目的 应用深度学习算法自动检测和分割CTA图像中的颅内动脉瘤.方法 搜集行头颅CTA检查的颅内动脉瘤患者原始CTA图像.对原始CTA图像进行预处理后,输入到U-net神经网络进行检测和分割.以人工标记为参考标准.结果 在测试集中,直径＞4 mm的动脉瘤,敏感度为92.0％,Dice中位数为0.82;直径＞5 mm的动脉瘤,敏感度为93.1％,Dice中位数为0.84;直径＞6 mm的动脉瘤,敏感度为95.5％,Dice中位数为0.87.与人工标记结果具有高度一致性.结论 深度学习算法可以自动检测和分割直径＞4 mm的动脉瘤,不仅可以节省人力和时间成本,在一定程度上为动脉瘤破裂造成蛛网膜下腔出血的预防及颅内动脉瘤治疗的选择提供参考依据.

Objectives The purpose of this retrospective study is to explore the diagnostic and prognostic roles of serum RMST in carotid artery stenosis (CAS). Methods Serum levels of RMST were detected in CAS patients, and the relationship between degree of carotid stenosis and RMST levels was analyzed. The ROC curve was drawn to evaluate RMST value in predicting the risk of CAS. Then, all CAS patients received a 5-year follow-up. K-M curve was used to analyze the significance of RMST on prognosis of CAS patients. Multi-factor cox logistic regression analysis was conducted to evaluate independent factors for outcome of CAS patients. Results An increased RMST expression was certified in CAS patients when compared with healthy controls. The increase of serum RMST expression was related to high degree of carotid stenosis. In addition, serum RMST was a possible diagnosis and an independent influencing factor of prognosis in patients with CAS. Conclusions Raised serum RMST level was found in patients with CAS. Detecting RMST expression levels was of high value for predicting the occurrence and outcomes in CAS.

颈动脉狭窄患者接受颈动脉支架(CAS)植入术后可发生支架内再狭窄(ISR),发生率约5％～20％;药物洗脱球囊(DEB)技术用于治疗CAS植入后再狭窄已取得显著成效.本文对DEB治疗CAS植入术后ISR研究进展进行综述.

1临床资料 患者,女,82岁.主因"阴道大出血伴全身乏力2 d"入院.查体:血压 122/72 mmHg(1 mmHg=0.133 kPa),神志清,贫血貌,巩膜苍白,腹部稍膨隆,阴道出血量大,余未见明显异常.红细胞计数1.65×1012/L、血红蛋白55 g/L、血小板计数107×109/L,病理结果示子宫内膜癌.既往合并子宫肌瘤、高血压3级、2型糖尿病及肝硬化等病史.给予患者内科止血及输血等对症治疗,患者阴道大出血不止,重度贫血症状无明显好转,于入院后第2天行双侧卵巢动脉栓塞术.

Background: Carotid artery stenosis (CAS) is the major pathogen of cerebral infarction and brain death. Early detec-tion and risk prediction could help the diagnosis and improve the outcome of patients. The clinical significance of lncRNA GAS5 (GAS5) and miR-222-3p in the diagnosis and progno-sis of CAS was evaluated in this study to explore novel effec-tive biomarkers of CAS. Methods: A total of 72 CAS patients and 63 healthy indi-viduals (control) were enrolled in this study. The expres-sion levels of GAS5 and miR-222-3p in study subjects were detected using PCR. The ROC, Kaplan-Meier, and Cox regression analyses were carried out to estimate the diagnos-tic and prognostic value of GAS5 and miR-222-3p in CAS. The interaction between GAS5 and miR-222-3p was dis-closed by the dual-luciferase reporter. Results: The reduced expression of GAS5 and elevated expression of miR-222-3p were observed in CAS patients compared with the healthy controls, and a significant corre-lation between their expression levels in CAS was revealed. GAS5 and miR-222-3p could discriminate CAS patients from the healthy controls with high sensitivity and specificity. The GAS5 downregulation and miR-222-3p upregulation could predict the poor prognosis of CAS patients and may be asso-ciated with the severe development of patients. In human vascular smooth muscle cells, miR-222-3p could negatively regulate the luciferase activity of GAS5. Conclusion: Both GAS5 and miR-222-3p served as the diagnostic and prognostic biomarkers of CAS. The function of GAS5 might result from the regulation of miR-222-3p, which needs further validation.

目的 探讨侧支循环水平对急性前循环大血管闭塞患者机械取栓治疗预后的影响.方法 回顾性分析2015年9月—2020年6月120例行机械取栓的急性前循环大血管闭塞病例的影像及临床资料,首先依据侧支循环水平不同分为侧支循环较好组(n=63)和侧支循环较差组(n=57),比较两组机械取栓治疗前、术后24 h、术后1周及术后1个月美国国立卫生研究院卒中量表(NIHSS)评分,以及术后神经功能改善情况、术后90 d改良Rankin量表(mRS)评分、症状性颅内出血发生率及病死率.将mRS评分为0～2分视为预后良好组(n=74),3～6分视为预后较差组(n=46),对影响预后的因素进行多因素Logistic回归分析.结果 术后24 h、术后1周及术后1个月,两组NIHSS评分均较治疗前显著降低,且侧支循环较好组均低于侧支循环较差组(P<0.05,P<0.01).侧支循环较差组术后神经功能恢复情况及90 d良好预后率低于侧支循环较好组,病死率和症状性颅内出血发生率高于侧支循环较好组(P<0.05).多因素Logistic回归分析结果显示,术后24 h NIHSS评分较高与侧支循环水平较差是影响急性前循环大血管闭塞行机械取栓预后的独立危险因素(P<0.05,P<0.01).结论 颅内侧支循环水平在一定程度上决定急性前循环大血管闭塞机械取栓治疗的预后,较好的侧支循环是取得良好预后的重要条件.

目的 应用随机游走算法半自动测量,提高CT血管造影(CTA)对颈动脉狭窄的诊断效率.方法 回顾性分析2019年6月至2019年9月同期行头颈部CTA及脑数字减影血管造影(DSA)患者的影像学资料,应用随机游走算法半自动提取CTA原始横断面图像颈动脉轮廓及血管中高亮区域的轮廓,进一步应用阈值法得到二值化图像并获取两部分面积,最后计算出颈动脉狭窄度,并与DSA评估结果相比较.结果 随机游走算法应用于CTA原始图像半自动测量颈动脉狭窄度,与DSA诊断结果具有高度一致性,一定程度上提高了传统CTA诊断轻、中度颈动脉狭窄的敏感性,对颈动脉重度狭窄的半自动诊断效能提升较大.结论 随机游走算法是半自动诊断颈动脉狭窄的可靠方法,可提高传统CTA的诊断效率.

病例1:患者男,75岁,因“发作性头晕2个月”入院;高血压病史20年,否认糖尿病、冠心病病史,无烟酒嗜好.查体及实验室检查无明显异常.血管造影:Ⅲ型主动脉弓型,右侧颈内动脉C1段起始部次全闭塞,病变段呈“蜂窝”状或“网格”状改变(即存在微孔道),前向血流缓慢(图1A);影像学诊断:微孔道型颈内动脉慢性闭塞.行血管内开通术,将8F导引导管置于右侧颈总动脉远端,送入多功能导管(5F,125 cm),使其头端置位于右侧颈内动脉起始部,引入微导管(Ethelon-10)、微导丝(Pilot 50)组合,尝试沿微孔道通过病变失败;引入2.0 mm×15 mm球囊、微导丝(Pilot 50)组合,在小球囊支撑下,微导丝经反复尝试成功穿过(未完全循微孔道)病变段,并向上到达右侧颈内动脉C1远端(图1B),但球囊未能跟进;换用1.25 mm×15mm球囊到达病变段进行扩张后再以2.0mm×15 mm小球囊重复扩张.沿微导丝送入脑保护伞(Spider,5 mm)至右侧颈内动脉C1远段,沿保护伞导熊引入5 mm×30 mm球囊再次扩张病变段血管(图1C),最后植入颈动脉支架(Protege 8～6 mm×40 mm)(图1D).术后血管造影示颈内动脉成功再通,患者头晕症状消失.

Vertebral artery (VA) stenosis is relevant to a high early risk of recurrent stroke and basilar artery (BA) is the most common intracranial site of atherosclerotic lesions. It is important to show predictive risk factors for transient ischemic attack (TIA) or posterior infarctions. The aim of the study is to investigate morphometry and hemodynamics in intracranial vertebral and basilar arteries of health and diseased patients to enhance the risk assessment. Based on the geometrical model reconstructed from CTA images in 343 patients, a transient three-dimensional computational model was used to determine the hemodynamics. Patients were classified in symmetric, asymmetric, hypoplastic, and stenotic groups while patients in the stenotic group were divided into unilateral, bilateral, bifurcation, and tandem stenotic sub-groups. Patients in bilateral, bifurcation, and tandem stenotic sub-groups had significantly lower basilar artery diameters than other groups. Patients in the stenotic group had significantly higher surface area ratio (SAR) of high time-averaged wall shear stress gradient (TAWSSG) and higher incidence of TIAs or posterior infarctions than other groups while patients in the tandem stenotic sub-group had the highest values (SAR-TAWSSG of 57±22% and TIAs or posterior infarction incidence of 54%). The high SAR-TAWSSG is predisposed to induce TIAs or posterior infarction.

目的 探讨颈内动脉颅外段起始部急性闭塞的不同开通策略及其可行性.方法 回顾性分析2015年5月至2018年1月收治的15例颈内动脉起始段急性闭塞患者临床资料.分别采用不同方法(微导管+微导丝、小球囊+微导丝、多功能管+超滑导丝)开通闭塞段,对开通策略制定、手术器械选择及其开通效果进行初步评估.结果 15例患者均成功开通闭塞段血管,发生远端栓塞事件2例.术后90 d随访均恢复良好,无明显后遗症状.结论 对于颈内动脉急性闭塞,手术策略上既要提高开通成功率,尽量缩短开通时间,更要兼顾手术安全.微导管、导丝配合通过病变方法应作为首选,但在特殊条件下其它开通方式可作为补充.

回顾性分析2015年5月至2018年5月河北大学附属医院介入血管外科应用远端-近端逆向操作技术开通9例颈内动脉起始段急性闭塞合并远端闭塞患者的临床资料.9例患者中,合并颈内动脉末端闭塞1例,合并同侧大脑中动脉闭塞7例,同侧大脑中动脉及大脑前动脉并存闭塞1例.9例患者的闭塞血管均成功再通,且未出现症状性颅内出血及远端栓塞等严重并发症.9例患者术后90 d改良Rankin量表评分(mRS)均提示预后良好(0～3分).远端-近端逆向操作技术对于颈动脉串联病变合并急性缺血性卒中患者可能是一种安全、有效的治疗选择,本文着重总结其介人器材的选择、手术策略的制定及具体操作细节.

Vertebral artery origin anomalies are typically incidental findings during angiography. We present an extremely rare variant in which the right vertebral artery has a double origin from the right subclavian artery and right common carotid artery in association with an aberrant right subclavian artery, which has never been reported before.

Objective To evaluate the feasibility of dual microcatheter "cross-regional" embolization technique in treating intracranial irregular aneurysms. Methods The clinical data of 19 patients with intracranial irregular aneurysms, who were treated with "cross-regional" embolization technique at authors' hospital during the period from May 2016 to May 2017, were retrospectively analyzed. The embolization strategy formulation, selection of embolization materials, surgical process and embolization effect were summarized. Results Successful treatment of intracranial irregular aneurysm was accomplished in all the 19 patients. In one patient, during the embolization process of the neck of aneurysm the steel coil was over-protruded into the parent artery, and stent implantation had to be carried out to rescue the therapy, and finally successful treatment was achieved. The technical success rate of "cross-regional" embolization was 95％. Complete embolization was obtained in 15 patients and subtotal embolization in 3 patients. Conclusion For the treatment of some specified intracranial irregular aneurysms, dual microcatheter "cross - regional" embolization technique is technically simple, and it is a safe and effective treatment option. (J Intervent Radiol, 2018, 27: 199-202)

颈动脉游离漂浮血栓(free floating thrombus,FFT)是指近端附着在颈动脉壁上而远端游离随血流做周期性运动的细长血栓 [1] ,多见于颈内动脉,既往罕见报道。存在FFT的患者发生脑动脉栓塞的风险很高,临床常表现为因缺血导致的神经功能缺损症状。颈动脉FFT的病因目前尚不明确,其最佳治疗方法仍然存在着争议。现报道河北大学附属医院介入血管外科收治的1例右侧颈总动脉FFT患者,并结合文献进行复习。

Posterior communicating artery (PCoA) aneurysms frequently rupture in small size (<7 mm). The aim of the study is to demonstrate morphometric and hemodynamic analyses in ruptured and unruptured PCoA aneurysms to improve predictive accuracy for rupture. Geometrical models were reconstructed from rotational DSA images of 57 ruptured and 22 unruptured side-wall PCoA aneurysms, which were classified into four two-dimensional (2D) groups by a combination of H/D and H/S ratios (H: dome height, D: dome diameter, and S: semi-axis height). Surface area ratio (SAR) of low time-averaged wall shear stress (TAWSS, ≤4 dynes cm-2) and high oscillatory shear index (OSI, ≥0.15) were computed in aneurysms. We hypothesized that a two-step analysis method, i.e., one-dimensionally morphometric and hemodynamic analyses in each 2D group, can enhance accuracy of PCoA aneurysm rupture evaluation. There was the highest incidence of H/D > 1 and H/S ≤ 2 with the largest surface area and SAR-TAWSS, but the lowest incidence of H/D ≤ 1 and H/S > 2 with the smallest surface area and SAR-TAWSS in ruptured PCoA aneurysms. PCoA aneurysms of H/D > 1 and H/S ≤ 2 with surface area > 70 mm2, H/D ≤ 1 and H/S > 2 with neck diameter > 2.3 mm, H/D ≤ 1 and H/S ≤ 2 with aneurysmal height/parent diameter ratio > 1.0, and H/D > 1 and H/S > 2 with aneurysmal angle > 115° need special attention for clinical diagnosis and treatment. The study highlighted the importance of the two-step analysis method for clinical evaluation of PCoA aneurysm rupture.

目的 探讨前交通动脉瘤介入栓塞术中载瘤动脉痉挛的原因、风险及处置.方法 回顾性分析收治的破裂前交通动脉瘤介入栓塞术中发生血管痉挛的8例患者临床资料,系统研究其影像学特征、栓塞材料选择及技术操作特点.结果 30例接受介入栓塞患者中发生血管痉挛8例,发生率为26.7％,其中3例经动脉灌注尼莫地平后缓解,栓塞得以顺利进行,5例经积极治疗后痉挛未缓解,其中1例术中血栓形成,部分栓塞,术后5d动脉瘤再破裂出血死亡;2例术中出血,经积极处置后好转;2例术中无法观察栓塞程度,部分栓塞.结论 前交通动脉瘤术中血管痉挛常见且严重影响手术效果,可形成血栓,术中、术后出血等严重并发症,原因多为术中导管、导丝等对血管壁的直接物理刺激,蛛网膜下腔出血的刺激等,围术期制订精准的治疗方案,术中对各种情况的准确判断、决策以及高超的手术技巧直接关系手术效果.

例1女,17岁.因突发意识不清伴呕吐4 h就诊.行头颅CT示小脑出血破入三、四脑室,以"自发性小脑出血破入脑室"收入院,并急诊行血肿清除手术.术后复查全脑血管造影及CTA提示右侧椎动脉双支起源,一支起源于迷走右锁骨下动脉,另一支起源于右侧颈总动脉,两支于第4颈椎体下缘水平汇合成右侧椎动脉主干(图1~8).

Objective To investigate the causes of intraoperative re-rupture of intracranial aneurysm with bleeding during endovascular interventional embolization procedure in patients with subarachnoid hemorrhage due to intracranial aneurysm,and to discuss its emergency treatment and prevention measures.Methods The clinical data of 11 patients with intracranial aneurysm,who were admitted to authors' hospital during the period from January 2011 to October 2016 and in whom intraoperative re-rupture of intracranial aneurysm with bleeding occurred in endovascular interventional embolization procedure,were retrospectively analyzed.The imaging features,the selection of embolization material and the key point of technical operation were evaluated.Results A total of 510 patients with intracranial aneurysmal subarachnoid hemorrhage received interventional embolization therapy,and among them 11 patients developed intraoperative re-rupture of intracranial aneurysm with bleeding,with the incidence being 2.2％.The cause of re-rupture was mainly due to the perforation of vascular wall by spring coil (n=8) or by micro-catheter (n=2).In the remaining one patient,re-bleeding occurred during the thrombolytic treatment for acute in-stent thrombosis.Through active emergency treatment,satisfactory prognosis was obtained in 10 patients,and no obvious neurological deficit was observed.One patient died.Conclusion Intraoperative re-rupture of intracranial aneurysm with bleeding during endovascular interventional embolization procedure is a severe,even catastrophic,complication.The main cause of re-rupture is due to the perforation of vascular wall mainly by spring coil or occasionally by micro-catheter.However,as long as positive and reasonable treatment measures are promptly adopted,its mortality and morbidity can be greatly reduced.

颈动脉冗长国内外文献报道并不少见, 但多较为久远, 而颈动脉冗长并发急性颅内大动脉闭塞实属罕见. 该文介绍1例急性缺血性脑卒中患者, 右侧大脑中动脉急性闭塞, 同时合并患侧颈内动脉冗长迂曲、 瘤样扩张, 经积极通过极端路径进行机械开通, 患者术后功能恢复良好. 结合以往文献, 进一步对颈内动脉冗长的病因、 病理及治疗等方面做简要阐述.