciós beavatkozásnak kell megelőznie a nyílt idegsebészeti műtétet. Közleményünkben első betegünknél a C.VI. csigolya teljes luxálódása okozta az egyoldali arteria vertebralis kétszegmensnyi dissectiós elzáródását, míg második betegünknél szúrásos sérülés okozott direkt arteria vertebralis kompressziót és dissectiót. Az arteria vertebralis elzáródása egyik esetben sem okozott neurológiai tüneteket. Mindkét esetünkben az arteria vertebralis sérülésének magasságában szülőérelzárást végeztünk az idegsebészeti műtét előtt.

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  • 文章类型: Case Reports
    椎基底动脉系统由两个椎动脉组成,这两个椎动脉联合在颅底附近形成基底动脉。椎基底动脉系统中的动脉瘤由于其独特的形态学特征而与其他脑动脉瘤不同。它们可以是大的和凸出的(巨大的),压在脑干上.或者,他们可能是脆弱的,分裂(解剖)或有一个细长的形状(梭形)。在光谱的另一端,椎动脉动脉瘤(VA)也可以是小且圆形的(囊状)。这些动脉瘤可能发生在椎动脉本身或连接小脑后下动脉(PICA)的地方。解剖学上,它们位于脑干和颅神经附近,在后窝深处。脑脊髓液通过心室系统的腔室在其内部循环而保持传输和流动。椎动脉动脉瘤破裂有时会导致脑室内出血(IVH),导致蛛网膜下腔出血,然后外渗到心室。持续且控制不佳的高血压影响约50%的IVH患者。在这个案例报告中,我们研究了一名74岁的女性,她抱怨突然发作的头痛,在急诊室困扰了她三天。八年前,她被诊断出患有全身性高血压,并且没有按照处方服用药物。她被发现脖子僵硬,血压为170/100mmHg,随后出现呕吐。放射学调查显示,VAA具有很高的破裂风险并引起IVH。
    The vertebrobasilar system is made up of the two vertebral arteries that unite to form the basilar artery near the base of the skull. Aneurysms in the vertebrobasilar system are distinct from other cerebral aneurysms due to their unique morphologic characteristics. They can be large and bulging (massive), pressing on the brainstem. Alternatively, they might be weak and splitting apart (dissecting) or have an elongated shape (fusiform). On the other end of the spectrum, Vertebral artery aneurysms (VAAs) can also be small and rounded (saccular). These aneurysms can occur at the vertebral artery itself or where it joins the posterior inferior cerebellar artery (PICA). Anatomically, they are situated near the brainstem and cranial nerves, deep within the posterior fossa. The cerebrospinal fluid is kept in transit and flux by the ventricular system\'s chambers circulating the fluid within themselves. An intraventricular hemorrhage (IVH) can occasionally result from vertebral artery aneurysmal ruptures that result in bleeding into the subarachnoid space and then extravasate into the ventricles. Persistent and poorly controlled hypertension affects about 50% of individuals with IVH. In this case report, we study a 74-year-old woman who complained of a sudden onset headache that had been bothering her for three days at the medical emergency room. She had been diagnosed with systemic hypertension eight years prior and had not taken her medicines as prescribed. She was discovered to have rigidity in her neck and a blood pressure reading of 170/100 mmHg, which had been followed by an episode of vomiting. Radiological investigations revealed a VAA that had a high risk of rupturing and causing an IVH.
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  • 文章类型: Journal Article
    背景:据报道,头痛患者椎动脉夹层(VAD)破裂的实际风险非常低,从0.4%到1.0%不等。作者报告了一例病例,其中解剖部位在解剖发生后数小时内迅速扩张,导致蛛网膜下腔出血(SAH)。
    方法:一位参加过马拉松的49岁健康人在跑步时发现头痛。2天后进行的磁共振成像(MRI)未发现可疑的右VAD,但是在左侧观察到一个字符串标志,建议左VAD。核磁共振三小时后,他出现了严重的头痛,在家里昏迷不醒,促使紧急服务人员将他送往医院。计算机断层扫描显示弥漫性SAH和右椎动脉迅速扩大的动脉瘤扩张。他接受了血管内内部捕获以防止再出血。他出院了,没有任何神经症状。随访2年后无复发或新的夹层发生。
    结论:即使没有典型的影像学表现,严格管理,比如血压控制,当临床发现强烈提示VAD时需要,VAD与原发性头痛的区别很重要。https://thejns.org/doi/10.3171/CASE24202。
    BACKGROUND: The reported actual risk of rupture for vertebral artery dissection (VAD) in patients presenting with headache is very low, ranging from 0.4% to 1.0%. The authors report a case in which the dissection site dilated rapidly within several hours after the dissection occurred resulting in subarachnoid hemorrhage (SAH).
    METHODS: A 49-year-old healthy man who had participated in a marathon noticed a headache while running. Magnetic resonance imaging (MRI) performed 2 days later revealed no findings suspicious for right VAD, but a string sign was observed in the left side, suggesting left VAD. Three hours following MRI, he developed severe headaches and became unconscious at home, prompting emergency services to rush him to the hospital. A computed tomography scan showed diffuse SAH and a rapidly enlarged aneurysmal dilatation in the right vertebral artery. He underwent endovascular internal trapping to prevent rebleeding. He was discharged without any neurological symptoms. No recurrence or new dissection occurred after 2 years of follow-up.
    CONCLUSIONS: Even in the absence of typical imaging findings, strict management, such as blood pressure control, is required when clinical findings strongly suggest VAD, and differentiation of VAD from primary headache is important. https://thejns.org/doi/10.3171/CASE24202.
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  • 文章类型: Case Reports
    颈部动脉夹层(CAD)是年轻人中风的常见原因,可分为自发性或创伤性。最初的症状是头痛,颈部疼痛,和头晕。最近,一名57岁的妇女在使用颈颈牵引装置后出现严重头痛。头颈部放射学检查显示右椎动脉夹层,这强调了认识到使用颈颈牵引装置会增加创伤性椎动脉夹层的风险的重要性。
    Cervical arterial dissection (CAD) is a common cause of stroke in young people which can be classified as either spontaneous or traumatic. The primary initial symptoms are headache, neck pain, and dizziness. Recently, a 57-year-old woman experienced a severe headache after using a cervical neck traction device. Radiological examination of the head and neck revealed right vertebral artery dissection, which emphasizes the importance of recognizing that using cervical neck traction devices increases the risk of traumatic vertebral artery dissection.
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  • 文章类型: Journal Article
    椎动脉形态特征在自发性椎动脉夹层(sVAD)中至关重要。我们旨在研究与缺血性卒中(IS)相关的形态学特征,并开发一种新的预测模型。126名患者中,最后分析了93个。我们构建了三维模型和形态学分析。将患者随机分为训练和验证队列(3:1比例)。LASSO选择的变量-包括五个形态学特征和五个临床特征-用于在训练队列中开发预测模型。该模型显示出较高的曲线下面积(AUC)为0.944(95CI,0.862-0.984),内部验证确认其一致性(AUC=0.818,95CI,0.597-0.948)。决策曲线分析(DCA)提示临床有用性。形态学特征显著有助于sVAD患者的风险分层。我们新开发的模型,结合跨学科参数,在临床上对预测IS风险是有用的。需要进一步验证和深入研究与sVAD相关的血液动力学。
    The vertebral artery\'s morphological characteristics are crucial in spontaneous vertebral artery dissection (sVAD). We aimed to investigate morphologic features related to ischemic stroke (IS) and develop a novel prediction model. Out of 126 patients, 93 were finally analyzed. We constructed 3D models and morphological analyses. Patients were randomly classified into training and validation cohorts (3:1 ratio). Variables selected by LASSO - including five morphological features and five clinical characteristics - were used to develop prediction model in the training cohort. The model exhibited a high area under the curve (AUC) of 0.944 (95%CI, 0.862-0.984), with internal validation confirming its consistency (AUC = 0.818, 95%CI, 0.597-0.948). Decision curve analysis (DCA) indicated clinical usefulness. Morphological features significantly contribute to risk stratification in sVAD patients. Our novel developed model, combining interdisciplinary parameters, is clinically useful for predicting IS risk. Further validation and in-depth research into the hemodynamics related to sVAD are necessary.
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  • 文章类型: Journal Article
    颈脑动脉夹层是年轻人缺血性卒中的重要原因。一些研究表明,动脉弯曲与夹层有关。我们搜索了Pubmed和Embase,以确定动脉迂曲与颈脑动脉夹层之间关联的研究,并对颈脑血管迂曲和夹层的流行病学进行综述,病理生理学,血管弯曲度的测量,弯曲和解剖之间的关联强度,临床表现和管理策略。据报道,解剖的颈部动脉弯曲的患病率约为22%-65%,而非解剖的动脉仅为8%-22%。在曲折的宫颈动脉弹性蛋白和中膜降解中,增加墙壁刚度,血流动力学的变化以及动脉壁炎症可能与夹层有关。动脉迂曲指数和椎基底动脉偏斜度用于测量血管迂曲水平。研究表明,这两种测量与颈脑动脉夹层之间存在独立关联。弯曲的不同解剖变体,如环,线圈和扭结可能与颈脑动脉夹层有不同程度的关联。有症状的颅外颈动脉夹层患者通常使用抗凝剂或抗血小板药物治疗,而颅内动脉夹层患者通常仅由于考虑蛛网膜下腔出血而使用抗血小板治疗。复发性缺血患者,脑血流受损或抗血栓药物禁忌症通常采用开放手术或血管内技术治疗。蛛网膜下腔出血和颅内动脉夹层的患者由于再次出血的风险高,通常需要手术干预。
    Cervicocerebral artery dissection stands out as a significant contributor to ischemic stroke in young adults. Several studies have shown that arterial tortuosity is associated with dissection. We searched Pubmed and Embase to identify studies on the association between arterial tortuosity and cervicocerebral artery dissection, and to perform a review on the epidemiology of cervicocerebral artery tortuosity and dissection, pathophysiology, measurement of vessels tortuosity, strength of association between tortuosity and dissection, clinical manifestation and management strategies. The prevalence of tortuosity in dissected cervical arteries was reported to be around 22%-65% while it is only around 8%-22% in non-dissected arteries. In tortuous cervical arteries elastin and tunica media degradation, increased wall stiffness, changes in hemodynamics as well as arterial wall inflammation might be associated with dissection. Arterial tortuosity index and vertebrobasilar artery deviation is used to measure the level of vessel tortuosity. Studies have shown an independent association between these two measurements and cervicocerebral artery dissection. Different anatomical variants of tortuosity such as loops, coils and kinks may have a different level of association with cervicocerebral artery dissection. Symptomatic patients with extracranial cervical artery dissection are often treated with anticoagulant or antiplatelet agents, while patients with intracranial arterial dissection were often treated with antiplatelets only due to concerns of developing subarachnoid hemorrhage. Patients with recurrent ischemia, compromised cerebral blood flow or contraindications for antithrombotic agents are usually treated with open surgery or endovascular technique. Those with subarachnoid hemorrhage and intracranial artery dissection are often managed with surgical intervention due to high risk of re-hemorrhage.
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  • 文章类型: English Abstract
    OBJECTIVE: Craniocervical dissections are among the most common causes of stroke in people aged under 50 years, which is why it is essential to clarify, diagnose, and treat them as quickly as possible. Dissections usually occur spontaneously due to bleeding into the vessel wall. The affected segments are usually the motion segments of the internal cerebral artery (C1 segment) and the vertebral artery (V3 segment). Clinically, there is head and/or neck pain and neurologic symptoms, which can vary according to the localization of the dissection.
    CONCLUSIONS: Pathognomonic is the detection of an intramural hematoma due to bleeding into the vessel wall. This can best be detected by magnetic resonance imaging (MRI) in native, fat-saturated T1 sequences (black-blood sequence). In addition, contrast-enhanced angiography should be performed using MRI or, alternatively, computed tomography (CT). As there is an increased risk of embolic or hemodynamically induced strokes, prophylactic treatment should be initiated immediately; it remains a case-by-case decision whether antiplatelet agents or oral anticoagulants are chosen for this purpose.
    UNASSIGNED: KLINISCHES PROBLEM: Dissektionen der hirnzuführenden Gefäße gehören zu den häufigsten Ursachen eines Schlaganfalls bei Personen unter 50 Jahren, weswegen eine schnellstmögliche Abklärung, Diagnostik und Therapie essenziell sind. Sie entstehen meistens spontan durch Einblutung in die Gefäßwand. Betroffen sind in der Regel die Bewegungssegmente an der A. cerebri interna (C1-Segment) und an der A. vertebralis (V3-Segment). Klinisch kommt es zu Kopf- und/oder Nackenschmerzen sowie neurologischen Symptomen, die sich entsprechend der Lokalisation der Dissektion unterscheiden können. EMPFEHLUNG FüR DIE PRAXIS: Pathognomisch ist der Nachweis eines intramuralen Hämatoms durch Einblutung in die Gefäßwand. Dieses lässt sich am besten in der Magnetresonanztomographie (MRT) in nativen, fettgesättigten T1-Sequenzen (Black-Blood-Sequenz) nachweisen. Zusätzlich sollte eine kontrastmittelgestützte Angiographie am besten in der MRT, alternativ in der Computertomographie (CT), erfolgen. Da ein erhöhtes Risiko für embolisch oder hämodynamisch bedingte Schlaganfälle besteht, sollte unmittelbar eine prophylaktische Therapie eingeleitet werden; dabei bleibt es eine Einzelfallentscheidung, ob hierfür Thrombozytenfunktionshemmer oder orale Antikoagulanzien gewählt werden.
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