Vertebral arter diseksiyonu

Özet

Vertebral arter diseksiyonu spontan gelişebileceği gibi boyun travması sonrasında da ortaya çıkabilir; oksipital-boyun ağrısına posterior dolaşım iskemisi eşlik edebilir. Boyun BT anjiyografi küçük çaplı vertebral arterde lümen daralmasını, intimal flebi ve diseksiyon psödoanevrizmasını gösterebilir. Duvar içi hematom lümen belirgin değişmeden de bulunabileceğinden, kuşku sürüyorsa yağ baskılı damar-duvar MR sekansları tamamlayıcı olabilir. V1’den kafa tabanına uzanan damar, iki taraflı çap ve baziler arter doluşuyla birlikte izlenmelidir. Lezyon hipoplazi ya da akım artefaktı sanılırsa beyin sapı veya serebellar iskemiye yol açan damar hasarı gözden kaçabilir.

Faz ve pencere

BTA tanısal

CTA’da vertebral arterde fokal veya uzun segment daralma, düzgün ya da konik lümen daralması, intimal flep/çift lümen ve psödoanevrizma aranır.

Önerilen pencereler: Anjiyo (G 600 / M 150), Yumuşak doku (G 400 / M 40), Kemik (G 1800 / M 400).

BT bulguları

• V1–V3 segmentinde normal damar kalibresine göre uzun, düzgün konik daralma veya tam opasifikasyon kaybı izlenir.
• Eksantrik lümen daralmasıyla birlikte damar dış çapının büyümesi, duvar içi hematomun oluşturduğu genişlemeyi düşündürür.
• İntimal flep ve birbirinden ayrılan gerçek ve yalancı lümen, CTA’da doğrudan görülebilen güçlü diseksiyon bulgularıdır.
• Damar duvarına komşu kontrast birikimi ya da lümenle devamlı fokal sakküler çıkıntı diseksiyon psödoanevrizmasını gösterir.
• V2’de transvers foramen içindeki damar düzensizliği, komşu servikal kırık veya faset yaralanmasıyla aynı seviyede olabilir.
• Vertebral arterin ekstrakraniyal V1–V3 segmentlerini ve intrakraniyal V4 segmentini baziler arter birleşimine kadar izleyin. Tek zamanlı CTA akım yönünü göstermez; etkilenen arterde retrograd doluş veya akım tersine dönmesini kesinleştiremez.
• Vertebral arter hipoplazisi genellikle tüm damar boyunca diffüz küçük kalibreyle seyreder; segmental daralma ise travmatik vertebral arter yaralanmasını düşündürebilir.

Ölçütler ve sınıflamalar

Denver/Biffl travmatik BCVI derecelendirmesi

Derece I: lümen düzensizliği veya <%25 daralma; derece II: >%25 daralma ya da intimal flep veya intralüminal trombüs; derece III: psödoanevrizma; derece IV: oklüzyon; derece V: transeksiyon.

Denver (Biffl) blunt cerebrovascular injury grading

Yalnız künt travmatik servikal damar yaralanmalarında kullanılır. Derece I: damar duvarı düzensizliği veya diseksiyon/intramural hematom ile <%25 lümen daralması. Derece II: >%25 daralma ya da intimal flep/intraluminal trombüs eşliğindeki diseksiyon/intramural hematom. Derece III: psödoanevrizma; derece IV: damar oklüzyonu; derece V: transeksiyon. Spontan vertebral arter diseksiyonu bu travma ölçeğiyle derecelendirilmez.

Normalde

Normal vertebral arter, subklavyen arterden köken alıp V1–V3 boyunca düzgün konturla seyreder; transvers foramen içindeki V2 segmentinde opasifikasyon kesintisizdir. Hipoplazi genellikle vertebral arterin tümü boyunca yaygın küçük kalibreyle seyreder ve transvers foramen de küçük olabilir; darlıklar ise segmental olma eğilimindedir.

Ayırıcı tanı

Konjenital vertebral arter hipoplazisi

küçük damar kalibresi uzun seyir boyunca sabittir; eşlik eden kemik transvers foramen de küçük olabilir.

Aterosklerotik plaklar intimal flep taklidi yapabilir ve yaşlı hastalarda yanlış pozitif verebilir.

Akım kaynaklı yalancı diseksiyon

çift fazlı/karışmış kontrast görünümü damar duvarı boyunca devam etmez ve kaynak kesitlerde gerçek flep doğrulanmaz.

Vertebral arter ve vertebro-baziler kavşaklarda duplikasyon veya fenestrasyon nadir bir anatomik varyanttır; bu durum TVAI'ye ait çift lümen işareti ile karıştırılmamalıdır.

Flep, duvar içi hematom veya psödoanevrizma gibi ek yapısal bulgular diseksiyonu destekler.

Fibromüsküler displazi (FMD) çok odaklı darlık ve tortüoziteyle, aterosklerotik veya ülserli plak ise intimal flep benzeri görünümle diseksiyonu taklit edebilir.

Tuzaklar

• MIP’te şüpheli görünen intimal flep veya çift lümen bulgusunu multiplanar rekonstrüksiyonlarla da değerlendir; birden çok görünüm anatomi ve patolojiyi daha güvenle değerlendirmeye yardımcı olur.
• Hipoplastik arterde kontrastın geç dolması yalancı oklüzyon izlenimi verebilir; V1 kökeninden kafa tabanına kadar sürekliliği ve transvers foramen çapını kontrol et.
• Kötü bolus zamanlaması arteriyel ve venöz kontrastın eşzamanlı görünmesine ve çift lümen izlenimine yol açabilir; dental veya metalik artefaktlar da CTA yorumunu kısıtlayabilir.
• Küçük duvar içi hematomlar CTA’da gözden kaçabilir; MR’da yağ baskılı görüntüleme bu hematomları saptamada daha üstündür.
• İntimal flep veya çift lümen görünümünü multiplanar rekonstrüksiyonlarda doğrulayın; yetersiz bolus zamanlaması ve damar tortüozitesi çift lümen, aterosklerotik veya ülserli plak ise intimal flep izlenimi oluşturabilir.

Kendini dene

1. Boyun ağrısı sonrası CTA’da C1 düzeyinde eksantrik dar lümen, geniş dış kontur ve ince septum var. En olası tanı?

   • Vertebral arter diseksiyonu
   • Vertebral arter hipoplazisi
   • Vazospazm
   • Aterosklerotik V1 stenozu
   Cevabı göster

   Vertebral arter diseksiyonu. Segmental dar lümenle dış kontur genişlemesi ve septum birlikte duvar ayrışmasını destekler. Hipoplazi genellikle tüm vertebral arter boyunca yaygın küçüklük gösterir; aterosklerotik veya ülserli plaklar CTA’da intimal flebi taklit edebilir.

2. Sol vertebral arter tüm boyun boyunca ince; transvers foramen de sağdan küçük ve lümen düzgün. Bu görünüm en çok neyi destekler?

   • Vertebral arter hipoplazisi
   • Diseksiyon psödoanevrizması
   • İntimal flep
   • Venöz kontrast reflüsü
   Cevabı göster

   Vertebral arter hipoplazisi. Damarın ve kemik kanalının birlikte uzun segmentli küçük olması gelişimsel hipoplaziyi destekler. Psödoanevrizma damar dışına kontrastla dolan bir çıkıntı olarak görülebilir; intimal flep çift lümen görünümü oluşturabilir.

3. Künt boyun travması sonrası vertebral arterde duvar düzensizliği ve <%25 lümen daralması var; intimal flep, trombüs, psödoanevrizma veya oklüzyon yok. Denver BCVI derecesi nedir?

   • Derece I
   • Derece II
   • Derece III
   • Derece IV
   Cevabı göster

   Derece I. Denver sınıflamasında <%25 daralmalı duvar düzensizliği derece I’dir. Derece II daha ileri daralma veya intimal flep/trombüs; derece III psödoanevrizma; derece IV oklüzyondur.

Kaynaklar

Bu sayfadaki 52 cümle ve 3 quiz sorusu aşağıdaki kaynaklardan alıntılarla otomatik olarak karşılaştırıldı; 12 cümle bu karşılaştırmada düzeltildi (2026-10-09).

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Eğitim amaçlıdır; hasta başında tanı ve tedavi kararının yerine geçmez, tıbbi tavsiye değildir. Metinler yapay zekâ desteğiyle yazıldı ve otomatik bir adımda kaynak alıntılarıyla karşılaştırıldı; bu bir tıbbi doğrulama değildir ve içerik uzman radyolog incelemesinden geçmedi. Klinik kararlarda güncel kılavuzları, kurum protokollerini ve radyoloji raporunu esas alın.