丘脑梗死

解洪荣：上海东方医院神经内科  以前写过脑干的供血相关文章，本文是继脑干供血继续细化。本文不仅仅提供了影像分布图，还突出了病变分布与病因的关系。本文也用颜色区分了重点，便于理解。谢谢解洪荣老师的分享！由于水平有限，不当地方请指正！对本文感兴趣的老师也可自行翻译！

Topographic patterns of thalamic infarcts in association with stroke syndromes and aetiologies

与中风综合征和病因相关的丘脑梗死的病灶分布模式

INTRODUCTION

引言

Thalamic infarcts can be divided into four groups based on the territories supplied by the four main arteries: polar, thalamoperforating, thalamogeniculate and posterior choroidal arteteries

丘脑梗塞可根据四条主要动脉供血区分为四组：极动脉、丘脑穿通动脉、丘脑膝状体动脉和脉络膜后动脉。

The thalamus is affected in various stroke syndromes, including isolated thalamic infarct, posterior cerebral artery (PCA) territory infarct, top of the basilar artery (TOB) syndrome and extended posterior circulation (EPC) infarct. However, the patterns of thalamic infarcts involving specific vascular territories in various stroke syndromes and aetiologies have been poorly defined. A few studies addressing these issues were limited to small number of patients

丘脑受累的各种中风综合征包括孤立性丘脑梗死、大脑后动脉（PCA）供血区梗死、基底动脉尖（TOB）综合征和广泛后循环（EPC）梗死。然而，不同中风综合征和病因中特定血管供血区的丘脑梗死模式还不明确。一些针对这些问题的研究仅限于少数患者。

Diffusion weighted MR imaging (DWI) provides more accurate detection of very small or multiple acute ischaemic lesions than other brain imaging modalities.In addition, DWI enables the differentiation between acute and chronic lesions.Thus the lesion pattern and underlying mechanism of acute ischaemic stroke can be more precisely estimated with DWI. The aim of this study was to characterise the topographic patterns of thalamic infarcts in various stroke syndromes and aetiologies by using DWI in patients with acute ischaemic stroke.

弥散加权磁共振成像（DWI）提供了比其他脑成像方式更准确的检测非常小或多个急性缺血性病变。此外，DWI还可以区分急性和慢性病变。因此，DWI可以更准确地评价急性缺血性卒中的病变模式和潜在机制。本研究的目的是通过在急性缺血性卒中患者中使用DWI来描述各种中风综合征和病因中丘脑梗死的病灶分布模式。

METHODS

研究方法

In this study, 168 consecutive patients with acute infarcts involving the thalamus were investigated by use of diffusion weighted MR imaging. Involved thalamic territories were classified into four vascular territories: anterior (polar artery), posteromedial (thalamoperforating artery), ventrolateral (thalamogeniculate artery) and posterolateral (posterior choroidal artery) territory. The distribution of thalamic infarcts involving specific vascular territories in association with various stroke syndromes and aetiologies were analysed.

本研究采用弥散加权磁共振成像对168例累及丘脑的急性梗死患者进行了研究。涉及的丘脑区域分为四个血管区域：前（极动脉）、后内侧（丘脑穿通动脉）、腹外侧（丘脑膝状体动脉）和后外侧（脉络膜后动脉）。分析了涉及特定血管区域的丘脑梗塞的分布与各种中风综合征和病因的相关性。

A total of 168 consecutive patients with acute infarcts involving the thalamus who were admitted to the Neurology Department of the Dankook University Hospital between March 2005 and April 2010 were retrospectively studied. The medical records, stroke registry and MR images were reviewed. Patients were included if they had acute ischaemic lesions involving the thalamus alone or with concomitant lesions outside the thalamus on DWI within 1 week of stroke onset.

回顾性研究了2005年3月至2010年4月收治于Dankook大学医院神经科的168例涉及丘脑的急性梗死患者。回顾了病历、中风登记和磁共振图像。如果患者在中风发作后1周内出现急性缺血性病变（仅累及丘脑）或DWI上伴发的丘脑外病变，则纳入研究。

All patients underwent MRI, MR angiography, transcranial Doppler, transthoracic echocardiograpy, 12 lead electrocardiography and standard blood tests. In selected patients, transoesophageal echo- cardiography, 24 h electrocardiography (Holter) monitoring and conventional angiography were performed as required.

患者均行MRI、磁共振血管造影、经颅多普勒、经胸超声心动图、12导联心电图和标准血液检查。对部分患者，根据需要进行经食管超声心动图、24小时心电图（Holter）监测和常规血管造影。

MRI consisted of axial T1 weighted (1.5 T; repetition time 417 ms; echo time 10 ms) and T2 weighted images (repetition time 5000 ms; echo time 80ms) with 5 mm sections. DWI was performed using a single shot echo planar, spin echo pulse sequence (1.5 T; repetition time 6000 ms; echo time 84 ms; b1⁄41000 s/mm2; field of view 260 mm; matrix 1283128; thickness 5 mm; 20 slices). Acute lesions were differentiated from chronic lesions using DWI. DWI and T2 weighted images were used to delineate the distribution of acute infarcts.

MRI包括T1加权图像（1.5 t；重复时间417 ms；回声时间10 ms）和T2加权图像（重复时间5000 ms；回声时间80 ms），截面5 mm。使用单次放炮回波平面、自旋回波脉冲序列（1.5 t；重复时间6000 ms；回波时间84 ms；b1/41000 s/mm2；视野260 mm；矩阵1283128；厚度5 mm；20片）进行DWI。使用DWI将急性病变与慢性病变区分开来。用DWI和T2加权图像描述急性梗塞的分布。

Thalamic territories were classified according to their arterial supply based on the previously reported template: (1) anterior territory, supplied by the polar or tuberothalamic artery; (2) posteromedial territory, supplied by the thalamoperforating artery; (3) ventrolateral territory, supplied by the thalamogeniculate artery; and (4) posterolateral territory, supplied by the posterior choroidal artery（figure1）

根据动脉供血区对丘脑区域进行划分：（1）前部区域，由丘脑极动脉或丘脑结节动脉供血；（2）后内侧区域，由丘脑穿通动脉供血；（3）腹外侧区域，由丘脑膝状体动脉供血（4）后外侧区域，由脉络膜后动脉供血（图1）

图1 涉及不同丘脑区域的急性梗死的弥散加权图像：（a）前部，（b）后内侧，（c）腹外侧和（d）后外侧区域。

Stroke syndromes were categorised according to the lesion topography as follows: (1) isolated thalamic infarct was defined as an infarct limited to the thalamus; (2) PCA territory infarct was defined as a unilateral infarct in the regions supplied by the PCA, including the thalamus, midbrain, medial temporal and occipital lobes; (3) TOB syndrome was defined as a bilateral infarct in the regions supplied by the rostral basilar artery and the superior cerebellar artery, including the thalamus, midbrain, occipital and medial temporal lobes, and superior cerebellum; and (4) EPC territory infarct was defined as multiple infarcts extending beyond the TOB territory.

中风综合征根据病变分布情况分为以下几类：（1）孤立性丘脑梗死被定义为仅限于丘脑的梗死；（2）PCA区域梗死被定义为PCA提供的区域内的单侧梗死，包括丘脑、中脑、内侧颞叶和枕叶；（3）TOB综合征被定义为双侧脑梗死，发生在基底动脉尖和小脑上动脉（包括丘脑、中脑、枕叶和内侧颞叶以及小脑上动脉）供血的区域；以及（4）EPC区脑梗死。CT定义为多发性梗死，超出TOB范围。

Stroke aetiologies were assigned to five categories according to the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria: (1) small vessel disease (SVD) in patients with a small (<15 mm) infarct in the thalamus without significant stenosis (>50%) in the large artery of the posterior circulation or cardiac sources of embolism; (2) large artery disease (LAD) in patients whose infarction size was >15 mm with an occlusion or severe stenosis (>50%) in the artery supplying the infracted areas or proximal to stroke lesions in the absence of cardiac sources of embolism; (3) cardioembolism; (4) cryptogenic cause; and (5) two or more causes. Other causes, including vasculitis, venous infarct and infarction related to an angiographic procedure, were excluded from the analysis because of the small number of patients.

根据TOAST（ORG 10172急性脑卒中治疗试验）分型标准分为5类：（1）丘脑小梗死（小于15 mm）患者的小血管疾病（SVD），后循环大动脉无明显狭窄（指的大于50%），或心源性栓塞；（2）梗塞面积大于15 mm的患者大动脉疾病（LAD），在没有心源性栓塞的情况下，伴有梗塞区或靠近中风病变的部位的供血动脉阻塞或严重狭窄（>50%）；（3）心脏栓塞（4）不明原因；（5）两个以上原因。其他原因，包括血管炎、静脉梗塞和与血管造影手术相关的梗塞，由于患者人数较少，被排除在分析范围之外。

The association between involved thalamic territories and stoke syndromes and between those and stroke aetiologies were analysed using the c2 test with Fisher’s exact test. Statistical significance was established at p<0.05. The descriptive statistics were also used to analyse the overall distribution of thalamic lesion patterns. SPSS software (V.12.0; SPSS, inc) was used for statistical analysis.

采用C2检验和Fisher精确检验分析了涉及的丘脑区域与中风综合征之间以及这些与中风病因之间的关系。P<0.05时有统计学意义。描述性统计也用于分析丘脑病变模式的总体分布。统计分析采用SPSS软件（V.12.0；SPSS，Inc）。

RESULTS

结果

There were 99 men and 69 women with a mean age of 66 years (range 27－91). Stroke risk factors included hypertension (blood pressure >160/90 mm Hg at least twice before the stroke) in 118 (70%) patients, diabetes mellitus in 56 (33%) patients, hypercholesterolaemia (serum cholesterol level >6.5 mmol/l) in 42 (25%) patients, current cigarette smoking in 44 (26%) patients and cardiac sources of embolism in 44 (26%) patients (atrial fibrillation in 29 patients, hypokinetic or akinetic ventricular segments in 16 patients, congestive heart failure in 10 patients and mitral valve disease in four patients). Thirty-four (20%) patients had a previous history of stroke.

男性99例，女性69例，平均年龄66岁（范围27－91）。卒中危险因素包括高血压（至少在卒中前两次血压＞160/90 mm Hg）118例（70%），糖尿病56例（33%），高胆固醇血症（血清胆固醇水平＞6.5 mmol/L）42例（25%），目前吸烟44例（26%）。心源性栓塞44例（26%）（房颤29例，心室壁节段性低运动或无运动16例，充血性心力衰竭10例，二尖瓣疾病4例）。中风病史34例（20%）。

Stroke syndromes and topographic patterns of thalamic infarcts

中风综合征和丘脑梗死的病灶分布模式

Isolated thalamic infarcts were found in 67 (40%) patients, PCA infarcts in 38 (23%) patients, TOB in 22 (13%) patients and EPC infarcts in 41 (24%) patients.

孤立性丘脑梗死67例（40%），PCA梗死38例（23%），TOB梗死22例（13%），EPC梗死41例（24%）。

The topography of thalamic involvement was confined to one thalamic vascular territory in 116 (69%) patients, extended to multiple thalamic territories unilaterally in 27 (16%) patients (two (3%) patients in isolated thalamic infarcts, 15 (39%) patients in PCA infarcts, three (14%) patients in TOB and seven (17%) patients in EPC infarcts) and bilaterally in 25 (15%) patients (14 (64%) patients in TOB and 11 (27%) patients in EPC infarcts).

116例（69%）患者的丘脑病灶分布仅限于一个丘脑血管区域，27例（16%）患者累及单侧丘脑多个区域（2例（3%）孤立性丘脑梗死，15例（39%）PCA梗死患者，3例（14%）TOB患者，7例（17%）EPC梗死患者）。25例（15%）患者累及双侧丘脑区域（14例（64%）TOB患者，11例（27%）EPC梗死患者）。

The most commonly affected thalamic territory was the ventrolateral territory, observed in 103 (61%) patients, followed by the posteromedial territory in 65 (39%) patients, posterolat- eral territory in 42 (25%) patients and anterior territory in 19 (11%) patients.

最常见的受影响的丘脑区域是腹外侧区域，有103（61%）名患者，其次是后内侧区域，有65（39%）名患者，后外侧区域有42（25%）名患者，前内侧区域有19（11%）名患者。

The patterns of thalamic territory involvement among different stroke syndromes are shown in table 1. There was a significant association between involvement of the ventrolateral thalamus and isolated thalamic infarcts (48% (49/103) vs 28% (18/65); p<0.01) or PCA infarcts (28% (29/103) vs 14% (9/ 65); p1⁄40.02), and between the posteromedial territory involvement and TOB (26% (17/65) vs 5% (5/103); p<0.001) or EPC infarcts (45% (29/65) vs 12% (12/103); p<0.001).

表1显示了不同中风综合征患者丘脑区域的参与模式。腹外侧丘脑受累与孤立的丘脑梗死（48%（49/103）对28%（18/65）；p<0.01）或PCA梗死（28%（29/103）对14%（9/65）；p＝0.02）以及后内侧区受累与TOB（26%（17/65）对5%（5／103; p<0.001）之间存在显著相关性，或EPC梗死（45%（29/65）对12%（12/103）；P<0.001）。

Taken together, the most common pattern of thalamic lesion was the single lesion restricted to the ventrolateral territory in isolated thalamic infarcts (47 patients (67%), p<0.01) and in PCA infarcts (14 patients (38%)), bilateral lesions involving both posteromedial territories in TOB (five patients (23%)) and unilateral lesion confined to the posteromedial territory in EPC infarcts (14 patients (34%)) (figure 2).

总之，最常见的丘脑病变模式是孤立性丘脑梗死（47例（67%），P<0.01）局限于腹外侧区域的单一病变，PCA梗死（14例（38%），TOB累及双侧丘脑后内侧区域（5例（23%））和EPC梗死局限于单侧丘脑后内侧区的病变（14例（34%））（图2）。

图2与特定中风综合征相关的丘脑病变的最常见模式。（a）孤立性丘脑梗塞中局限于腹外侧区域的单一病变。（b）仅限于大脑后动脉区梗死腹外侧区的单一病变。（c）基底动脉尖综合征后内侧区域的双侧病变。（d）后循环梗塞时局限于后内侧区域的单侧病变。

Stroke aetiologies and topographic patterns of thalamic infarcts

中风病因与丘脑梗死的病灶分布模式

Stroke aetiologies were SVD in 60 (36%) patients, LAD in 30 (18%) patients, cardioembolism in 31 (18%) patients, cryptogenic cause in 39 (23%) patients and two or more causes in eight (5%) patients. Of the 30 patients with LAD, four (13%) had a stenosis or occlusion in the proximal PCA, 18 (60%) in the basilar artery, five (17%) in the vertebral artery and three (10%) in both the basilar and vertebral arteries.

SCV 60例（36%），LAD  30例（18%），31例（18%）出现心源性栓塞，39例（23%）为隐性原因，8例（5%）出现两种或两种以上原因。在30例LAD患者中，4例（13%）在PCA近端出现狭窄或闭塞，18例（60%）在基底动脉，5例（17%）在椎动脉，3例（10%）在基底动脉和椎动脉。

The patterns of thalamic territory involvement among different stroke aetiologies are shown in table 2. The ventro-lateral territory was most frequently affected in association with SVD (43 patients (72%), p1⁄40.03). The posteromedial (19 patients (63%), p<0.01) and ventrolateral territories (15 patients (50%)) were commonly involved in LAD. In cardioembolic stroke, the posteromedial (14 patients (45%)), ventrolateral (16 patients (52%)) and posterolateral (16 patients (52%)) territories were almost equally affected.

表2显示了不同中风病因学中丘脑区域参与的模式。腹外侧区域最常受到与SVD相关的影响（43例患者（72%），p1/40.03）。LAD患者多为后内侧（19例，63%），腹外侧（15例，50%），P<0.01。在心源性卒中中，后内侧区（14例（45%），腹外侧区（16例（52%）和后外侧区（16例（52%）受影响几乎相同。

Consequently, the most common pattern of thalamic lesion was the single ventrolateral lesion in SVD (43 patients (72%),p<0.01) and unilateral (seven patients (23%)) or bilateral (six patients (20%)) posteromedial lesion in LAD. In cardioembolism and cryptogenic cause, however, various lesion patterns were commonly observed without any specific dominant pattern, including the unilateral lesion involving the posteromedial or ventrolateral territory and unilateral lesion involving the combined ventrolateral and posterolateral territories.

因此，最常见的丘脑病变类型是SVD中的单个腹外侧病变（43例（72%），P<0.01），单侧（7例（23%）或双侧（6例（20%）。然而，在心源性栓塞和隐源性原因中，通常观察到各种病变模式，没有任何特定的模式，包括累及后内侧或腹外侧区域的单侧病变和累及腹外侧和后外侧联合的单侧病变。

DISCUSSION

讨论

To our knowledge, this is the largest series of thalamic infarcts focusing on the topographic patterns of thalamic lesions. Furthermore, DWI used in this study has the advantage in detecting acute small and multiple thalamic lesions compared with CT and traditional MRI.

据我们所知，这是主要集中在丘脑病变的病灶分布模式研究上的最大的一系列丘脑梗塞。此外，与CT和传统MRI相比，DWI在检测急性小而多发性丘脑病变方面具有优势。

Most studies on thalamic infarcts were limited to isolated thalamic infarcts. In this series, however, thalamic infarcts with concomitant infarcts outside the thalamus were also included. The data showed that 60% of thalamic infarcts were accompanied by infarcts in other structures. In other studies, the percentage of thalamic infarcts associated with other territory infarcts was 21%, 38% and 61%.These variable results may be due to the difference in the age of the study population and in the inclusion methods among the studies.

大多数关于丘脑梗塞的研究仅限于孤立的丘脑梗塞。然而，在这一系列中，还包括伴发于丘脑外的丘脑梗死。数据显示60%的丘脑梗塞伴有其他区域的梗塞。在其他研究中，与其他区域梗死相关的丘脑梗死百分比为21%、38%和61%。这些可变结果可能是由于研究人群的年龄和研究中的纳入方法不同造成的。

Topographic patterns of thalamic infarcts associated with stroke syndromes

与中风综合征相关的丘脑梗死的病灶分布模式

In the isolated thalamic infarcts, most of the lesions were restricted to one thalamic territory (97%) whereas infarcts tended to involve multiple thalamic territories in other stroke syndromes (39% in PCA, 77% in TOB and 44% in EPC infarcts).

在孤立的丘脑梗死中，大多数病变仅限于一个丘脑区域（97%），而其他卒中综合征的梗死倾向于涉及多个丘脑区域（PCA 39%，TOB 77%，EPC 44%）。

Consistent with previous reports, the ventrolateral territory was most commonly involved in isolated thalamic infarcts.However, there are only a few reports with respect to the specific thalamic territories involved in association with other stroke syndromes. In studies on patients with PCA infarcts, the lesions involving the thalamus were largely limited to the ventrolateral and posterolateral territory,while in another study the lesions most frequently involved the posteromedial and/or ventrolateral territory.In this study, involvement of the ventrolateral territory was the most common (14 patients (37%)), followed by involvement of combined ventrolateral and posterolateral territories (11 patients (29%)). Although the results are different among the different studies, the ventrolateral thalamus was the consistent region involved predominantly after PCA infarcts.

与以前的报道一致，腹外侧区最常发生孤立的丘脑梗死。然而，关于涉及与其他中风综合征相关的特定丘脑区域的报告很少。在对PCA梗死患者的研究中，涉及丘脑的病变主要局限于腹外侧和后外侧区域，而在另一项研究中，病变最常涉及后内侧和/或腹外侧区域。在本研究中，腹外侧区域受累最为常见（14例（37%），其次是腹外侧和后外侧区域合并受累（11例（29%）。尽管不同研究的结果不同，但腹外侧丘脑是PCA梗死后主要累及的一致区域。

In TOB and EPC infarcts, the posteromedial territory was more commonly involved (77% and 71%, respectively) than other vascular territories and often bilaterally involved in TOB. In the literature, both territories in the medial thalamus were frequently infarcted after TOB, but the detailed frequency was not available.None of the previous studies have reported the pattern of thalamic involvement in EPC infarcts. The results in this study suggest that the pattern of thalamic involvement is similar between TOB and EPC infarcts. However, involvement of multiple or bilateral thalamic territories was more frequent in TOB than in EPC infarcts (multiple, 77% vs 44%; bilateral, 64% vs 27%).

在TOB和EPC梗死中，后内侧区比其他血管区更易受累（分别为77%和71%），而且通常是双侧受累。在文献中，TOB常累及丘脑的两个区域，但具体的发病率尚不清楚。以前的研究都没有报道过丘脑参与EPC梗死的模式。本研究的结果表明TOB和EPC梗死患者丘脑受累的模式相似。然而，TOB中多个或双侧丘脑区域的参与率高于EPC梗死（多个，77%对44%；双侧，64%对27%）。

Topographic patterns of thalamic infarcts associated with stroke aetiologies

与中风病因相关的丘脑梗塞的病灶分布模式

In the stroke caused by SVD, the predominant vascular territory of thalamic infarcts was the ventrolateral territory (72% (43/ 60)). This may be attributed to the small vessel changes related to hypertensive arteriolopathy that are frequently observed in the thalamogeniculate arteries

在SVD引起的中风中，丘脑梗塞的主要血管区域是腹外侧区域（72%（43/60））。这可能是由于与高血压性动脉病相关的小血管改变引起的，这种变化在丘脑膝状体动脉中常见。

In cardioembolic stroke, various lesion patterns were commonly found, affecting the ventrolateral, posteromedial or posterolateral territory. These results contrast with other reports in which the posteromedial thalamic infarcts were most commonly caused by cardioembolism.Those studies, however, included mainly patients with isolated thalamic infarcts. Although the posteromedial territory was the frequent region (45% (14/31)) of cardiogenic embolism, the ventrolateral (52% (16/31)) and posterolateral territory (52% (16/31)) were also frequent areas of cardioembolism. Therefore, the posteromedial territory was not the specific region of cardioembolism. Moreover, the paramedian territory was most frequently involved in a cryptogenic cause (31% (20/65)) and LAD (29% (19/65)), and the most frequent site of thalamic infarction caused by LAD (63% (19/30)).

在心源性栓塞卒中中，常见的病变类型有多种，影响腹外侧、后内侧或后外侧区域。这些结果与其他报告形成了对比，其中后内侧丘脑梗死最常见于心源性栓塞。然而，这些研究主要包括孤立性丘脑梗死患者。尽管后内侧区是心源性栓塞的常见区域（45%（14/31）），腹外侧区（52%（16/31））和后外侧区（52%（16/31））也是心源性栓塞的常见区域。因此，后内侧区域不是心脏栓塞的特定区域。此外，旁正中区域最常见于不明原因（31%（20/65））和LAD（29%（19/65）），以及LAD引起的丘脑梗死（63%（19/30））。

Thalamic lesions were classified into four territories based on the template reported by Tatu et al.In some patients, however, the thalamic lesions did not correspond exactly to any of the categories. In these cases, the lesions were categorised into one of the most similar territories or into combined territories if the lesion size was larger than 15 mm. These cases may represent individual variations of the territories supplied by the thalamic arteries or a borderzone mechanism of stroke between adjacent territories.

根据Tatu等人的报告，丘脑病变分为四个区域。然而，在一些患者中，丘脑病变并不完全符合任何类型。在这些病例中，病变被分为最相似的区域之一，如果病变尺寸大于15 mm，则分为联合区域。这些病例可能代表丘脑动脉供血区域的个别变化或相邻区域之间中风的分水岭机制。

The patients with an incomplete work-up were not included in this study. Most of those patients did not undergo MR imaging because of impaired consciousness after severe stroke. This may have resulted in selection bias in the group of TOB and EPC infarcts. However, the proportion of such patients was relatively small and the results nevertheless showed that the posteromedial territory, which is known to be associated with consciousness, was mainly involved in TOB (77%) and EPC (71%) infarcts.

未完成工作的患者不包括在本研究中。由于严重中风后意识受损，大多数患者没有接受磁共振成像。这可能导致TOB和EPC梗死组的选择偏倚。然而，这些患者的比例相对较小，但结果表明，已知与意识相关的后内侧区主要参与TOB（77%）和EPC（71%）梗死。

In conclusion, the present study provides information on the topographic patterns of thalamic infarcts involving specific vascular territories on DWI and highlights the association of the involvement of a particular thalamic territory and the specific stroke syndromes and aetiologies.

总之，本研究提供了特定血管区域丘脑梗死的DWI病灶分布情况，并强调了特定丘脑区域与特定中风综合征和病因之间的联系。