Zusammenfassung
Die sonographischen hämodynamischen und strukturellen Befunde bei Karotisdissektionen sind in einer Reihe von Studien beschrieben worden, ihre Assoziation mit der Häufigkeit und Topografie zerebraler Infarkte wurde bisher jedoch kaum untersucht. Wir haben daher die Relevanz der Befunde der extrakraniellen Doppler- und Duplex-Sonographie in Hinblick auf die mögliche Pathogenese des Hirninfarktes bei Karotisdissektionen analysiert. 87 Patienten (44 w, 43 m; Alter 16 - 68 Jahre) wurden mit 92 Dissektionen konsekutiv in die Studie aufgenommen, neurologisch und mit extrakranieller Doppler-Sonographie und Farbduplex-Sonographie untersucht. Die Diagnosesicherung erfolgte durch weitere Methoden (intraarterielle und MR-Angiographie, axiale zervikale Magnetresonanztomographie [MRT]). Assoziierte Hirninfarkte wurden durch zerebrale Computertomographie bzw. MRT diagnostiziert. 53 % der Patienten erlitten einen Infarkt ipsilateral zur Dissektion, hiervon 13 (27 %) einen kompletten Mediainfarkt, 23 (47 %) einen territorialen Teilinfarkt und 6 (12 %) einen lentikulostriatären Infarkt. In nur 7 Fällen (14 %) kam ein kortikaler oder subkortikaler Grenzzoneninfarkt zur Darstellung. Doppler-sonographisch fanden sich hämodynamisch pathologische Befunde in 96 % der Dissektionen, am häufigsten war das bidirektionale Widerstandssignal (60 %). Dieses Dopplersignal war zudem signifikant (64 %, p < 0,05) mit einem zerebralen Infarkt assoziiert. Alle vier Patienten mit doppler-sonographischem Normalbefund hatten keinen Hirninfarkt. Die Duplex-Sonographie hatte ohne hämodynamische Information eine geringe Sensitivität für die Karotisdissektion, so ergaben sich in 50 % strukturelle Normalbefunde, jedoch erlitten 54 % dieser Patienten einen Hirninfarkt. Diese Studie zeigt, dass Karotisdissektionen mit hämodynamisch relevanter Obstruktion häufiger mit Hirninfarkten assoziiert sind, deren Pathogenese dennoch vorwiegend embolisch ist.
Abstract
Hemodynamic and structural sonographic pathology of internal carotid artery (ICA) dissection has been reported in a number of studies. However, the association of sonographic findings with the frequency and topography of cerebral infarcts has scarcely been studied to date. Therefore, we attempted to determine the significance of Doppler and duplex abnormalities in ICA dissection for the presumed pathogenesis of associated stroke. 87 patients (44 w, 43 m, range 16 - 68 years) with 92 ICA dissections were consecutively included in the study. All patients had a neurological examination and extracranial Doppler studies, color coded duplex sonography was performed in 74 dissections. Diagnosis was confirmed by additional methods (intraarterial und MR-angiography, axial cervical MRI). All patients had cranial CT or MRI to assess the acute stroke lesion. Ipsilateral stroke occurred in 53 % of the ICA dissections. Of these, 27 % had complete middle cerebral artery (MCA) infarcts, 47 % had territorial and 12 % lenticulostriate infarcts. In only 7 cases (14 %) subcortical/cortical borderzone infarcts were found. Doppler sonography provided abnormal hemodynamic findings in 96 % of the dissections. Most frequently, a high resistance Doppler signal with bidirectional flow components was found (60 %). This Doppler signal was significantly associated with cerebral infarcts (64 %; p < 0.05), whereas the four patients with normal Doppler did not suffer a stroke. Duplex sonography without hemodynamic Doppler information had a low sensitivity for carotid dissection, because 50 % of the studies were normal, however, 54 % of these patients suffered a stroke. This study demonstrates, that ICA dissections with significant hemodynamic obstruction are more frequently associated with cerebral infarcts while their pathogenesis is predominantly embolic.
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Dr. med. Hans-Bernd Hülsbömer
Klinik für Neurologie · Marienhospital Düsseldorf
Rochusstraße 2
40479 Düsseldorf
Email: hb.huelsboemer@marien-hospital.de