闭塞载瘤动脉术前脑缺血耐受性的预测和价值

对于复杂性难治性颅内动脉瘤往往需要闭塞载瘤动脉。术前需要对患者脑血流进行充分评价，试验观察阻断或闭塞载瘤动脉后侧支循环代偿情况。文章介绍了Matas试验、球囊试验闭塞系列研究、^131Xe CT测定脑血流和脑氧测定联合脑血流速度研究等脑血流动力学研究方法，根据颈动脉围阻断期脑组织对缺血的耐受性，来制定相应的血流动力学治疗策略。     

脑动脉瘤术中暂时阻断脑血流后脑缺血———多变量分析

对长径１５ｍｍ以上的大动脉瘤、宽颈动脉瘤及困难部位的脑动脉瘤进行夹闭时,暂时阻断载瘤动脉是手术中一种非常重要的方法。但阻断脑血流后有发生脑缺血的危险。作者以１４４例术中暂时阻断脑血流的脑动脉瘤患者为研究对象,用多变量分析探讨与术后神经功能缺损症状有关...     

血管重建术治疗难治性颅内动脉瘤

对于需要闭塞载瘤动脉的难治性颅内动脉瘤,血管重建技术是解决脑血流代偿不足的良好方法.随着显微手术技术的发展,移植血管通畅率的不断提高,血管重建治疗难治性颅内动脉瘤的疗效也在不断提高.     

载瘤动脉闭塞术仍然是治疗颈内动脉巨大动脉瘤的有效方法——长期随访的经验

载瘤动脉闭塞术是大型或巨大动脉瘤的主要治疗方法。Clareneon等对26例经载瘤动脉闭塞术治疗的颈内动脉大型或巨大动脉瘤的长期随访结果进行了分析,其中22例在证实患者可耐受球囊闭塞试验后,进行了载瘤动脉闭塞术。20例患者接受了临床随访,18例患者接受了血管造影随访。随访平均6．1（1．5—11）年。随访发现,75％的患者临床症状消失,10％的患者症状有部分消失,15％的患者症状无明显变化。     

前循环动脉瘤术中皮质和头皮脑电监测对手术策略的影响

目的探讨皮质和头皮脑电联合监测在前循环动脉瘤术中对手术策略的影响,以及患者术后因临时阻断载瘤动脉发生缺血事件的情况。方法对行开颅手术的52例患者（58个前循环颅内动脉瘤）同时进行术中皮质和头皮的脑电监测。前者用于监测载瘤动脉临时阻断后可能的皮质缺血,后者用于监测麻醉药物对脑电影响。综合分析术中双相脑电变化对手术决策及患者术后病情的影响。结果对52例患者中的40个动脉瘤的41支主要动脉采用了临时阻断,其中34例皮质和头皮脑电均无明显改变,18例患者的19支动脉临时阻断后,皮质脑电出现明显抑制,头皮脑电无明显变化。在皮质脑电明显变化的18例患者中,发生术后阻断载瘤动脉相关缺血事件9例,其中永久神经功能障碍5例。脑电信息影响手术策略19次,其中因皮质脑电明显变化改变吻合方式1例,预防性去骨瓣减压2例,采用分次阻断7例,快速夹闭7例,另有2例阻断30min皮质脑电无明显变化而安全永久性闭塞载瘤动脉。52例中有1例因未充分理解脑电明显变化信息而行术后二次手术。结论前循环动脉瘤术中阻断载瘤动脉时,皮质和头皮脑电联合监测可实时监测局部皮质血流,为手术决策提供参考。重视并理解脑电提供的信息,可以减少阻断血管相关并发症及避免复杂的血管重建、二次手术等。     

颅内远端动脉瘤血管内介入治疗的临床分析

目的观察颅内远端动脉瘤血管内介入治疗的疗效。方法回顾性分析2013年1月至2016年12月安徽省立医院神经外科收治的31例颅内远端动脉瘤患者的临床资料,其中囊状动脉瘤12例,10例为窄颈,2例缺乏明确瘤颈;梭形动脉瘤19例,均缺乏明确瘤颈。10例窄颈囊状动脉瘤均行弹簧圈填塞瘤体,2例缺乏明确瘤颈囊状动脉瘤1例行支架辅助弹簧圈填塞瘤体,1例行弹簧圈闭塞动脉瘤及载瘤动脉;4例梭形动脉瘤行弹簧圈闭塞动脉瘤及载瘤动脉,11例梭形动脉瘤行Onyx胶闭塞动脉瘤及载瘤动脉,4例梭形动脉瘤行弹簧圈联合Onyx胶闭塞动脉瘤及载瘤动脉。术后随访6~36个月。结果对所有患者成功行血管内介入治疗,无再出血病例,术后即刻造影显示11例囊状动脉瘤均完全闭塞,1例囊状动脉瘤和19例梭形动脉瘤患者动脉瘤及载瘤动脉均完全闭塞。8例行Onyx胶闭塞动脉瘤及载瘤动脉患者头部CT见不同程度脑梗死发生(6例无新发神经功能缺损,2例出现新发神经功能缺损),1例弹簧圈联合Onyx胶闭塞动脉瘤及载瘤动脉患者头部CT显示脑梗死发生,但无新发神经功能缺损,其余患者未出现脑梗死及新发神经功能缺损。DSA随访发现1例囊状动脉瘤患者瘤颈复发,其余所有患者未见明显动脉瘤复发。结论颅内远端动脉瘤血管内介入治疗安全、有效,选择何种介入治疗方式根据动脉瘤形态、位置、载瘤动脉迂曲程度及供血区域的重要性。     

椎动脉巨大动脉瘤自发完全血栓形成及载瘤动脉闭塞:1例报告及文献复习

颅内巨大动脉瘤自发性完全血栓形成伴载瘤动脉闭塞较为罕见.我们报道了1例罕见的椎动脉巨大动脉瘤完全血栓形成及载瘤动脉白发性闭塞患者,并对相关文献进行了复习,讨论其发病率、临床表现、发生机制、诊断和治疗.     

动脉瘤夹闭术常规术中血管造影的评价

动脉瘤夹闭术后,通常需要进行血管造影评价夹闭位置,排除残余动脉瘤或载瘤动脉闭塞。术后血管造影残余动脉瘤和载瘤动脉闭塞的发生率高达12％和19％。术中血管造影可立即改变夹闭部位来防止这些意外。 Chiang等对1996—《2000年美国马里兰州Johns Hopkins医院所有手术治疗的动脉瘤患者进行了前瞻性研究,共284例动脉瘤患者。对337个动脉瘤进行了303次手术治疗,平均年龄51岁(14～85岁),其中男     

血管内栓塞治疗大脑后动脉瘤

目的探讨应用血管内介入栓塞治疗大脑后动脉瘤的方法和安全性。方法回顾性分析应用血管内栓塞治疗的8例大脑后动脉瘤患者的临床特点、治疗方法及预后。结果①8例患者共有8个动脉瘤,其中P1段动脉瘤1例,P1与P2交界处动脉瘤2例,P2段动脉瘤3例,P3段动脉瘤2例;梭形或夹层动脉瘤6例,囊状动脉瘤2例。②球囊闭塞载瘤动脉1例,弹簧圈动脉瘤内填塞同时阻断载瘤动脉5例,动脉瘤内填塞保留载瘤动脉2例。③术后DSA示动脉瘤均完全消失,6例载瘤动脉阻断的患者术后无缺血症状,所有患者均未出现神经功能缺损和其他介入相关并发症。④术后3—6个月复查DSA,未见动脉瘤复发。临床随访1～12年,所有患者均恢复正常生活。结论血管内介入栓塞大脑后动脉瘤是安全、有效的治疗方法。     

3D-CTA、3D-DSA评估脑动脉瘤患者行显微外科夹闭术的治疗效果

目的 以三维CT血管成像（3D-CTA）、三维脑血管造影（3D-DSA）检查评估脑动脉瘤患者行显微外科夹闭术的效果,为合理选择脑动脉瘤显微外科夹闭后的评估方法提供依据.方法 对25例行显微外科夹闭术后的脑动脉瘤患者行3D-CTA、3D-DSA复查,分别对有无动脉瘤夹闭不全、动脉瘤颈残留/成角、载瘤动脉狭窄、载瘤动脉闭塞和动脉瘤夹滑脱移位5种影像学特征进行分析、赋值和计分,并进行统计分析.结果 25例患者中,术后3D-CTA复查显示载瘤动脉狭窄2例,未见动脉瘤夹闭不全、动脉瘤颈残留/成角、载瘤动脉闭塞和动脉瘤夹滑脱移位;3D-DSA复查显示动脉瘤夹闭不全1例、动脉瘤颈残留/成角1例、载瘤动脉狭窄2例,未见载瘤动脉闭塞和动脉瘤夹滑脱移位.两种检查方法的评分比较无统计学差异（P＞0.05）.结论 3D-CTA对显微外科夹闭术后的总体评价效果与3D-DSA具有可比性,但其对动脉瘤夹闭不全和动脉瘤颈残留/成角的显示不及3D-DSA.     

The effect of hemodynamically significant carotid artery disease on the hemodynamic status of the cerebral circulation

Although the presence of a hemodynamically significant carotid artery lesion is commonly used as an indicator of impaired cerebral circulation, the effect of such lesions on cerebral perfusion pressure and cerebral blood flow has never been determined accurately. We used positron emission tomography (PET) to study 19 patients with unilateral hemodynamically significant carotid artery disease (greater than 66% diameter reduction) and no evidence of cerebral infarction. According to PET measurements in the cerebral hemisphere distal to the lesion, 7 patients had normal cerebral hemodynamics, 8 had reduced perfusion pressure with normal blood flow, and 4 had reduced blood flow. Neither the percent stenosis nor the residual lumen diameter in the carotid artery was a reliable indicator of the hemodynamic status of the cerebral circulation. However, a significant relationship was found between the PET measurements of cerebral hemodynamics and the arteriographic circulation pattern (p = 0.006). The role of hemodynamic factors in the pathogenesis and treatment of cerebrovascular disease cannot be determined from the severity of carotid artery disease alone.     

Indications for cerebral revascularization through the system of the external carotid artery

The paper analyzes the study into the specific features of cerebral hemodynamics in patients with internal carotid artery occlusion. The study was performed by using Doppler ultrasound techniques. It revealed three different types of collateral blood flow of the brain according to the function of orbital anastomosis. The authors propose a new unique assessment of indications for a reconstructive operation on the external carotid artery for brain revascularization. The criteria proposed by the authors for assessing the cerebral hemodynamics enable the clear-cut indications for the above operation to be defined. The paper also summarizes the experience in examining and surgically managing 38 patients with internal carotid artery occlusion, who underwent revascularization of 39 channels of the external carotid artery.     

Hemodynamic influences of losartan on the brain in hypertensive patients.

The effects of angiotensin II receptor blockers on cerebral hemodynamics in humans have not been well elucidated. The present study evaluated the effects of losartan on cerebral hemodynamics in hypertensive patients using positron emission tomography. Ten patients with essential hypertension (mean age, 60.8 years) were examined. In each patient, regional cerebral blood flow was measured by [O-15] labeled water positron emission tomography before and after the oral administration of losartan for 8 to 23 weeks. In 8 patients, the baseline regional cerebral blood flow measurement was followed by 1,000 mg of acetazolamide challenge to measure the cerebral perfusion reserve. Systemic blood pressures before and after treatment were 153.8 +/- 10.8/96.0 +/- 6.5 mmHg (systolic mean +/- SD/diastolic mean +/- SD) and 133.4 +/- 11.2/83.6 +/- 6.5 mmHg, respectively; this difference was significant. The baseline global cerebral blood flow values before and after treatment were 38.4 +/- 6.9 ml/min/100 g and 38.2 +/- 8.2 ml/min/100 g, respectively; this difference was not significant. The results of the global cerebral blood flow response to the acetazolamide challenges were not statistically different before and after treatment. A regional analysis showed no statistical difference in regional cerebral blood flow or cerebral perfusion reserve throughout the brain before and after treatment. Losartan's effect on reducing the blood pressure did not affect either the baseline regional cerebral blood flow or the cerebral perfusion reserve in patients with mild to moderate hypertension. The inclusion of losartan in anti-hypertensive regimens could be advantageous for cerebral circulation in patients with essential hypertension.     

慢性进展性大脑中动脉主干闭塞的神经影像和脑血流

目的 探讨慢性进展性大脑中动脉主干闭塞患者的临床、神经影像和脑血流动力学改变.方法 对75例大脑中动脉主干闭塞患者行头颅核磁共振成像、CT和经颅多普勒超声检测.结果 65例（86.7%）出现脑缺血症状及体征.70例（93.3%）头颅核磁共振或CT显示不同类型脑梗死,最常见的是低灌注分水岭梗死和腔隙性脑梗死.60例（80.0%）闭塞侧大脑中动脉深度范围血流速度明显降低,70例（93.3%）闭塞侧大脑前动脉血流速度代偿性增快,45例（60.0%）闭塞侧大脑后动脉血流速度代偿性增快.结论 经颅多普勒超声和神经影像学检查有助于评估慢性进展性大脑中动脉主干闭塞患者的病情发展和预后,为了解颅内侧支循环代偿状况和更深入研究缺血性脑血管病的发病机制提供客观依据.     

经颅多普勒检测糖尿病患者脑血流动力学变化

目的探讨2型糖尿病患者脑动脉血流动力学的变化.方法应用经颅多普勒超声（TCD）检测103例2型糖尿病患者脑动脉平均血流速度、血流频谱形态、搏动指数、血流速度异常动脉分布情况,并与103例健康者进行比较.结果两组受检动脉均为1 133支,糖尿病组脑内动脉血流速度异常102支,异常率为9.0%;103例患者中血流频谱形态异常83例,占80.6%;46例搏动指数增高,占44.7%,与对照组的3.1%、44.7%及18.4%比较,差异有显著性（P＜0.05）;血流速度减慢的受累动脉以椎-基底动脉为主,血流速度增快和血管狭窄较少见于大脑后动脉.结论TCD检查可为临床2型糖尿病患者脑血管疾病的防治提供依据.     

Middle cerebral arterial blood flow velocity and hemodynamics in heart surgery

The aim of this study was to evaluate the effects of propofol, isoflurane, and sevoflurane on middle cerebral arterial blood flow velocity during open heart surgery, and the relationship between these effects and hemodynamic parameters. Fifty-two patients undergoing coronary artery bypass on cardiopulmonary bypass were divided randomly into 3 groups: the first group received 100 microg x kg(-1) x min(-1) propofol, the other groups received one minimum alveolar concentration of sevoflurane or isoflurane for anesthesia maintenance. Middle cerebral arterial blood flow velocities were measured by transcranial Doppler, and hemodynamics were measured by the thermodilution technique. Middle cerebral arterial blood flow velocities decreased significantly after administration of isoflurane and propofol, but there was no significant difference between the groups. After weaning from cardiopulmonary bypass, cerebral blood flow increased and came close to the value after induction in all groups. The pulsatility index and resistivity index increased significantly only after the propofol infusion, but there was no significant difference between the groups.     

原发性高血压早期肾损害超声 多普勒肾血流测定的评价

目的探讨原发性高血压（EH）早期肾损害超声多普勒肾血流测定的诊断价值。方法对60例EH患者按血、尿β     

Objective evaluation of various extracardiac factors of cerebral origin in extrasystole]

Partial integral rheography was used to study the volume velocity of brain blood supply (BBS) in 39 flying operators aged 20-39 years during continuously increasing bicycle ergometer testing. In good exercise tolerance, the dynamics of cerebral blood flow was found to be biphasic: 1) a rapid increase in BBS volume velocity at the first stages of exercise and 2) its subsequent stabilization. Stabilization of cerebral blood flow at 25% levels of blood minute volume was achieved by tonic tension autoregulation of the intracerebral arteries and adequate venous return. During the bicycle ergometer testing, the examinees with transient premature contractions showed impaired autoregulation, i.e. a considerable decrease in regional artery tone, cerebrovascular hyperperfusion and circulatory disorder resulting in the ++cerebro-cardiac syndrome with extracardiac premature beats. With drug therapy of extracardiac premature contractions, the tone of cerebral arteries and the level of intracranial hemodynamics should be borne in mind and corrected.     

老年脑卒中患者颈动脉彩色多普勒超声检查分析

目的用彩色多普勒超声观察老年脑卒中患者颈动脉形态、结构和血流动力学的改变。方法应用５ＭＨｚ线阵探头彩色多普勒血流显像仪观察５３例脑卒中患者和５９例健康老年人两侧颈动脉内中膜厚度、斑块情况，两侧颈总动脉截面积、平均流速和血流量以及血流动力学改变。结果（ｌ）脑卒中组两侧颈动脉内中膜厚度较对照组明显增厚，出现斑块４１例，占７７％，而对照组无１例出现斑块；（２）脑卒中组两侧颈总动脉平均流速较对照组明显减低，颈总动脉管腔截面积较对照组明显扩大，两组脑血流量改变不明显；（３）脉冲多普勒血流频谱显示脑卒中组收缩期峰值流速值和舒张末流速值均明显小于对照组，收缩一峰与收缩二峰比值两组均大于经验诊断阈值１．０５，反映外周阻力的指标搏动指数（ＰＩ）和阻力指数（ＲＩ）脑卒中组明显高于对照组。结论老年脑卒中患者颈动脉粥样硬化程度明显加重，由于代偿机制而保持了一定的脑血流量，其颈动脉血流速度降低而外周阻力增高。     

Hemodynamics of the lower extremities in patients with decubitus ulcers using the ultrasonic Doppler method

Our clinical experience indicates that decubitus ulcers with tissue loss/necrosis extending beyond the subcutaneous fat in aged patients are liable to become refractory and that most of these patients experience a cold feeling/cyanosis in the lower extremities. In order to determine the relationship between the severity of the decubitus ulcers and the hemodynamics in the lower extremities, we conducted a blood flow test using the ultrasonic Doppler method on the lower extremities in patients. Sixty-eight inpatients (38 men, 30 women, with an average age of 80.5 +/- 7.6 years old) were selected. B-mode tomographs were obtained with an ultrasonic diagnostic apparatus. The power Doppler method was used to measure blood flow rate, vascular lumen diameter, and intravascular blood flow at the dorsalis pedis artery, posterior tibial artery, peroneal artery furcation, and femoral artery. The subjects were divided into three groups: patients without decubitus ulcers; patients with mild to moderate decubitus ulcers of IAET Classification grade I-III; and patients with severe decubitus ulcers (IAET Classification grade IV), and the measurements were compared among the groups. The results revealed a tendency for the vascular lumen to become narrowed and intravascular blood flow to be reduced at all sites as decubitus ulcers increased in severity and showed the hemodynamics in the lower extremities to be particularly poor in the severe group. We measured the hemodynamics in the lower extremity with the ultrasonic Doppler method from the viewpoint of decubitus ulcer prevention and found differences in blood flow in the lower extremities according to the severity of decubitus ulcers. A reduction in blood flow in the lower extremities is considered to indirectly indicate a susceptibility to decubitus ulcers and to serve as a sign of its exacerbation. We consequently considered the test to be useful and concluded that deterioration of hemodynamics due to the progress of arteriosclerosis is one of the causes of decubitus ulcer exacerbation.