摘要
目的探讨术中多模态监测在颞浅动脉-大脑中动脉(STA-MCA)搭桥术中对血流动力学参数、血脑屏障破坏的评估价值及其与术后灌注变化的关联。方法选择南京医科大学连云港临床医学院(连云港市第一人民医院)神经外科自2023年3月至2024年10月收治的60例缺血性脑血管病患者为研究对象,其中烟雾病患者17例、慢性颈内动脉闭塞和(或)慢性症状性MCA狭窄/闭塞患者43例。患者均经CTA或DSA确诊,均接受STA-MCA M4段搭桥治疗,术中均使用微血管多普勒超声(MDU)、荧光素钠造影及吲哚菁绿血管造影结合Flow800(ICG-Flow800)监测血脑屏障破坏等级以及动脉吻合前后受体动脉收缩期峰值流速(PSV)及血流方向,术后7 d、1个月时均使用CTP复查脑血流灌注改善情况。将患者按动脉吻合前受体动脉血流方向分为进侧裂组(27例)与出侧裂组(33例),并进一步根据受体动脉PSV细分为≤10 cm/s亚组、>10 cm/s亚组。回顾性收集患者的临床及影像学资料,并进行如下分析:(1)比较患者术前、术后7 d、术后1个月时CTP参数如脑血容量、脑血流量、平均通过时间、达峰时间的差异;(2)比较动脉吻合前受体动脉PSV与吻合后受体动脉血流出侧裂速度(RA.EXV)或受体动脉血流进侧裂速度(RA.ESV)的差异;(3)比较动脉吻合前后脑表面静脉ICG-Flow800荧光强度曲线参数如延迟时间、上升时间、曲线斜率、达峰时间、最大荧光强度等的差异;(4)采用Spearman秩相关检验分析所有患者动脉吻合前受体动脉PSV与术前CTP参数的相关性,动脉吻合后进侧裂组患者的RA.ESV、出侧裂组患者的RA.EXV与术后7 d CTP参数的相关性,以及所有患者的血脑屏障破坏等级与术前CTP参数、动脉吻合前受体动脉PSV、动脉吻合后RA.ESV或RA.EXV的相关性。结果(1)术后所有受体动脉的血流方向均变为双向。患者术后脑血流灌注情况较术前均有不同程度改善,其中术后7 d、1个月时患者的平均通过时间较术前明显缩短,术后1个月时患者的脑血流量较术前明显升高,差异均有统计学意义(P<0.05)。(2)统计分析显示,当受体动脉PSV≤10 cm/s时,无论进出侧裂组,动脉吻合后RA.ESV或RA.EXV均较吻合前受体动脉PSV明显升高,差异均有统计学意义(P<0.05)。(3)所有患者动脉吻合后脑表面静脉ICG-Flow800荧光强度曲线参数均较术前明显改善,差异均有统计学意义(P<0.05)。(4)所有患者术前受体动脉PSV与术前脑血流量呈正相关关系(r_(s)=0.445,P=0.020),进侧裂组患者动脉吻合后RA.ESV与术后7 d的达峰时间呈正相关关系(r_(s)=0.490,P=0.009),所有患者的血脑屏障破坏等级与术前达峰时间呈正相关关系(r_(s)=0.478,P=0.012)。结论术中多模态监测在STA-MCA搭桥术中可以为术者提供详细的血流动力学及血脑屏障破坏数据,实时评估手术效果,从而利于手术决策优化。
Objective To explore the value of intraoperative multimodal monitoring in superficial temporal artery-middle cerebral artery(STA-MCA)bypass surgery in evaluating hemodynamic parameters and blood-brain barrier disruption,as well as their correlations with postoperative perfusion changes.Methods A retrospective case series study was performed;60 patients with ischemic cerebrovascular diseases admitted to Department of Neurosurgery,Lianyungang Clinical Medical College of Nanjing Medical University(Lianyungang First People's Hospital)from March 2023 to October 2024 were selected,including 17 patients with moyamoya disease and 43 patients with chronic internal carotid artery occlusion and/or chronic symptomatic MCA stenosis/occlusion.All patients were confirmed by CTA or DSA and underwent STA-MCA M4 segment bypass surgery.Intraoperatively,microvascular Doppler ultrasound(MDU),sodium fluorescein angiography,and indocyanine green angiography combined with Flow800(ICG-Flow800)were used to monitor the blood-brain barrier disruption grade,as well as the peak systolic velocity(PSV)and blood flow direction of the STA and recipient artery before and after arterial anastomosis.Cerebral blood perfusion improvement was reexamined by CT perfusion(CTP)7 days and 1 month after surgery.These 60 patients were divided into a group with blood flow into the sylvian fissure(inflow group,n=27)and a group with blood flow out of the sylvian fissure(outflow group,n=33)according to the direction of recipient artery blood flow before arterial anastomosis,and further subdivided into subgroups with PSV≤10 cm/s and>10 cm/s based on the recipient artery PSV.Clinical and imaging data of these patients were collected and analyzed as follows:(1)CTP parameters such as cerebral blood volume,cerebral blood flow,mean transit time,and time to peak before surgery,7 days after surgery,and 1 month after surgery were compared;(2)differences between the recipient artery PSV before arterial anastomosis and recipient artery exiting sylvian fissure velocity(RA.EXV)or recipient artery entering sylvian fissure velocity(RA.ESV)of the recipient artery after anastomosis were compared;(3)differences in ICG-Flow800 fluorescence intensity curve parameters such as delay time,rise time,curve slope,time to peak,and maximum fluorescence intensity of the cerebral surface veins before and after arterial anastomosis were compared;(4)spearman rank correlation was used to analyze the correlation of recipient artery PSV before arterial anastomosis with preoperative CTP parameters in all patients,the correlations of RA.ESV in the inflow group or RA.EXV in the outflow group with CTP parameters 7 days after surgery,and the correlations of blood-brain barrier disruption grade with preoperative CTP parameters,recipient artery PSV before arterial anastomosis,and RA.ESV or RA.EXV after arterial anastomosis in all patients.Results(1)The blood flow direction of all recipient arteries became bidirectional after surgery.Cerebral blood perfusion improved to varying degrees after surgery:the mean transit time 7 days and 1 month after surgery,and cerebral blood flow 1 month after surgery were significantly higher compared with those before surgery(P<0.05).(2)Regardless of the blood flow direction(into or out of the sylvian fissure),the RA.ESV or RA.EXV after anastomosis was significantly higher than the recipient artery PSV before anastomosis when the recipient artery PSV≤10 cm/s(P<0.05).(3)For all patients,the ICG-Flow800 fluorescent intensity curve parameters of cerebral surface veins after anastomosis improved significantly compared with that before anastomosis(P<0.05).(4)Preoperative recipient artery PSV was positively correlated with preoperative CBF in all patients(r_(s)=0.445,P=0.020).In the inflow group,postoperative RA.ESV was positively correlated with Tmax 7 days after surgery(r_(s)=0.490,P=0.009).The blood-brain barrier disruption grade was positively correlated with preoperative Tmax in all patients(r_(s)=0.478,P=0.012).Conclusion Intraoperative multimodal monitoring in STA-MCA bypass surgery can provide surgeons with detailed hemodynamic parameters and blood-brain barrier disruption data,enabling real-time evaluation of surgical outcomes to optimize operative decision-making.
作者
陈鹏宇
徐德智
彭澳
吕宁
宋凯·木合亚提
刘希光
Chen Pengyu;Xu Dezhi;Peng Ao;Lyu Ning;Sunghar Muheyat;Liu Xiguang(Department of Neurosurgery,Lianyungang Clinical College of Nanjing Medical University(Lianyungang First People's Hospital),Lianyungang 222000,China;Department of Neurosurgery,Lianyungang Hospital Affiliated to Xuzhou Medical University(Lianyungang First People's Hospital),Lianyungang 222000,China)
出处
《中华神经医学杂志》
北大核心
2025年第6期588-598,共11页
Chinese Journal of Neuromedicine
关键词
烟雾病
颞浅动脉-大脑中动脉搭桥术
多模态监测
受体动脉
血流动力学
血脑屏障
Moyayoya disease
Superficial temporal artery-middle cerebral artery bypass surgery
Multimodal monitoring
Receptor artery
Hemodynamics
Blood-brain barrier
