腔隙性和腔隙性梗死:概念和现代应用的历史

D. Todman
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Lacune is derived from the Latin, lacuna, a pit or hole and in French, la lacune, a gap or empty space. Max Durand-Fardel in 1842 applied the term to these deep cavities and referred to the multiple small holes in the hemispheric white matter as ‘l'état cribalé' (sieve-like state) [2]. Pierre Marie correlated clinical findings with multiple lacunes and described sudden hemiplegia with good recovery and a slow gait with small steps ‘marche à petits pas de Déjérine', pseudo bulbar palsy and dementia [3]. He concluded that lacunae could be softenings caused by a ‘local arteriosclerotic process' or a process of ‘destructive vaginalitis', a dilatation of the perivascular space. During the first half of the twentieth century the terms were seldom used in the English-language medical literature. Charles Miller Fisher popularised the lacunar hypothesis with careful clinical and pathological studies published in the 1960's [4]. He proposed that lacunar infarcts were small (< 15 mm diameter) infarcts due to occlusion of a single penetrating branch of a large artery and associated with a number of well-defined clinical syndromes including pure motor hemiparesis, pure sensory stroke, sensorimotor stroke, ataxic hemiparesis and dysarthria clumsy hand. Fisher's pathological studies established that the arteriopathy in lacunes was a segmental disorganisation of the arterial vessel wall associated with an eosinophilic deposit or lipohyalinosis which was principally due to chronic hypertension. He also described atherosclerotic plaques, stenoses or occlusions of the penetrating or parent artery whilst a small percentage demonstrated haemosiderin-laden macrophages representing old micro-haemorrhages. Brain imaging including CT and MRI has allowed the detection of lacunae in vivo. Newer MRI techniques employing diffusion weighted imaging (DWI) with measurement of the apparent diffusion co-efficient (ADC) have higher sensitivity for detecting small deep infarcts [5]. Imaging however is not able to demonstrate that an infarct is due to an occlusion of a single perforating artery. Many studies have also found that classical lacunar infarcts, confirmed on imaging, have other non-lacunar mechanisms of infarction including large vessel or cardiac embolism. The lacunar hypothesis has long been controversial. Its detractors point to the variety of pathophysiologic mechanisms and demonstration of potential embolic sources in many cases [6]. Advocates of the model note that a minority of lacunes may result from emboli but that there are compelling clinical and epidemiological reasons for retaining lacunes as a distinct ischaemic stroke subtype [7]. Lacune and lacunar infarct are terms that are part of the medical parlance and have a history of use for over 150 years. Should they still be used or is it preferable to abandon them altogether? The concept is best reserved for the pathological lesion and the term subcortical stroke or small Lacune and lacunar infarct: A history of the concept and modern use 2 of 3 deep infarct used for the clinical and radiological descriptions. A new system of categorisation of stroke subtypes based on aetiology was developed for the Trial of ORG 10172 in Acute Ischaemic Stroke (TOAST) [8]. The 5 subtypes of (1) large-artery atherosclerosis, (2) cardioembolism, (3) small-vessel occlusion, (4) stroke of other determined aetiology and (5) stroke of undetermined aetiology had a high interphysician agreement rate. 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Pierre Marie correlated clinical findings with multiple lacunes and described sudden hemiplegia with good recovery and a slow gait with small steps ‘marche à petits pas de Déjérine', pseudo bulbar palsy and dementia [3]. He concluded that lacunae could be softenings caused by a ‘local arteriosclerotic process' or a process of ‘destructive vaginalitis', a dilatation of the perivascular space. During the first half of the twentieth century the terms were seldom used in the English-language medical literature. Charles Miller Fisher popularised the lacunar hypothesis with careful clinical and pathological studies published in the 1960's [4]. He proposed that lacunar infarcts were small (< 15 mm diameter) infarcts due to occlusion of a single penetrating branch of a large artery and associated with a number of well-defined clinical syndromes including pure motor hemiparesis, pure sensory stroke, sensorimotor stroke, ataxic hemiparesis and dysarthria clumsy hand. 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引用次数: 0

摘要

Lacune这个词最早出现在19世纪中期的欧洲文献中,但在英语医学文献中很少使用,直到20世纪60年代查尔斯·米勒·费舍尔的出版物。腔隙假说是有争议的,该术语最好用于病理病变。TOAST研究中提出的新的脑卒中临床分类已显示出较高的医师间一致性,并被广泛采用。lacune这个词最早是由法国医生amsamdsamade Dechambre(1812-1886)在描述死后大脑皮层下白质软化时使用的[1]。1838年,他在《巴黎公报》上发表了一篇论文,报告了一位最初从偏瘫中康复的病人的病理情况:“许多大小和形状各异的小腔隙,或多或少充满了乳白色的液体……”Lacune一词来源于拉丁语lacuna(坑或洞)和法语la Lacune(空隙或空的空间)。1842年,Max Durand-Fardel将该术语应用于这些深空腔,并将半球白质中的多个小孔称为' l' samat cribal '(筛状状态)[2]。Pierre Marie将临床表现与多发凹痕相关联,并描述了恢复良好的突发性偏瘫和小步缓慢的步态“marche petits pas de dsamjsamrine”、假性球麻痹和痴呆[3]。他得出结论,腔隙可能是由“局部动脉硬化过程”或“破坏性阴道炎”(血管周围空间的扩张)引起的软化。在二十世纪上半叶,英语医学文献中很少使用这些术语。Charles Miller Fisher在20世纪60年代发表了仔细的临床和病理研究,普及了腔隙假说[4]。他提出腔隙性梗死是由于大动脉的单个穿透性分支闭塞而导致的小梗死(直径< 15mm),并与许多明确定义的临床综合征相关,包括纯运动性偏瘫、纯感觉性卒中、感觉运动性卒中、共济失调性偏瘫和发音障碍性手笨拙。Fisher的病理研究证实,陷窝中的动脉病变是动脉血管壁的节段性紊乱,与嗜酸性粒细胞沉积或脂透明质沉积有关,主要是由慢性高血压引起的。他还描述了动脉粥样硬化斑块、穿透性动脉或母动脉狭窄或闭塞,同时一小部分表现为满载血黄素的巨噬细胞,代表陈旧性微出血。包括CT和MRI在内的脑成像已经可以在体内检测到腔隙。较新的MRI技术采用弥散加权成像(DWI)测量表观弥散系数(ADC),对于检测小的深部梗死具有更高的灵敏度[5]。然而,影像学不能证明梗死是由于单个穿通动脉闭塞所致。许多研究还发现,经影像学证实的经典腔隙性梗死具有其他非腔隙性梗死机制,包括大血管或心脏栓塞。腔隙假说长期以来一直存在争议。它的批评者指出了多种病理生理机制,并在许多情况下证明了潜在的栓塞源[6]。该模型的倡导者指出,少数凹窝可能是由栓塞引起的,但有令人信服的临床和流行病学理由将凹窝保留为独特的缺血性卒中亚型[7]。腔隙性和腔隙性梗死是医学术语的一部分,已有150多年的使用历史。它们是应该继续使用,还是应该完全放弃?该概念最好用于病理病变和术语皮层下卒中或小腔隙和腔隙性梗死:该概念的历史和用于临床和放射学描述的3 / 2深度梗死的现代用法。急性缺血性卒中(TOAST)的ORG 10172试验开发了一种基于病因的卒中亚型分类新系统[8]。(1)大动脉粥样硬化、(2)心脏栓塞、(3)小血管闭塞、(4)其他原因确定的脑卒中和(5)原因不明的脑卒中5种亚型的医师间一致性较高。通过使用这一术语,医生可以避免某些先入为主的观念,并保持开放的心态,以最佳的调查和治疗个别中风患者。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Lacune and lacunar infarct: A history of the concept and modern use
Lacune was a term first used in the European literature in the mid 19th century but was little used in English language medical literature until the publications of Charles Miller Fisher in the 1960's. The lacunar hypothesis is controversial and the terminology is best reserved for the pathological lesion. New clinical classifications of stroke such as that proposed in the TOAST study have demonstrated a high interphysician agreement rate and are widely employed. The term lacune was first used by the French physician, Amédée Dechambre (1812-1886) in his description of postmortem cerebral softenings in subcortical white matter [1]. His paper published in 1838 in the Gazette Médicale de Paris reported the pathology in a patient who had initially recovered from hemiplegia, ‘A number of small lacunes of variable size and form, more or less filled with milky fluid...’. Lacune is derived from the Latin, lacuna, a pit or hole and in French, la lacune, a gap or empty space. Max Durand-Fardel in 1842 applied the term to these deep cavities and referred to the multiple small holes in the hemispheric white matter as ‘l'état cribalé' (sieve-like state) [2]. Pierre Marie correlated clinical findings with multiple lacunes and described sudden hemiplegia with good recovery and a slow gait with small steps ‘marche à petits pas de Déjérine', pseudo bulbar palsy and dementia [3]. He concluded that lacunae could be softenings caused by a ‘local arteriosclerotic process' or a process of ‘destructive vaginalitis', a dilatation of the perivascular space. During the first half of the twentieth century the terms were seldom used in the English-language medical literature. Charles Miller Fisher popularised the lacunar hypothesis with careful clinical and pathological studies published in the 1960's [4]. He proposed that lacunar infarcts were small (< 15 mm diameter) infarcts due to occlusion of a single penetrating branch of a large artery and associated with a number of well-defined clinical syndromes including pure motor hemiparesis, pure sensory stroke, sensorimotor stroke, ataxic hemiparesis and dysarthria clumsy hand. Fisher's pathological studies established that the arteriopathy in lacunes was a segmental disorganisation of the arterial vessel wall associated with an eosinophilic deposit or lipohyalinosis which was principally due to chronic hypertension. He also described atherosclerotic plaques, stenoses or occlusions of the penetrating or parent artery whilst a small percentage demonstrated haemosiderin-laden macrophages representing old micro-haemorrhages. Brain imaging including CT and MRI has allowed the detection of lacunae in vivo. Newer MRI techniques employing diffusion weighted imaging (DWI) with measurement of the apparent diffusion co-efficient (ADC) have higher sensitivity for detecting small deep infarcts [5]. Imaging however is not able to demonstrate that an infarct is due to an occlusion of a single perforating artery. Many studies have also found that classical lacunar infarcts, confirmed on imaging, have other non-lacunar mechanisms of infarction including large vessel or cardiac embolism. The lacunar hypothesis has long been controversial. Its detractors point to the variety of pathophysiologic mechanisms and demonstration of potential embolic sources in many cases [6]. Advocates of the model note that a minority of lacunes may result from emboli but that there are compelling clinical and epidemiological reasons for retaining lacunes as a distinct ischaemic stroke subtype [7]. Lacune and lacunar infarct are terms that are part of the medical parlance and have a history of use for over 150 years. Should they still be used or is it preferable to abandon them altogether? The concept is best reserved for the pathological lesion and the term subcortical stroke or small Lacune and lacunar infarct: A history of the concept and modern use 2 of 3 deep infarct used for the clinical and radiological descriptions. A new system of categorisation of stroke subtypes based on aetiology was developed for the Trial of ORG 10172 in Acute Ischaemic Stroke (TOAST) [8]. The 5 subtypes of (1) large-artery atherosclerosis, (2) cardioembolism, (3) small-vessel occlusion, (4) stroke of other determined aetiology and (5) stroke of undetermined aetiology had a high interphysician agreement rate. By employing this terminology, the physician can avoid certain preconceptions and keep an open mind regarding the optimal investigation and treatment of individual patients with stroke.
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