Ekstrakraniyal karotis stenozu

Özet

Karotis bifurkasyonundaki aterosklerotik plak, ipsilateral retinal veya serebral iskemiye yol açabilen ekstrakraniyal damar hastalığının sık nedenidir. Boyun BT anjiyografi, plak düzeyini ve lümen daralmasını hızlı biçimde gösterir; kalsifikasyon ve damar kıvrımları ölçümü güçleştirebilir. Darlık, distal normal internal karotis çapına göre NASCET yöntemiyle raporlanmalı; distal damar küçülmüşse near-occlusion olasılığı ayrıca ele alınmalıdır. Kritik darlığın veya eşlik eden trombüsün atlanması, inme kaynağının eksik tanımlanmasına ve damar lezyonunun yanlış sınıflanmasına neden olabilir.

Faz ve pencere

BTA tanısal

İnce kesit kontrastlı BTA ve damar merkez hattına dik multiplanar rekonstrüksiyonlarda bulb ve proksimal ICA'daki plak, rezidüel opak lümen ve stenoz sonrası distal ICA kalibresi değerlendirilir; kalsifik plak blooming artefaktıyla lümeni olduğundan dar gösterebilir.

Önerilen pencereler: Anjiyo (G 600 / M 150), Yumuşak doku (G 400 / M 40).

BT bulguları

• Eksantrik bulb plağı — CCA bifurkasyonunda başlayıp ICA ostiumuna uzanan, lümeni bir taraftan basan duvar kalınlaşması.
• Rezidüel lümen — en dar noktada kontrastla dolu kanalın çapı; eksantrik lezyonda aksiyel görüntü yerine damar eksenine dik kesitte ölçülür.
• NASCET darlık yüzdesi — 1 − (en dar lümen çapı / stenoz distalindeki paralel duvarlı normal ICA çapı) oranının yüzdeye çevrilmesi.
• Distal ICA kalibresi — stenozun hemen distalindeki internal karotis arter çapının belirgin şekilde daraldığı durumlar near-occlusion olarak sınıflandırılır; bu durumda klasik stenoz oranları yanıltıcı olabilir.
• Kalsifiye plak — yüksek atenüasyonlu duvar plağı; blooming gerçek açıklığı örtebildiğinden yumuşak doku penceresi ve ince kesitlerle yeniden kontrol edilir.
• Tandem hastalık — servikal darlıkla birlikte distal ICA, karotis sifonu veya intrakraniyal ana damarlarda ikinci bir stenoz ya da oklüzyon bulunması.
• İpsilateral intrakraniyal doluş — ACom/PCom kollateralleri ve distal arter opasifikasyonu, ileri darlıkta akımın etkisini gösterir.

Ölçütler ve sınıflamalar

NASCET çap ölçümü

% stenoz = [1 − (minimum rezidüel lümen / stenoz distalindeki normal ICA çapı)] × 100

NASCET klinik stenoz sınıfları

<50%; 50–69%; 70–99%; oklüzyon

NASCET

Darlık, en dar rezidüel lümenin stenoz distalindeki normal ICA lümenine oranından hesaplanır. Geleneksel sınıflama <50%, 50–69%, 70–99% ve oklüzyondur; distal ICA kollapsı varsa oran tek başına kullanılmaz ve near-occlusion tanımlanır.

Normalde

NASCET yöntemine göre stenoz derecesi, en dar rezidüel lümen çapının stenozun hemen distalindeki normal iç karotis arter çapına oranla hesaplanır.

Ayırıcı tanı

Karotis diseksiyonu

bulb plağından çok distal servikal ICA'da uzun, düzgün daralma, mural hematom veya intimal flep görülür.

Near-occlusion

bulbda kritik plak darlığına distal ICA'nın belirgin incelmesi eşlik eder; klasik NASCET oranı yanıltıcı biçimde düşük çıkabilir.

Akut lümen trombüsü

karotis bulbusundaki carotid web ile ilişkili yüzen trombüs CTA’da gösterilebilir.

Fibromüsküler displazi

distal ICA'da çok odaklı daralma ve genişleme dizisi bulunur; bifurkasyon merkezli eksantrik plak beklenmez.

Karotis kıvrımlanması

yaşa bağlı olarak artan damar tortuositesi, özellikle bifurkasyondan proksimal segmentlerde infleksion sayısı ve açı metriğiyle kantitatif olarak değerlendirilebilir.

Tuzaklar

• Kalsifik plak blooming'i rezidüel lümeni kapatabilir; lümeni yumuşak doku/anjiyo penceresinde ve farklı düzlemde doğrulayın.
• NASCET paydasını bulb çapından almayın; ölçüm, stenoz distalinde duvarları paralel olan normal ICA segmentinden yapılır.
• Near-occlusion uyarısı — stenoz derecesi yüksek olsa bile distal internal karotis arter çapında belirgin bir daralma gözlenirse, yakın-oklüzyon (near-occlusion) tanısı düşünülmeli ve klasik stenoz oranları yanıltıcı olabilir.
• Karotis kıvrımlanmasını değerlendirirken BTA'da damar tortuositesi ve bifurkasyon açıları gibi geometrik parametreleri inceleyin.

Kendini dene

1. NASCET’e göre karotis darlık yüzdesini hesaplarken payda olarak hangi çap kullanılır?

   • Darlık distalindeki normal ICA çapı
   • Karotis bulbusunun en geniş çapı
   • Darlık öncesi CCA çapı
   • Aynı taraf ECA çapı
   Cevabı göster

   Darlık distalindeki normal ICA çapı. NASCET yönteminde en dar rezidüel lümen çapı, stenoz distalindeki normal ve paralel duvarlı ICA çapına oranlanır. Bulbus, CCA ve ECA çapları bu yöntemin paydası değildir.

2. Kritik bulb plağının distalinde ipsilateral ICA incelmiş ve karşı ICA'dan belirgin küçük. Bu durumda hangi yaklaşım uygundur?

   • NASCET yüzdesini doğrudan yazmak
   • Near-occlusion araştırmak
   • Fibromüsküler displazi demek
   • Normal varyant kabul etmek
   Cevabı göster

   Near-occlusion araştırmak. Distal ICA'nın küçülmesi, kritik proksimal darlığa bağlı near-occlusion için uyarıcıdır; distal referans daraldığı için standart NASCET yüzdesi yanıltıcı olur. Displazi distal çok odaklı kontur değişikliği yapar, normal varyant plağa bağlı kritik bulb stenozunu açıklamaz.

İlgili konular

• Karotis akut tromboz/oklüzyonu

Kaynaklar

Bu sayfadaki 40 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 9 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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