大脑中动脉狭窄或闭塞显微手术治疗单中心经验并文献复习

目的探讨颞浅动脉-大脑中动脉(STA-MCA)搭桥术治疗成人大脑中动脉狭窄或闭塞的疗效。方法回顾性分析31例行STA-MCA搭桥术治疗的大脑中动脉狭窄或闭塞患者的临床资料,术前均行全脑血管造影(DSA)评价颈外动脉-颞浅动脉、颈内动脉、大脑中动脉的狭窄程度,CT灌注成像(CTP)评估脑血流灌注情况。手术采用经额颞入路STA-MCA M4段搭桥术。术后5~7 d行头部CT血管造影(CTA)及CTP评价吻合口通畅情况及脑血流动力学变化情况,术前术后采用改良Rankin量表(mRs)评估患者神经功能状况,出院后定期进行临床及影像学随访。结果31例患者中,11例以头晕起病,7例以肢体麻木、无力起病,7例以语言功能障碍起病,6例以短暂性脑血管发作(TIA)引起的肢体活动障碍起病。31例患者中,脑叶灌注减少者10例,多个脑叶交界区域灌注减少者15例,单侧基底节区血流量减少者6例;严重狭窄12例,次全闭塞6例,完全闭塞为13例;单发血管狭窄病人20例,多发血管狭窄11例。31例患者术后复查头部CT示术区未见新发梗塞或出血,颅内情况稳定,复查头部CTA及CTP示29例搭桥血管通畅,脑灌注较术前好转。31例患者中术后1例出现头皮切口愈合不良,3例出现高灌注引起的烦躁,3例出现低灌注梗死引起的神经功能障碍,3例肢体肌力改善,4例语言功能障碍症状改善,6例术前反复TIA发作患者术后症状未再发作,其余患者术后无明显并发症,且临床症状较术前无明显改变。31例患者术后mRs评分示患者的神经功能较术前明显好转,差异有统计学意义。31例患者完成随访23例,mRs评分示患者的神经功能较出院时进一步改善,复查DSA或CTA及CTP提示搭桥血管通畅,脑灌注较出院时进一步好转。结论STA-MCA搭桥术是治疗大脑中动脉狭窄或闭塞患者的有效方法,并有利于改善患者的神经功能,但需大样本、多中心、长期随访等研究结果进一步验证。

Microsurgical treatment of middle cerebral artery stenosis or occlusion:a single center experience and literature review

Objective To investigate the effect of superficial temporal artery-middle cerebral artery(STA-MCA)bypass in the treatment of MCA stenosis or occlusion.Methods The clinical and imaging data of 31 MCA stenosis or occlusion patients with STA-MCA bypass were analyzed retrospectively.All the 31 patients underwent digital subtraction angiography(DSA)to evaluate the stenosis degree of external carotid artery-superficial temporal artery,internal carotid artery,middle cerebral artery,and underwent CT perfusion(CTP)to evaluate cerebral blood flow perfusion.The operation was performed by STA-MCA M4 segment bypass via the frontotemporal approach.CT angiography(CTA)and CTP were conducted 5-7 days after operation to evaluate the patency of anastomosis and the changes of cerebral hemodynamics.Modified Rankin scale(mRs)was used to evaluate the neurological function before and after operation.Clinical and imaging follow-up were conducted regularly after discharge.Results Of the 31 patients,the initial symptoms of 11 cases were dizziness,7 were numbness and weakness of limbs,7 were language dysfunction and 6 were dyskinesia caused by transient cerebrovascular attack(TIA).Among the 31 patients,the decreased perfusion of 10 cases were cerebral lobes,15 were multiple cerebral lobes,6 were unilateral basal ganglia,12 were severe stenosis,6 were subtotal occlusion,13 were complete occlusion.20 were single vessel stenosis and 11 cases were multiple vessel stenosis.CT scan showed that there was no new infarction or hemorrhage in the operation area,and the intracranial condition was stable.CTA and CTP scan showed that the bypass vessels were unobstructed in 29 cases,and the cerebral perfusion was improved.Among the 31 patients,1 had poor healing of scalp incision,3 had dysphoria caused by high perfusion,3 had neurological dysfunction caused by low perfusion infarction,3 had improvement of limb muscle strength,4 had improvement of language dysfunction symptoms,and 6 with recurrent TIA before operation had no recurrence after operation.The other patients had no obvious complications,or clinical symptoms improvements.The mRs score of 31 patients after operation showed that the neurological function of was significantly improved than pre-operation,and the difference was statistically significant.Of the 31patients,23 were followed up.The mRs score showed that the neurological function of 23 patients was further improved.DSA or CTA and CTP showed that the bypass vessels were unobstructed,and cerebral perfusion was further improved than that at discharge.Conclusion STA-MCA bypass is an effective method for the treatment of MCA stenosis or occlusion,and it is helpful to improve the nerve function of patients.However,it needs to be further verified by large sample,multicenter and long-term follow-up.