摘要
目的：
统计基底动脉延长扩张症(basilar dolichoectasia, BD)的症状学表现,探讨症状性与非症状性BD的临床差异,分析BD与脑白质病变的关系。
方法：
根据既定标准,对2012.1-2013.1在我科行头颅MRA或CTA检查全部患者进行筛查,选出符合BD诊断的患者,根据临床表现分为症状组与非症状组,并对两组进行基线数据的统计分析,包括年龄、性别、血管危险因素、血糖、血脂、血压、尿酸、肾功能等。根据症状表现的不同,进一步分出血管症状者和压迫症状者,并分析不同症状表现的临床差异。最后,评估BD患者的脑白质病变程度,并分析BD与脑白质病变的相关性。
结果：
BD在该数据库的发生率为7.3%。症状性BD患者的基底动脉直径、舒张压和尿酸水平显著高于非症状性BD者。血管性症状的患者基底动脉直径显著大于无血管性症状者(t=-2.612,P<0.05),而且血管性症状者的基线收缩压、舒张压、既往高血压病史发生率均显著高于无血管性症状者。压迫症状组患者尿酸(P<0.05)和主动脉直径(P<0.05)高于无压迫症状组。BD患者基底动脉直径与脑白质病变显著相关(R=0.495,P<0.05)。
结论：
症状性BD患者的动脉直径更大,舒张压更高,尿酸水平也更高。血管性症状者基底动脉直径更大,但压迫症状者的基底动脉直径与无压迫症状者的无显著差异。BD患者的直径越大,脑白质病变程度越严重。对BD患者尽早严格控制血压可能有利于减少症状(尤其是血管性症状)的发生率,对尿酸增高的BD患者可能考虑降尿酸治疗。
Objective:
To investigate differences in clinical manifestations between patients with symptomatic and non-symptomatic basilar dolichoectasia (BD) and to find out the relationship between BD and leukoencephalopathy.
Methods:
We retrospectively analyzed our patients with CTA or MRA admitted in our hospital from January2012to January2013. We compared the baseline characteristics, risk factors of cerebrovascular events, and kidney function between patients with symptomatic and non-symptomatic basilar dolichoectasia. We also divided the symptoms into vascular events and compressive symptoms. We computed the correlation coefficients between basilar diameter and the degree of leukoencephalopathy.
Results:
The diameter of basilar artery in symptomatic BD patients was larger, and the level of diastolic blood pressure and uric acid were higher, compared to those without symptoms. The group of vascular symptoms had greater basilar artery diameter, higher baseline systolic/diastolic blood pressure, and higher incidence rate of previous history of hypertension, compared to those without vascular symptoms. BD patients with compressive symptoms had higher level of uric acid than those with non-compressive symptoms. The diameter of basilar artery correlated significantly with leukoencephalopathy.
Conclusion:
Patients with symptomatic BD have larger basilar diameter and higher blood pressure. The larger diameter of the basilar artery indicates the higher risk of leukoencephalopathy. We suggest that strict control of blood pressure in the early stage may be beneficial to reduce symptoms (especially the incidence of the vascular symptoms) of BD patients and uric acid lowering therapy may be considered for patients with high level of uric acid.
引文
[1]Caplan LR. Dilatative arteriopathy (Dolichoectasia):what is known and not known. Ann Neurol,2005.57(4):p.469-71.
[2]Tsutsumi S, Yasumoto Y, Ito M. Atypical megadolichoectasia manifesting as brain infarction rapidly followed by fatal subarachnoid hemorrhage. J Neuroimaging,2010.20(4):p.376-8.
[3]D'Andrea F, Maiuri F, Gangemi M, Laconetta G. Megadolichobasilar anomaly. Clinical and diagnostic considerations on 30 cases. Acta Neurol,1992.14(4-6):p. 611-9.
[4]Scott M, Stauffer HM. A case of aneurysmal malformation of the vertebral and basilar arteries causing cranial nerve involvemen. Am J Roentgenol Radium Ther Nucl Med,1964.92:p.836-7.
[5]Takamiya Y, Toya S, Kawase T, Takenaka N, Shiga H. Trigeminal neuralgia and hemifacial spasm caused by a tortuous vertebrobasilar system. Surg Neurol 1985;24(5):559-62.
[6]Smoker WR, Corbett JJ, Gentry LR, et al. High-resolution computed tomography of the basilar artery:Clinical pathologic correlation and review. Am J Neuroradiol,1986.7(1):61-72.
[7]Ince B, Petty GW, Brown RD, Jr., et al. Dolichoectasia of the intracranial arteries in patients with first ischemic stroke:a population-based study. Neurology 1998;50(6):p.1694-1698.
[8]Pico F, Labreuche J, Touboul PJ, et al. Intracranial arterial dolichoectasia and small-vessel disease in stroke patients. Ann Neurol,2005.57(4):p.472-479.
[9]Ubogu EE, Zaidat OO. Vertebrobasilar dolichoectasia diagnosed by magnetic resonance angiography and risk of stroke and death:a cohort study. J Neurol Neurosurg Psychiatry,2004.75(1):p.22-26.
[10]Park JM, Koo JS, Kim BK, et al. Vertebrobasilar dolichoectasia as a risk factor for cerebral microbleeds. Eur J Neurol,2013.20(5):p.824-30.
[11]Ken Ikeda, Yoshikazu Nakamura, Takehisa Hirayama, et al. Cardiovascular risk and neuroradiological profiles in asymptomatic vertebrobasilar dolichoectasia. Cerebrovasc Dis,2010.30(1):p.23-8.
[12]范晓颖,唐光健,蒋学祥。头颅CT平扫诊断椎基底动脉延长扩张症。中国医学影像技术,2002.1(3)：p.214-217。
[13]Jose Gutierrez, Ralph L.Sacco and Cliton B.Wright. Dolichoectasia-an evolving artery disease. Nat. Rev. Neurol,2011.7(1):p.41-50.
[14]Klinge, Braunsdorf H, W.E. Clinical signs associated with megadolichobasilar artery anomaly. Neurosurg Rev,1991.14(4):p.303-307.
[15]Chen KD, et al. Mechanotransduction in response to shear stress. Roles of receptor tyrosine kinases, integrins, and Shc. J.Biol.Chem,1999.274(26):p. 18393-400.
[16]Sho E, et al. Arterial enlargement in response to high flow requires early expression of matrix metalloproteinases to degrade extracellular matrix. Exp.Mol.Pathol,2002.73(2):p.142-153.
[17]Tronc F, et al. Role of matrix metalloproteinases in blood flow-induced arterial enlargement:interaction with NO. Arterioscler. Thromb. Vasc. Biol, 2000.20(12):E120-126.
[18]Meng H, et al. Complex hemodynamics at the apex of an arterial bifurcation induces vascular remodeling resembling cerebral aneurysm initiation. Stroke, 2007.38(6):p.1924-1931.
[19]Hoi Y, et al. In vivo assessment of rapid cerebrovascular morphological adaptation following acute blood flow increase. J. Neurosurg,2008.109(6):p. 1141-1147.
[20]Lehoux S, Castier Y and Tedgui A. Molecular mechanisms of the vascular responses to haemodynamic forces. J.Intern.Med,2006.259:p.381-392.
[21]Silverman IE, Berman DM, Dike GL, et al. Vertebrobasilar dolichoectasia associated with Marfan syndrome. J.Stroke Cerebrovasc. Dis,2000.9:p.196-8.
[22]Rubinstein MK and Cohen NH. Ehlers-Danlos syndrome associated with multiple intracranial aneurysms. Neurology,1964.14:p.125-132.
[23]Mitsias P and Levine SR. Cerebrovascular complications of Fabry's disease. Ann. Neural,1996.40(1):p.10-14.
[24]Steen GR, Langston JW, Ogg RJ, et al. Ectasia of the basilar artery in children with sickle cell disease:relationship to hematocrit and psychometric measures. J. Stroke Cerebrovasc. Dis,1998.7(1):p.32-43.
[25]Garzuly, Marodi FL, Erdos M., et al. Megadolichobasilar anomaly with thrombosis in a family with Fabry's disease and a novel mutation in the alpha-galactosidase A gene. Brain,2005.128(9):p.2078-83.
[26]Schievink WI, Torres VE, Wiebers DO and Huston J. Intracranial arterial dolichoectasia in autosomal dominant polycystic kidney disease. J. Am. Soc. Nephrol 1997.8(8):p.1298-1303.
[27]Graf S, Schischma A, Eberhardt KE, et al. Intracranial aneurysms and dolichoectasia in autosomal dominant polycystic kidney disease. Nephrol. Dial. Transplant,2002.17(5):p.819-823.
[28]Nakatomi H, Seqawa H, Kurata A, et al. Clinicopathological study of intracranial fusiform and dolichoectatic aneurysms:insight on the mechanism of growth. Stroke,2000.31(4):p.896-900.
[29]Levine RL, Turski PA, Grist TM. Basilar artery dolichoectasia:Review of the literature and six patients studied with magnetic resonance angiography. J. Neuroimaging,1995.5(3):p.164-170.
[30]Passero SG, Calchetti B. and Bartalini S. Intracranial bleeding in patients with vertebrobasilar dolichoectasia. Stroke,2005.36(7):p.1421-5.
[31]Pico F, Labreuche J, Cohen A, et al. Intracranial arterial dolichoectasia is associated with enlarged descending thoracic aorta. Neurology,2004.63(11):p. 2016-21.
[32]Sacks JG, Lindenburg R. Dolichoectatic intracranial arteries:symptomatology and pathogenesis of arterial elongation and distension. Johns Hopkins Med J, 1969.125(2):p.95-106.
[33]Yu YL, Moseley IF, Pullicino P, McDonald WI. The clinical picture ofectasia of the intracerebral arteries. J Neurol Neurosurg Psychiatry,1982.45(1):p.29-36.
[34]Nishizaki I, Tamaki N, Takeda N, Shirakuni T, Kondoh T, Matsumoto S. Dolichoectatic basilar artery:a review of 23 cases. Stroke,1986.17(6):p. 1277-81.
[35]Pico F, Labreuche J, Seilhean D, Duyckaerts C, Hauw JJ and Amarenco P. Association of small-vessel disease with dilatative arteriopathy of the brain: neuropathologic evidence. Stroke,2007.38(4):p.1197-202.
[36]Fazekas F, Chawluk JB, Alavi A, Hurtig HI, Zimmerman RA. MR signal abnormalities at 1.5T in Alzheimer's dementia and normal aging. Am J Neuroradiol,1987.149(2):351-6.
[37]Siddiqui A,Chew NS, Miszkiel K. Vertebrovasilar dolichoectasia a rare cause of obstructive hydrocephalus. Br J Radiol,2008.81(964):e123-e126.
[38]Wu XW, Muzny DM, Lee CC, Caskey CT. Two independent mutational events in the loss of urate oxidase during hominoid evolution. J Mol Evol, 1992.34(1):p.78-84.
[39]Gersch C, Palii SP, Kim KM, Anerhofer A, Johnson RJ. Inactivation of nitric oxide by uric acid. Nucleosides Nucleotide Nucleic Acids,2008.27(8):p.967-78.
[40]Schwartz IF, Grupper A, Chernichovski T, et al. Hyperuricemia attenuates aortic nitric oxide generation, through inhibition of arginine transport in rats. J Vasc Res,2011.48(3):p.252-60.
[41]Zhaikov S, Krotova K, Hu H, et al. Uric acid decreases NO production and increases arginase activity in cultured pulmonary artery endothelial cells. Am J Physiol Cell Physiol,2008.295(5):C1183-90.
[42]Kanellis J and Johnson RJ. Elevated uric acid and ischemic stroke:Accumulating evidence that it is injurious and not neuroprotective. Stroke,2003.34(8):p.1956-7.
[43]Kanbay M, Segal M, Afsar B, et al. The role of uric acid in the pathogenesis of human cardiovascular disease. Heart,2013.99(11):p.759-66.
[44]Pico F, Labreuche J, Gourfinkel An I, Amarenco P. On behalf of the GENIC investigators. Basilar artery diameter and 5-year mortality in paitents with stroke. Stroke,2006.37(9):2342-7.
[45]Sarikaya S and Sarikaya B. Natural history of vertebrobasilar dolichoectasia. Neurology,2008.71(18):p.66-72.
[46]Anson JA, Lawton MT and Spetzler RE Characteristics and surgical treatment of dolichoectatic and fusiform aneurysms. J. Neurosurg,1996.84(2):p.185-193.
[47]Pico F, Biron Y, Bousser MG and Amarenco P. Concurrent dolichoectasia of basilar and coronary arteries. Neurology,2005;65(9):p.1503-4.
[48]Nijensohn DE, Saez RJ and Reagan TJ. Clinical significance of basilar artery aneurysms. Neurology,1974.24(4):p.301-5.
[49]Vermeer SE, Hollander M, van Dijk EJ, et al. Silent brain infarcts and white matter lesions increase stroke risk in the general population:The Rotterdam scan study. Stroke,2003.34(5):p.1126-1129.
[50]Grueter BE and Schulz UG. Age-related cerebral white matter disease (leukoaraiosis):a review. Postgrad Med J,2012.88(1036):p.79-87.
[51]Rosenberg GA, Sullivan N, Esiri MM. White matter damage is associated with matrix metalloproteinases in vascular dementia. Stroke,2011.32(5):p.1162-1168.
[52]Pico F, Jacob MP, Labreuche J, et al. Matrix metalloproteinase-3 and intracranial arterial dolichoectasi. Ann Neurol,2010.67(4):p.508-15.
[53]Lamblin N, Bauters C, Hermant X, Lablanche JM, Helbecque N, Amouyel P. Polymorphisms in the promoter regions of MMP-2, MMP-3, MMP-9 and MMP-12 genes as determinants of aneurysmal coronary artery disease. J Am Coll Cardiol,2002.40(1):p.43-48.
[54]Keeling WB, Armstrong PA, Stone PA, Bandyk DF, Shames ML. An overview of matrix metalloproteinases in the pathogenesis and treatment of abdominal aortic aneurysms. Vasc Endovasc Surg,2005.39(6):p.457-464.
[55]Baccin CE, Krings T, Alvarez H, et al. A report of two cases with dolichosegmental intracranial arteries as a new feature of PHACES syndrome. Childs Nerv Syst,2007.23(5):p.559-567.
[56]Laforet P, Petiot P, Nicolino M, et al. Dilative arteriopathy and basilar artery dolichoectasia complicating late-onset Pompe disease. Neurology, 2008.70(22):p.2063-2066.
[57]Brichaux JC, Gense D, Greselle JF, et al. Radioclinical problems raised by megalodolichobasilar artery:17 cases and review of the literature. J Neuroradiol, 1989.16(1):p.11-24.
[1]Caplan LR. Dilatative arteriopathy (Dolichoectasia):what is known and not known. Ann Neurol,2005.57(4):p.469-71.
[2]Lou M and Caplan LR. Vertebrobasilar dilatative arteriopathy (dolichoectasia). Ann. N.Y. Acad. Sci,2010.1184:p.121-33.
[3]Ince B, Petty GW, Brown RD, Jr., et al. Dolichoectasia of the intracranial arteries in patients with first ischemic stroke:a population-based study. Neurology 1998;50(6):p.1694-1698.
[4]Pico F, Labreuche J, Touboul PJ, et al. Intracranial arterial dolichoectasia and small-vessel disease in stroke patients. Ann Neurol,2005.57(4):p.472-479.
[5]Ubogu EE, Zaidat 00. Vertebrobasilar dolichoectasia diagnosed by magnetic resonance angiography and risk of stroke and death:a cohort study. J Neurol Neurosurg Psychiatry,2004.75(1):p.22-26.
[6]Park JM, Koo JS, Kim BK, et al. Vertebrobasilar dolichoectasia as a risk factor for cerebral microbleeds. Eur J Neurol,2013.20(5):p.824-30.
[7]Ken Ikeda, Yoshikazu Nakamura, Takehisa Hirayama, et al. Cardiovascular risk and neuroradiological profiles in asymptomatic vertebrobasilar dolichoectasia. Cerebrovasc Dis,2010.30(1):p.23-8.
[8]范晓颖,唐光健,蒋学祥。头颅CT平扫诊断椎基底动脉延长扩张症。中国医学影像技术,2002.1(3)：p.214-217。
[9]Wolfe T, Ubogu EE, Fernandes-Filho JA and Zaidat OO. Predictors of clinical outcome and mortality in vertebrobasilar dolichoectasia diagnosed by magnetic resonance angiography. J. Stroke Cerebrovasc. Dis,2008.17(6):388-93.
[10]Jose Gutierrez, Ralph L.Sacco and Cliton B.Wright. Dolichoectasia- an evolving artery disease. Nat. Rev. Neurol,2011.7(1):p.41-50.
[11]Sarikaya S and Sarikaya B. Natural history of vertebrobasilar dolichoectasia. Neurology,2008.71(18):p.66-72.
[12]Levine RL, Turski PA, Grist TM. Basilar artery dolichoectasia:Review of the literature and six patients studied with magnetic resonance angiography. J. Neuroimaging,1995.5(3):p.164-170.
[13]Savitz SI, Ronthal M, Caplan LS. Verbebral artery compression of medulla. Arch Neurol,2006.63(2):p.234-241.
[14]Passero SG, Calchetti B. and Bartalini S. Intracranial bleeding in patients with vertebrobasilar dolichoectasia. Stroke,2005.36(7):p.1421-5.
[15]Saloheimo P, Juvela S and Hillbom M. Use of aspirin, epistaxis and untreated hypertension as risk factors for primary intracerebral hemorrhage in middle-aged and elderly people. Stroke,2001.32(2):p.399-404.
[16]Rabb CH and Barnwell SL. Catastrophic subarachnoid hemorrhage resulting from ruptured vertebrobasilar dolichoectasia:case report. Neurosurgery, 1998.42(2):p.379-82.
[17]Barker FG II, Jannetta PJ, Bissonette DJ, et al. Microvascular decompression for hemifacial spasm. J.Neurosurg,1995.82(2):p.201-10.
[18]Staikov IN, Mattle HP. Vertebrobasilar dolichoectasia and exertional headache. J. Neurol. Neurosurg. Psychiatry,1994.57(12):p.1544.
[19]Siddiqui A, Chew NS and Miszkiel K. Vertebrobasilar dolichoectasia:a rare cause of obstructive hydrocephalus:case report. Br. J. Radiol,2008.81(964): p.123-126.
[20]Breig A, Ekbom K, Greitz T, et al. Hydrocephalus due to elongated basilar artery:a new clinicoradiological syndrome. Lancet,1967.1(7495):p.874-75.
[21]Gautier JC, Hauw JJ, Awada A, et al. Dolichoectatic intracranial arteries. Association with aneurysms of the abdominal aorta. Rev. Neurol.(Paris),1988.144(6-7):p.437-46.
[22]Hegedus K. Ectasia of the basilar artery with special reference to possible pathogenesis. Surg. Neurol,1985.24(4):463-9.
[23]Brichaux JC, Gense D, Greselle JF,et al. Radioclinical problems raised by megalodolichobasilar artery:17 cases and review of the literature. J Neuroradiol 1989;16(1):p.11-24.
[24]Klinge H and Braunsdorf WE. Clinical signs associated with megadolichobasilar artery anomaly. Neurosurg Rev,1991.14(4):p.303-7.
[25]Chen KD, et al. Mechanotransduction in response to shear stress. Roles of receptor tyrosine kinases, integrins and Shc. J. Biol. Chem,1999.274(26):p. 18393-400.
[26]Sho E, Sho M, Singh TM, et al. Arterial enlargement in response to high flow requires early expression of matrix metalloproteinases to degrade extracellular matrix. Exp.Mol.Pathol,2002.73(2):p.142-153.
[27]Tronc F, Mallat Z, Lehoux S, et al. Role of matrix metalloproteinases in blood flow induced arterial enlargement:interaction with NO. Arterioscler. Thromb. Vase. Biol,2000.20(12):p.120-126.
[28]Meng H, et al. Complex hemodynamics at the apex of an arterial bifurcation induces vascular remodeling resembling cerebral aneurysm initiation. Stroke, 2007.38(6):p.1924-31.
[29]Pico F, Jacob MP, Labreuche J, et al. Matrix metalloproteinase-3 and intracranial arterial dolichoectasia. Ann Neurol,2010.67(4):p.508-15.
[30]Smoker WR, Corbett JJ, Gentry LR, et al. High-resolution computed tomography of the basilar artery, vertebrobasilar dolichoectasia:clinical-pathologic correlation and review. Am. J. Neuroradiol,1986.7(1):p.61-72.
[31]Pico F, Labreuche J, Touboul PJ and Amarenco P. Intracranial arterial dolichoectasia and its association with carotid atherosclerosis and stroke subtype. Neurology,2003.61(12):p.1736-42.
[32]Pico F, Labreuche J, Cohen A, et al. Intracranial arterial dolichoectasia is associated with enlarged descending thoracic aorta. Neurology,2004.63(11):p. 2016-21.
[33]Pico F, Biron Y, Bousser MG and Amarenco P. Concurrent dolichoectasia of basilar and coronary arteries. Neurology,2005;65(9):p.1503-4.
[34]Yu YL, Moseley IF, Pullicino P, McDonald WI. The clinical picture ofectasia of the intracerebral arteries. J Neurol Neurosurg Psychiatry,1982.45(1):p.29-36.
[35]Nishizaki I, Tamaki N, Takeda N, Shirakuni T, Kondoh T, Matsumoto S. Dolichoectatic basilar artery:a review of 23 cases. Stroke,1986.17(6):p. 1277-81.
[36]Silverman IE, Berman DM, Dike GL, et al. Vertebrobasilar dolichoectasia associated with Marfan syndrome. J.Stroke Cerebrovasc. Dis,2000.9:p.196-8.
[37]Rubinstein MK and Cohen NH. Ehlers-Danlos syndrome associated with multiple intracranial aneurysms. Neurology,1964.14:p.125-132.
[38]Mitsias P and Levine SR. Cerebrovascular complications of Fabry's disease. Ann. Neurol,1996.40(1):p.10-14.
[39]Steen GR, Langston JW, Ogg RJ, et al. Ectasia of the basilar artery in children with sickle cell disease:relationship to hematocrit and psychometric measures. J. Stroke Cerebrovasc. Dis,1998.7(1):p.32-43.
[40]Garzuly, Marodi FL, Erdos M., et al. Megadolichobasilar anomaly with thrombosis in a family with Fabry's disease and a novel mutation in the alpha-galactosidase A gene. Brain,2005.128(9):p.2078-83.
[41]Schievink WI, Torres VE, Wiebers DO and Huston J 3rd. Intracranial arterial dolichoectasia in autosomal dominant polycystic kidney disease. J. Am. Soc. Nephrol,1997.8(8):p.1298-303.
[42]Graf S, Schischma A, Eberhardt KE, et al. Intracranial aneurysms and dolichoectasia in autosomal dominant polycystic kidney disease. Nephrol. Dial. Transplant,2002.17(5):p.819-823.
[43]Grueter BE and Schulz UG. Age-related cerebral white matter disease (leukoaraiosis):a review. Postgrad Med J,2012.88(1036):p.79-87.
[44]Pico F, Labreuche J, Seilhean D, Duyckaerts C, Hauw JJ and Amarenco P. Association of small-vessel disease with dilatative arteriopathy of the brain: neuropathologic evidence. Stroke,2007.38(4):p.1197-202.
[45]Rosenberg GA, Sullivan N, Esiri MM. White matter damage is associated with matrix metalloproteinases in vascular dementia. Stroke,2011.32(5):p.1162-1168.
[46]Park JM, Koo JS, Kim BK, et al. Vertebrovasilar dolichoectasia as a risk factor for cerebral microbleeds. Eur J Neurol,2013.20(5):824-30.
[47]Milandre L, Bonnefoi B, Pestre P, et al. Vertebrobasilar arterial dolichoectasia. Complications and prognosis. Rev. Neurol.(Paris),1991.147(11):p.714-22.
[48]Pico F, Labreuche J, Gourfinkel An I, Amarenco P. On behalf of the GENIC investigators. Basilar artery diameter and 5-year mortality in paitents with stroke. Stroke,2006.37(9):2342-7.