基底动脉弯曲与血管性眩晕或后循环梗死的关联研究
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摘要
背景：
随着磁共振血管成像(MRA)及CT血管成像(CTA)作为脑血管检查方法的广泛应用,发现有许多基底动脉呈不同程度弯曲的患者或健康体检者。而临床和影像学医师大多只是关注有无血管狭窄和闭塞,忽视了血管弯曲的存在。基底动脉弯曲的原因尚不清楚,是否与动脉粥样硬化有关,是否是缺血性脑卒中发生的相关因素也存在着争议。大家较为关注的是基底动脉延长迂曲症研究,发现其与后循环脑血管病可能存在着关联,然而临床上有许多不能归属于基底动脉延长迂曲症的基底动脉弯曲,这种基底动脉弯曲与血管性眩晕或后循环脑梗死的关系尚不为关注。
目的：
探讨椎动脉优势、基底动脉弯曲与血管性眩晕或后循环梗死的关系；分析椎基底动脉迂曲或发育异常在不同年龄及不同部位后循环梗死患者中的分布差异；基于头颅MRA或CTA对颅内外血管评估结果,分析基底动脉弯曲及脑干梗死患者的临床危险因素；并探讨基底动脉弯曲长度和理论长度等的变化、血管危险因素暴露与桥脑梗死之间的关系。进而拓宽对脑血管病的血管病因认识。
对象与方法：
本研究自2009年4月至2012年12月连续收集入住我院神经内科的年龄≥18岁的眩晕或年龄≥40岁的急性后循环梗死患者,详细记录病史资料、相关量表及辅助检查资料,尤其关注后循环血管状态。数据处理分为5个部分。1.至2010年2月连续纳入81例住院眩晕患者,选取资料完整并符合入组标准的64例进行分析。头部MRA检查发现椎动脉优势的眩晕患者作为研究组,以非椎动脉优势的眩晕患者作为对照组。对患者眩晕程度进行分级和脑干听觉诱发电位(BAEP)检查,分析两组患者基底动脉情况、BAEP的变化及其与椎动脉优势的关系。
2.至2011年7月共有269例眩晕患者住院,选取资料完整并符合入组标准的237例进行分析。对连续入选的眩晕患者进行颅内外血管MRA或CTA检查及血管危险因素筛查。分为基底动脉弯曲和无弯曲的患者,把基底动脉弯曲进行分级,采用多因素Logistic回归分析寻找基底动脉弯曲的危险因素。
3.至2011年7月共有急性后循环梗死患者117例,选取资料完整并符合入组标准的96例进行分析。入组患者均经头颅核磁共振(MRI)弥散加权成像(DWI)确定急性后循环脑梗死的诊断。采用头颈部MRA或CTA评定基底动脉、椎动脉、大脑后动脉及颈内动脉病变、发育情况和迂曲等状态。根据梗死部位为脑干梗死,小脑梗死组,丘脑、颞叶内侧面及枕叶梗死组,后循环联合部位梗死组；根据年龄分为大于65岁组和小于65岁组；对血管评估结果进行年龄和不同部位的分层分析。
4.至2011年12月共有急性后循环梗死患者129例,选取资料完整并符合入组标准的脑干梗死患者65例,结合同时期资料完整的急性大半脑梗死128例,进行危险因素分析。对连续入选的急性脑干梗死患者进行颅内外血管MRA或CTA检查及血管危险因素筛查。把基底动脉弯曲进行分级,结合急性大脑半球梗死患者,采用多因素Logistic回归分析寻找脑干梗死危险因素。
5.至2012年12月共有急性桥脑梗死患者97例住院,选择资料完整并符合入组标准的88例进行分析。对连续入选的患者均经MRI-DWI确定急性桥脑梗死的诊断,根据基底动脉情况分为基底动脉弯曲组和无弯曲组,设立基底动脉弯曲无脑梗死并拟诊为血管性眩晕患者为对照组。依MRA测量基底动脉弯曲患者的基底动脉理论长度(BAL)和基底动脉弯曲长度(BL)及基底动脉直径、双侧椎动脉直径,详细记录血管危险因素暴露情况,比较三组之间血管危险因素的差异。对桥脑梗死患者危险因素进行单因素和多因素分析,把BL进行分级,探讨其与桥脑梗死的关系,并把双侧椎动脉直径差异进行分级,进一步分析双侧椎动脉直径差异与BL和BAL之间的相关性。
结果：
1.椎动脉优势患者眩晕严重级别与非椎动脉优势患者比较差异有统计学意义(P<0.01),椎动脉优势组基底动脉形状异常率与非椎动脉优势组比较差异有统计学意义(P<0.05)。椎动脉优势组I、V波峰潜伏时(PL)、III-V峰间潜伏时(IPL)、Ⅰ-Ⅴ IPL及Ⅲ-Ⅴ/Ⅰ-Ⅲ匕值均较非椎动脉优势组增大,差异均有统计学意义(P<0.01),III波PL与非优势组比较,差异均有统计学意义(P<0.05),Ⅰ-ⅢIPL与非优势组比较,差异无统计学意义(P>0.05)。椎动脉优势与BAEP各主要异常指标之间有明显相关性,与Ⅲ-Ⅴ/Ⅰ-Ⅲ相关性最显著(r=0.617,P=0.013)。
2.多因素Logistic回归分析显示,基底动脉延长(OR值21.56,95%CI：6.74-18.24,P<0.001)和椎动脉优势(OR值36.34,95%CI：6.98-24.38,P<0.001)是眩晕患者基底动脉弯曲的危险因素。
3.大于65岁组与小于65岁组比较,椎动脉优势、椎基底动脉发育或起源异常情况比较差异无统计学意义(P>0.05),椎基底动脉狭窄或闭塞、椎基底动脉血管迂曲情况比较差异有统计学意义(P<0.05)。脑干梗死组和小脑梗死组与椎动脉狭窄或闭塞、基底动脉狭窄或闭塞、椎动脉优势、椎动脉迂曲及基底动脉弯曲均有关联,颞叶内侧面、枕叶及丘脑梗死组和后循环联合部位梗死组病例仅与椎动脉狭窄或闭塞、基底动脉狭窄或闭塞有关联。
4.多因素Logistic回归分析显示,伴有糖尿病(OR=4.02,95%CI:1.80-9.01; P=0.001).基底动脉狭窄(OR=1.00,95%CI:1.02-1.05;P＜0.001)和基底动脉弯曲≥2级(OR=1.38,95%CI:1.01-1.06；P=0.009)是脑干梗死的发生危险因素。
5.基底动脉弯曲组桥脑梗死患者椎动脉优势占71.7%,基底动脉无弯曲桥脑梗死患者椎动脉优势占54.8%,两组比较差异有统计学意义(x2=8.696,P=0.003)。与基底动脉无弯曲桥脑梗死患者血管危险因素比较,年龄≥65岁、高血压、吸烟及高同型半胱氨酸等病史在基底动脉弯曲桥脑梗死组的优势比增加,差异有统计学意义(P<0.05)。基底动脉弯曲桥脑梗死组和对照组比较,BAL和BL差异有统计学意义(P<0.05)；与对照组血管病危险因素比较,年龄≥65岁、高血压病、高胆固醇及2型糖尿病等病史在基底动脉弯曲并桥脑梗死组的优势比增加,差异有统计学意义(P<0.05)。椎动脉直径差异与BL呈正相关性(r=0.769,P<0.001)。对桥脑梗死患者相关危险校正其它相关因素后,进行多因素分析表明,BL3级(BL>3.77mm)是桥脑梗死的危险因素(OR=2.74,95%CI1.27-4.48).
结论：
1.椎动脉优势眩晕患者基底动脉弯曲发生率高、眩晕严重级别高、BAEP异常发生率较高。椎动脉优势与BAEP异常有相关性。
2.基底动脉延长和椎动脉优势与眩晕患者基底动脉弯曲有关系,可能是基底动脉弯曲的危险因素。
3.椎基底动脉迂曲和发育异常在后循环梗死患者较为常见；椎基底动脉迂曲多发生在老年患者中,而椎基底动脉发育异常在老年或非老年患者中均较常见。
4.2型糖尿病、基底动脉狭窄和基底动脉弯曲≥2级可能是脑干梗死的危险因素。
5.双侧椎动脉直径差异与BL呈正相关性；基底动脉弯曲暴露在高龄、高血压病、高胆固醇血症及2型糖尿病等血管危险因素下,增加桥脑梗死发生的可能性。基底动脉弯曲患者,BL＞3.77mm是桥脑梗死的危险因素。
Background
Basilar artery curvature is commonly found, but usually neglected by doctors, in both patients and healthy physical examinees through magnetic resonance angiography (hereafter as MRA) and CT angiography (hereafter as CTA). Clinical and radiological doctors are more concerned with existence of vascular stenosis and occlusion. Causes of basilar artery curvature, its relationship with and its role in ischemic stroke are not clear yet. Though more researches are on vertebrobasilar dolichoectasia(VBD) and its association with posterior circulation cerebral vascular disease, some different vertebrobasilar tortuosities as well as their relationship with vascular vertigo and cerebral infarction deserve our concern.
Objective
In order to investigate vertebral artery dominance(hereafter as VAD), basilar artery (BA) curvature, vascular vertigo, posterior circulation infarction and their correlation. In the light of MRA, we analyzed the clinical risk factors of basilar artery curvature and brainstem infarction in patients and also explored the measurement parameters, exposure rates of vascular risk factors and their correlation with pontine infarction.
Objects and Methods
The present study was collected data in our hospital department of neurology, including18years of age or older with vertigo patients or40years of age or older with acute posterior circulation infarction patients from April,2009to December,2012. A detailed history data, related scale and auxiliary examination data were recorded, vascular lesions of posterior circulation artery was focused on especially. Data process was divided into5parts.
1. A total of81patients with vertigo patients were in hospital from the beginning to February,2010. This prospective study involved64patients with vertigo, including35patients with VAD (VAD group) and29without VAD (non-VAD group) as detected by head magnetic resonance angiography. Age, sex, and other clinical histories were comparable in both groups. The degree of vertigo was graded and BAEP examination was performed in each patient. BAEP changes as well as their correlations with VAD were analyzed in both groups.
2. A total of269patients with vertigo patients were in hospital from the beginning to July,2011, and237were completed analysis. Intracranial and extracranial vascular MRA or CTA examination was performed and vascular risk factors were screened on vertigo. Based on MRA or CTA, basilar artery curvature was classified, and multivariate Logistic regression analysis was used to search for risk factors of basilar artery curvature.
3. A total of117patients with acute posterior circulation infarction were in hospital from the beginning to July,2011, and96were included. Acute posterior circulation infarction patients confirmed by cranial magnetic resonance imaging (hereafter as MRI) were included. Vessel lesions were recorded by head and neck MRA or CTA, such as tortuosity hypoplasia or stenosis of basilar artery, vertebral artery, posterior cerebral artery and internal carotid artery. According to the location of infarction, patients were divided into brainstem infarction group, cerebellar infarction group, thalamus, medial surface of temporal lobe and occipital lobe infarction group, combined infarct group; according to age, patients were divided into more than65years old group and less than65years old group. Differences of vascular lesions in different age and location were analyzed.
4. A total of129patients with acute posterior circulation infarction were in hospital from the beginning to December,2011, and65brainstem infarction patients were enrolled. Intracranial and extracranial vascular MRA or CTA examination was performed and vascular risk factors were screened on brainstem infarction patients. Based on MRA or CTA, basilar artery curvature was classified, and multivariate Logistic regression analysis was used to search for risk factors of brainstem infarction.
5. A total of97acute pontine infarction patients were in hospital from the beginning to December,2012, and88were enrolled. Selected in hospital patients with acute pontine infarction diagnosed by magnetic resonance diffusion weighted imaging as research subjects, and they were divided into BA bending group and group without bending BA according to magnetic resonance angiography (MRA). BA bending in vascular vertigo patients without cerebral infarction was the control group. BAL and BL as well as diameters of BA and bilateral vertebral arteries were measured through MRI. Exposures of vascular risk factors were carefully recorded. Multivariate and single-factor analyses were applied to explore risk factors of pontine infarction patients. BL was classified to investigate its relationship with pontine infarction and differences of bilateral arteries diameters were also classified to further explore their correlation with BL and BAL.
Results
1. Compared with that of non-VAD group, the vertigo severity level of patients with VAD was statistically significant (P＜0.01); there was statistical significance between the rate of abnormal BA shapes in VAD group and non-VAD group (P＜0.05). Peak latencies (Ⅰ, Ⅲ, and Ⅴ) in the VAD group were longer than those in the non-VAD group (P＜0.01), but the difference in the III did not reach statistical significance (t=1.916, P＞0.05). Interpeak latencies (Ⅲ-Ⅴ and Ⅰ-Ⅴ) were longer in the VAD group than those in the non-VAD group (P＜0.05); there was no significant difference in the interpeak latencies of Ⅰ-Ⅲ (P＞0.05). The Ⅲ-Ⅴ/Ⅰ-Ⅲ ratios were higher in the VAD group than those in the non-VAD group. The vertigo severity level was significantly higher in the VAD group than that in the non-VAD group (3.2±1.0versus2.2±0.7). The vertigo severity level correlated with VAD and every major anomaly index of BAEP; its correlations with Ⅲ-Ⅴ/Ⅰ-Ⅲ were remarkably significant (r=0.617, P=0.013).
2. Logistic multiple regression analysis showed that the basilar artery extension (OR21.56,95%CI:6.74-18.24, P=0.001) and vertebral artery dominance (OR36.34,95%CI:6.98-24.38, P＜0.001) were the risk factors for basilar artery curvature.
3. There was no statistical significance between group above the age of65and group under65in VAD, vertebrobasilar artery development or origin abnormality(P>0.05) but in vertebrobasilar artery stenosis or occlusion, vertebrobasilar artery tortuosity (P<0.05). Vertebral artery stenosis or occlusion, basilar artery stenosis or occlusion, vertebral artery dominance, vertebral artery and basilar artery tortuosity were all correlated with brainstem infarction group, cerebellar infarction group, whereas thalamus, medial surface of temporal lobe and occipital lobe infarction group, combined infarct group were only linked to vertebral artery stenosis or occlusion, basilar artery stenosis or occlusion.
4. Multivariate Logistic regression analysis found that the patients with diabetes (OR=4.02,95%CI:1.80-9.01; P=0.001), basilar artery stenosis (OR=1.00,95%CI:1.02-1.05; P＜0.001) and basilar artery curvature degree≥2(OR=1.38,95%CI:1.01-1.06; P=0.009) were independently correlated with brainstem infarction.
5. In pontine infarction patients with BA bending, vertebral artery dominance(VAD) accounted for71.7%, while in patients without basilar artery bending, VAD accounted for54.8%, and there was significant difference (x2=8.696, P=0.003). Comparison of vascular risk factors in patients with and without BA bending indicated odds ratio increased in BA bending group above65years of age, hypertension history, smoking history and high homocysteine history, and the difference was statistically significant (P＜0.05). In BA bending patients with pontine infarction and those without infarction, BAL and BL had significant difference (P＜0.05); In terms of vascular risk factors, odds ratio increased in BA bending patients with pontine infarction with age above65, hypertension, high cholesterol and type2diabetes history, and the difference was statistically significance (P＜0.05). After other relevant factors were adjusted, multivariate analysis showed that BL in grade3was an independent predictor of pontine infarction (OR=2.74,95%CI1.27to4.48). Diameter difference of VAs and BL showed positive correlation, and there was statistical significance (r=0.769, P＜0.001).
Conclusions
1. The incidence of abnormal BA shapes and abnormal BAEP, and the vertigo severity level were higher in VAD patients. Moreover, VAD was found to correlate with abnormal BAEP, suggesting that VAD contributed to vertigo of vascular origin.
2. Basilar artery extension and VAD were probably risk factors of basilar artery curvature.
3. Patients with posterior circulation infarction had high rates of vertebrobasilar artery developmental abnormalities and tortuosity. Vertebrobasilar artery tortuosity occurred more frequently in patients aged above65years whereas vertebrobasilar artery developmental abnormalities occurred with similar frequency in patients aged under65years and beyond65years.
4. Diabetes mellitus, basilar artery stenosis and basilar artery tortuosity≥2grade were probably risk factors of brainstem infarction.
5. Diameter difference of bilateral vertebral artery was positively correlated with the BL. Basilar artery curvature exposed to some vascular risk factors would increase the probability of pontine infarction. The infarct lesions usually appeared opposite to the tortuosity, and the symptoms are relatively light. In patients with basilar artery curvature, BL beyond3.77mm was considered as the risk factor of pontine infarction.
随着磁共振血管成像(MRA)及CT血管成像(CTA)作为脑血管检查方法的广泛应用,发现有许多基底动脉呈不同程度弯曲的患者或健康体检者。而临床和影像学医师大多只是关注有无血管狭窄和闭塞,忽视了血管弯曲的存在。基底动脉弯曲的原因尚不清楚,是否与动脉粥样硬化有关,是否是缺血性脑卒中发生的相关因素也存在着争议。大家较为关注的是基底动脉延长迂曲症研究,发现其与后循环脑血管病可能存在着关联,然而临床上有许多不能归属于基底动脉延长迂曲症的基底动脉弯曲,这种基底动脉弯曲与血管性眩晕或后循环脑梗死的关系尚不为关注。
目的：
探讨椎动脉优势、基底动脉弯曲与血管性眩晕或后循环梗死的关系；分析椎基底动脉迂曲或发育异常在不同年龄及不同部位后循环梗死患者中的分布差异；基于头颅MRA或CTA对颅内外血管评估结果,分析基底动脉弯曲及脑干梗死患者的临床危险因素；并探讨基底动脉弯曲长度和理论长度等的变化、血管危险因素暴露与桥脑梗死之间的关系。进而拓宽对脑血管病的血管病因认识。
对象与方法：
本研究自2009年4月至2012年12月连续收集入住我院神经内科的年龄≥18岁的眩晕或年龄≥40岁的急性后循环梗死患者,详细记录病史资料、相关量表及辅助检查资料,尤其关注后循环血管状态。数据处理分为5个部分。1.至2010年2月连续纳入81例住院眩晕患者,选取资料完整并符合入组标准的64例进行分析。头部MRA检查发现椎动脉优势的眩晕患者作为研究组,以非椎动脉优势的眩晕患者作为对照组。对患者眩晕程度进行分级和脑干听觉诱发电位(BAEP)检查,分析两组患者基底动脉情况、BAEP的变化及其与椎动脉优势的关系。
2.至2011年7月共有269例眩晕患者住院,选取资料完整并符合入组标准的237例进行分析。对连续入选的眩晕患者进行颅内外血管MRA或CTA检查及血管危险因素筛查。分为基底动脉弯曲和无弯曲的患者,把基底动脉弯曲进行分级,采用多因素Logistic回归分析寻找基底动脉弯曲的危险因素。
3.至2011年7月共有急性后循环梗死患者117例,选取资料完整并符合入组标准的96例进行分析。入组患者均经头颅核磁共振(MRI)弥散加权成像(DWI)确定急性后循环脑梗死的诊断。采用头颈部MRA或CTA评定基底动脉、椎动脉、大脑后动脉及颈内动脉病变、发育情况和迂曲等状态。根据梗死部位为脑干梗死,小脑梗死组,丘脑、颞叶内侧面及枕叶梗死组,后循环联合部位梗死组；根据年龄分为大于65岁组和小于65岁组；对血管评估结果进行年龄和不同部位的分层分析。
4.至2011年12月共有急性后循环梗死患者129例,选取资料完整并符合入组标准的脑干梗死患者65例,结合同时期资料完整的急性大半脑梗死128例,进行危险因素分析。对连续入选的急性脑干梗死患者进行颅内外血管MRA或CTA检查及血管危险因素筛查。把基底动脉弯曲进行分级,结合急性大脑半球梗死患者,采用多因素Logistic回归分析寻找脑干梗死危险因素。
5.至2012年12月共有急性桥脑梗死患者97例住院,选择资料完整并符合入组标准的88例进行分析。对连续入选的患者均经MRI-DWI确定急性桥脑梗死的诊断,根据基底动脉情况分为基底动脉弯曲组和无弯曲组,设立基底动脉弯曲无脑梗死并拟诊为血管性眩晕患者为对照组。依MRA测量基底动脉弯曲患者的基底动脉理论长度(BAL)和基底动脉弯曲长度(BL)及基底动脉直径、双侧椎动脉直径,详细记录血管危险因素暴露情况,比较三组之间血管危险因素的差异。对桥脑梗死患者危险因素进行单因素和多因素分析,把BL进行分级,探讨其与桥脑梗死的关系,并把双侧椎动脉直径差异进行分级,进一步分析双侧椎动脉直径差异与BL和BAL之间的相关性。
结果：
1.椎动脉优势患者眩晕严重级别与非椎动脉优势患者比较差异有统计学意义(P<0.01),椎动脉优势组基底动脉形状异常率与非椎动脉优势组比较差异有统计学意义(P<0.05)。椎动脉优势组I、V波峰潜伏时(PL)、III-V峰间潜伏时(IPL)、Ⅰ-Ⅴ IPL及Ⅲ-Ⅴ/Ⅰ-Ⅲ匕值均较非椎动脉优势组增大,差异均有统计学意义(P<0.01),III波PL与非优势组比较,差异均有统计学意义(P<0.05),Ⅰ-ⅢIPL与非优势组比较,差异无统计学意义(P>0.05)。椎动脉优势与BAEP各主要异常指标之间有明显相关性,与Ⅲ-Ⅴ/Ⅰ-Ⅲ相关性最显著(r=0.617,P=0.013)。
2.多因素Logistic回归分析显示,基底动脉延长(OR值21.56,95%CI：6.74-18.24,P<0.001)和椎动脉优势(OR值36.34,95%CI：6.98-24.38,P<0.001)是眩晕患者基底动脉弯曲的危险因素。
3.大于65岁组与小于65岁组比较,椎动脉优势、椎基底动脉发育或起源异常情况比较差异无统计学意义(P>0.05),椎基底动脉狭窄或闭塞、椎基底动脉血管迂曲情况比较差异有统计学意义(P<0.05)。脑干梗死组和小脑梗死组与椎动脉狭窄或闭塞、基底动脉狭窄或闭塞、椎动脉优势、椎动脉迂曲及基底动脉弯曲均有关联,颞叶内侧面、枕叶及丘脑梗死组和后循环联合部位梗死组病例仅与椎动脉狭窄或闭塞、基底动脉狭窄或闭塞有关联。
4.多因素Logistic回归分析显示,伴有糖尿病(OR=4.02,95%CI:1.80-9.01; P=0.001).基底动脉狭窄(OR=1.00,95%CI:1.02-1.05;P＜0.001)和基底动脉弯曲≥2级(OR=1.38,95%CI:1.01-1.06；P=0.009)是脑干梗死的发生危险因素。
5.基底动脉弯曲组桥脑梗死患者椎动脉优势占71.7%,基底动脉无弯曲桥脑梗死患者椎动脉优势占54.8%,两组比较差异有统计学意义(x2=8.696,P=0.003)。与基底动脉无弯曲桥脑梗死患者血管危险因素比较,年龄≥65岁、高血压、吸烟及高同型半胱氨酸等病史在基底动脉弯曲桥脑梗死组的优势比增加,差异有统计学意义(P<0.05)。基底动脉弯曲桥脑梗死组和对照组比较,BAL和BL差异有统计学意义(P<0.05)；与对照组血管病危险因素比较,年龄≥65岁、高血压病、高胆固醇及2型糖尿病等病史在基底动脉弯曲并桥脑梗死组的优势比增加,差异有统计学意义(P<0.05)。椎动脉直径差异与BL呈正相关性(r=0.769,P<0.001)。对桥脑梗死患者相关危险校正其它相关因素后,进行多因素分析表明,BL3级(BL>3.77mm)是桥脑梗死的危险因素(OR=2.74,95%CI1.27-4.48).
结论：
1.椎动脉优势眩晕患者基底动脉弯曲发生率高、眩晕严重级别高、BAEP异常发生率较高。椎动脉优势与BAEP异常有相关性。
2.基底动脉延长和椎动脉优势与眩晕患者基底动脉弯曲有关系,可能是基底动脉弯曲的危险因素。
3.椎基底动脉迂曲和发育异常在后循环梗死患者较为常见；椎基底动脉迂曲多发生在老年患者中,而椎基底动脉发育异常在老年或非老年患者中均较常见。
4.2型糖尿病、基底动脉狭窄和基底动脉弯曲≥2级可能是脑干梗死的危险因素。
5.双侧椎动脉直径差异与BL呈正相关性；基底动脉弯曲暴露在高龄、高血压病、高胆固醇血症及2型糖尿病等血管危险因素下,增加桥脑梗死发生的可能性。基底动脉弯曲患者,BL＞3.77mm是桥脑梗死的危险因素。
Background
Basilar artery curvature is commonly found, but usually neglected by doctors, in both patients and healthy physical examinees through magnetic resonance angiography (hereafter as MRA) and CT angiography (hereafter as CTA). Clinical and radiological doctors are more concerned with existence of vascular stenosis and occlusion. Causes of basilar artery curvature, its relationship with and its role in ischemic stroke are not clear yet. Though more researches are on vertebrobasilar dolichoectasia(VBD) and its association with posterior circulation cerebral vascular disease, some different vertebrobasilar tortuosities as well as their relationship with vascular vertigo and cerebral infarction deserve our concern.
Objective
In order to investigate vertebral artery dominance(hereafter as VAD), basilar artery (BA) curvature, vascular vertigo, posterior circulation infarction and their correlation. In the light of MRA, we analyzed the clinical risk factors of basilar artery curvature and brainstem infarction in patients and also explored the measurement parameters, exposure rates of vascular risk factors and their correlation with pontine infarction.
Objects and Methods
The present study was collected data in our hospital department of neurology, including18years of age or older with vertigo patients or40years of age or older with acute posterior circulation infarction patients from April,2009to December,2012. A detailed history data, related scale and auxiliary examination data were recorded, vascular lesions of posterior circulation artery was focused on especially. Data process was divided into5parts.
1. A total of81patients with vertigo patients were in hospital from the beginning to February,2010. This prospective study involved64patients with vertigo, including35patients with VAD (VAD group) and29without VAD (non-VAD group) as detected by head magnetic resonance angiography. Age, sex, and other clinical histories were comparable in both groups. The degree of vertigo was graded and BAEP examination was performed in each patient. BAEP changes as well as their correlations with VAD were analyzed in both groups.
2. A total of269patients with vertigo patients were in hospital from the beginning to July,2011, and237were completed analysis. Intracranial and extracranial vascular MRA or CTA examination was performed and vascular risk factors were screened on vertigo. Based on MRA or CTA, basilar artery curvature was classified, and multivariate Logistic regression analysis was used to search for risk factors of basilar artery curvature.
3. A total of117patients with acute posterior circulation infarction were in hospital from the beginning to July,2011, and96were included. Acute posterior circulation infarction patients confirmed by cranial magnetic resonance imaging (hereafter as MRI) were included. Vessel lesions were recorded by head and neck MRA or CTA, such as tortuosity hypoplasia or stenosis of basilar artery, vertebral artery, posterior cerebral artery and internal carotid artery. According to the location of infarction, patients were divided into brainstem infarction group, cerebellar infarction group, thalamus, medial surface of temporal lobe and occipital lobe infarction group, combined infarct group; according to age, patients were divided into more than65years old group and less than65years old group. Differences of vascular lesions in different age and location were analyzed.
4. A total of129patients with acute posterior circulation infarction were in hospital from the beginning to December,2011, and65brainstem infarction patients were enrolled. Intracranial and extracranial vascular MRA or CTA examination was performed and vascular risk factors were screened on brainstem infarction patients. Based on MRA or CTA, basilar artery curvature was classified, and multivariate Logistic regression analysis was used to search for risk factors of brainstem infarction.
5. A total of97acute pontine infarction patients were in hospital from the beginning to December,2012, and88were enrolled. Selected in hospital patients with acute pontine infarction diagnosed by magnetic resonance diffusion weighted imaging as research subjects, and they were divided into BA bending group and group without bending BA according to magnetic resonance angiography (MRA). BA bending in vascular vertigo patients without cerebral infarction was the control group. BAL and BL as well as diameters of BA and bilateral vertebral arteries were measured through MRI. Exposures of vascular risk factors were carefully recorded. Multivariate and single-factor analyses were applied to explore risk factors of pontine infarction patients. BL was classified to investigate its relationship with pontine infarction and differences of bilateral arteries diameters were also classified to further explore their correlation with BL and BAL.
Results
1. Compared with that of non-VAD group, the vertigo severity level of patients with VAD was statistically significant (P＜0.01); there was statistical significance between the rate of abnormal BA shapes in VAD group and non-VAD group (P＜0.05). Peak latencies (Ⅰ, Ⅲ, and Ⅴ) in the VAD group were longer than those in the non-VAD group (P＜0.01), but the difference in the III did not reach statistical significance (t=1.916, P＞0.05). Interpeak latencies (Ⅲ-Ⅴ and Ⅰ-Ⅴ) were longer in the VAD group than those in the non-VAD group (P＜0.05); there was no significant difference in the interpeak latencies of Ⅰ-Ⅲ (P＞0.05). The Ⅲ-Ⅴ/Ⅰ-Ⅲ ratios were higher in the VAD group than those in the non-VAD group. The vertigo severity level was significantly higher in the VAD group than that in the non-VAD group (3.2±1.0versus2.2±0.7). The vertigo severity level correlated with VAD and every major anomaly index of BAEP; its correlations with Ⅲ-Ⅴ/Ⅰ-Ⅲ were remarkably significant (r=0.617, P=0.013).
2. Logistic multiple regression analysis showed that the basilar artery extension (OR21.56,95%CI:6.74-18.24, P=0.001) and vertebral artery dominance (OR36.34,95%CI:6.98-24.38, P＜0.001) were the risk factors for basilar artery curvature.
3. There was no statistical significance between group above the age of65and group under65in VAD, vertebrobasilar artery development or origin abnormality(P>0.05) but in vertebrobasilar artery stenosis or occlusion, vertebrobasilar artery tortuosity (P<0.05). Vertebral artery stenosis or occlusion, basilar artery stenosis or occlusion, vertebral artery dominance, vertebral artery and basilar artery tortuosity were all correlated with brainstem infarction group, cerebellar infarction group, whereas thalamus, medial surface of temporal lobe and occipital lobe infarction group, combined infarct group were only linked to vertebral artery stenosis or occlusion, basilar artery stenosis or occlusion.
4. Multivariate Logistic regression analysis found that the patients with diabetes (OR=4.02,95%CI:1.80-9.01; P=0.001), basilar artery stenosis (OR=1.00,95%CI:1.02-1.05; P＜0.001) and basilar artery curvature degree≥2(OR=1.38,95%CI:1.01-1.06; P=0.009) were independently correlated with brainstem infarction.
5. In pontine infarction patients with BA bending, vertebral artery dominance(VAD) accounted for71.7%, while in patients without basilar artery bending, VAD accounted for54.8%, and there was significant difference (x2=8.696, P=0.003). Comparison of vascular risk factors in patients with and without BA bending indicated odds ratio increased in BA bending group above65years of age, hypertension history, smoking history and high homocysteine history, and the difference was statistically significant (P＜0.05). In BA bending patients with pontine infarction and those without infarction, BAL and BL had significant difference (P＜0.05); In terms of vascular risk factors, odds ratio increased in BA bending patients with pontine infarction with age above65, hypertension, high cholesterol and type2diabetes history, and the difference was statistically significance (P＜0.05). After other relevant factors were adjusted, multivariate analysis showed that BL in grade3was an independent predictor of pontine infarction (OR=2.74,95%CI1.27to4.48). Diameter difference of VAs and BL showed positive correlation, and there was statistical significance (r=0.769, P＜0.001).
Conclusions
1. The incidence of abnormal BA shapes and abnormal BAEP, and the vertigo severity level were higher in VAD patients. Moreover, VAD was found to correlate with abnormal BAEP, suggesting that VAD contributed to vertigo of vascular origin.
2. Basilar artery extension and VAD were probably risk factors of basilar artery curvature.
3. Patients with posterior circulation infarction had high rates of vertebrobasilar artery developmental abnormalities and tortuosity. Vertebrobasilar artery tortuosity occurred more frequently in patients aged above65years whereas vertebrobasilar artery developmental abnormalities occurred with similar frequency in patients aged under65years and beyond65years.
4. Diabetes mellitus, basilar artery stenosis and basilar artery tortuosity≥2grade were probably risk factors of brainstem infarction.
5. Diameter difference of bilateral vertebral artery was positively correlated with the BL. Basilar artery curvature exposed to some vascular risk factors would increase the probability of pontine infarction. The infarct lesions usually appeared opposite to the tortuosity, and the symptoms are relatively light. In patients with basilar artery curvature, BL beyond3.77mm was considered as the risk factor of pontine infarction.
引文
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