放疗后鼻咽癌幸存者中椎动脉假性动脉瘤伴复发性后循环短暂性脑缺血发作：一例病例报告

文献信息

中文摘要

背景： 放射性骨肉瘤（RIOS）、放射性骨坏死（ORN）以及放疗后假性动脉瘤是鼻咽癌（NPC）放疗后公认的晚期并发症。尽管放疗后假性动脉瘤通常表现为危及生命的出血，但其相关的缺血性表现鲜有报道。
病例介绍： 一名50岁男性，有鼻咽癌放疗史，15年后发生左侧颈椎椎旁RIOS，并疑似合并颈椎放射性骨坏死（C-ORN）。他出现复发性、短暂且完全可逆的后循环短暂性脑缺血发作（TIAs）。计算机断层血管造影（CTA）显示C1-C2破坏性改变、左侧椎动脉（VA）部分血栓形成的假性动脉瘤，以及延伸至V4段和左小脑后下动脉的残余远端显影。约两周后进行的数字减影血管造影（DSA）显示病变远端无顺行充盈，而右侧VA血管造影证实后循环灌注充分。血管内载瘤动脉闭塞完全排除了该病变。在6个月随访期间未再发生TIA或新的缺血性并发症。
结论： 放疗后RIOS、疑似C-ORN以及破坏性上颈椎改变可能累及VA并促成假性动脉瘤形成。假性动脉瘤的进行性血栓形成可能与复发性后循环TIA相关。对于存在其他原因无法解释的后循环症状的患者，有必要在CTA上仔细评估椎动脉，并在有指征时辅以DSA。

英文摘要

BACKGROUND: Radiation-induced osteosarcoma (RIOS), osteoradionecrosis (ORN), and post-radiotherapy pseudoaneurysms are recognized late complications of radiotherapy for nasopharyngeal carcinoma (NPC). Although post-radiotherapy pseudoaneurysms usually present with life-threatening hemorrhage, associated ischemic manifestations are rarely described.
CASE PRESENTATION: A 50-year-old man with a history of NPC treated with radiotherapy developed a left cervical paravertebral RIOS 15 years later, with suspected coexisting cervical spine osteoradionecrosis (C-ORN). He experienced recurrent, brief, and fully reversible posterior circulation transient ischemic attacks (TIAs). Computed tomography angiography (CTA) demonstrated destructive C1-C2 changes, a partially thrombosed left vertebral artery (VA) pseudoaneurysm, and residual distal opacification extending to the V4 segment and left posterior inferior cerebellar artery. Digital subtraction angiography (DSA) performed approximately two weeks later showed no antegrade filling beyond the lesion, while right VA angiography confirmed adequate posterior circulation perfusion. Endovascular parent artery occlusion completely excluded the lesion. No further TIAs or new ischemic complications occurred during the 6-month follow-up.
CONCLUSION: Post-radiotherapy RIOS, suspected C-ORN, and destructive upper cervical changes may compromise the VA and contribute to pseudoaneurysm formation. Progressive thrombosis of the pseudoaneurysm may be associated with recurrent posterior circulation TIAs. Careful assessment of the vertebral arteries on CTA, supplemented by DSA when indicated, is warranted in patients with otherwise unexplained posterior circulation symptoms.