联合血管重建术治疗烟雾病疗效评价

目的 探讨联合血管重建术治疗烟雾病的疗效.方法 23例缺血型烟雾病患者均采用颞浅动脉-大脑中动脉分支吻合与脑-硬膜-肌肉血管融合术（STA-MCA＋ EDMS）手术方法.术前、术后1周及术后3个月行mRS评分,并测量术前、术后1周手术侧大脑中动脉分布区的CT灌注参数.结果 22例患者术后1周行DSA或CTA检查示吻合口通畅,1例吻合血管闭塞.术后3个月mRS评分与术前、术后1周两组比较,差异有统计学意义（P＜0.05）.所有患者手术侧大脑中动脉分布区CT灌注成像各参数分别行分析,结果显示：术后1周示CBF增加,MTT、TTP缩短,与术前比较差异有统计学意义（P＜0.05）.结论 联合血管重建术能改善缺血型烟雾病患者症状.     

烟雾病颅内血管重建术后头皮切口愈合不良因素分析

目的研究烟雾病颅内血管重建术后头皮切口愈合不良的因素,为降低其发生的概率提供一定的依据。方法收集2012年1月—2018年12月在南昌大学第一附属医院确诊为烟雾病并行颅内血管重建术的患者资料397例,根据切口愈合不良诊断标准,将切口愈合不良者作为观察组,愈合良好者作为对照组。整理两组患者资料,愈合不良的影响因素采用二项Logistic回归分析。结果多因素分析显示,高血压病史、未保留颞浅动脉额支、手术时间长与术后切口愈合不良的发生呈正相关,并且高血压病史的影响最显著。结论高血压病史、未保留颞浅动脉额支、手术时间长是烟雾病行颅内血管重建术后头皮切口愈合不良的主要因素。[国际神经病学神经外科学杂志, 2021, 48(2):159-162]     

联合血管重建术治疗烟雾病疗效分析

目的探讨联合血管重建术治疗烟雾病的疗效。方法 2006年1月至2011年3月采用颞浅动脉-大脑中动脉搭桥+颞肌贴敷术治疗烟雾病患者21例,术前1d、术后1周及术后3月采用改良Rankin评分(mRS)进行神经功能评估。结果 21例患者无1例发生颅内血肿等并发症,术后临床功能均有不同程度改善;除2例行双侧血管重建术外其余均行单侧手术治疗;术后常规行MRA或CTA检查均示吻合口均通畅。术前1d、术后1周h术后3月mRS评分分别为(3.05±1.43)分,(2.90±1.58)分,(1.43±1.50)分,术前1d与术后1周mRS评分无明显差异(P>0.05),但术前1d与术后3月和术后1周与术后3月均差异显著(P<0.05)。本组无死亡病例。结论联合血管重建术能有效改善患者症状。     

CT脑灌注联合血管成像在烟雾病血管重建术中的应用效果

目的观察CT脑灌注联合血管成像在烟雾病血管重建术中的应用效果。方法选取我院2014-01—2016-05收治的36例烟雾病患者,于术前、术后对所有患者行CT脑灌注联合血管成像检查,根据检查结果为血管重建制定合理的手术方案,对术前、术后侧额、颞叶的达峰时间(TTP)、平均通过时间(MTT)、脑血流量(CBF)、脑血容量(CBV)进行定性和定量测量,并进行对比分析。结果 36例患者中,1例行直接重建,术后侧额、颞叶CBF、CBV增加,TTP延长,MTT无显著变化,吻合血管通畅;35例行间接重建,术后侧额、颞叶CBF、CBV增加,TTP、MTT降低,侧支吻合血管形成,术后TTP、MTT平均值低于术前,CBF、CBV平均值高于术前,差异有统计学意义(P0.05)。结论 CT脑灌注联合血管成像应用于烟雾病血管重建术,术前可掌握患者靶组织的灌注状态、血管形态及脑组织缺血程度,术后可评判血管吻合情况和脑血流量改善情况,有利于手术方式的选择和术后疗效的观察,值得推广应用。     

阿司匹林在成人缺血型烟雾病血管重建术后的应用

目的 探讨阿司匹林在成人缺血型烟雾病血管重建术后的应用效果。方法 回顾性分析2017年10月至2019年10月收治的符合入选标准的81例成人缺血型烟雾病的临床资料。47例术后应用阿司匹林（观察组）,34例未使用阿司匹林（对照组）。结果 观察组吻合口通畅率（97.87%,46/47）与对照组（94.12%,32/34）无统计学差异（P>0.05）。术后3个月,观察组改良Rankin量表评分[（1.38±1.05）分]明显低于对照组[（1.88±1.01）分;P<0.05]。观察组术后短暂性脑缺血发作发生率（4.26%）、脑梗死发生率（6.38%）均明显低于对照组（分别为23.53%、26.47%;P<0.05）。两组颅内出血、硬膜下血肿发生率均无统计学差异（P>0.05）。结论 阿司匹林可减少成人缺血型烟雾病血管重建术后脑缺血事件,同时改善病人预后,并且不增加颅内出血风险     

磁共振灌注成像在烟雾病血管重建术中的临床应用价值

目的 探讨磁共振灌注成像（PWI）在烟雾病血管重建术中的应用价值。方法 回顾性分析2015年1月到2018年1月血管重建术治疗的33例成年缺血型烟雾病的临床资料。术前、术后3个月,采用DSA检查评估血管重建术效果;采用PWI评估脑灌注。结果 33例中,术后27例临床表现明显好转。术后3个月,DSA显示脑部供血状况良好;PWI显示相对脑血容量增加不明显（P>0.05）,但是额叶和颞叶相对脑血流量显著增加（P<0.05）,相对平均血流通过时间和相对达峰时间均明显缩短（P<0.05）。结论 PWI可以定量地分析烟雾病血管重建术前后的脑血流动力学参数的变化,有效地评估手术效果。     

尼莫地平预防烟雾病血管重建术后脑梗死的效果分析

目的 探讨尼莫地平预防烟雾病血管重建术后脑梗死的效果。方法 回顾性分析2016年7月至2019年5月联合血管重建术治疗的73例烟雾病的临床资料。46例使用尼莫地平（观察组）,27例未使用尼莫地平（对照组）。术后1周复查颅脑CT或DWI观察新发脑梗死。结果 73例中,术后1周发生脑梗死19例,发生率为26.03%。观察组术后脑梗死发生率（17.39%,8/46）明显低于对照组（40.74%,11/27;P<0.05）。多因素logistic回归分析显示,未使用尼莫地平是烟雾病联合血管重建术后脑梗死独立危险因素（P<0.05）。结论 烟雾病联合血管重建术后脑梗死发生率较高,使用尼莫地平可以有效预防预防脑梗死。     

血管重建术治疗缺血型烟雾病的疗效分析

目的 探讨血管重建术治疗缺血型烟雾病的疗效。方法 回顾性分析2015年5月至2017年7月收治的26例缺血型烟雾病的临床资料,26例均在经颅多普勒超声辅助下行血管重建术。结果 22例术后症状明显改善,1例肌力较前下降,1例恢复期发生脑出血,2例言语功能无明显改善。22例复查DSA示烟雾血管均不同程度减少,侧支循环形成,其中2例烟雾血管完全消失。结论 血管重建术可明显改善缺血型烟雾病的局部脑血流灌注,改善临床症状,是治疗烟雾病的有效方法     

烟雾病颅内外血管重建术后新生血管能力的相关因素分析

目的 观察颞浅动脉-大脑中动脉分支吻合联合脑-硬脑膜-颞肌血管融合术(STA-MCA+EDMS)与脑-硬脑膜-颞肌血管融合术(EDMS)后疗效及预后对比分析。方法 回顾性分析2018年6月—2021年6月南京医科大学附属脑科医院166例行大脑半球行STA-MCA+EDMS联合手术或EDMS间接手术治疗的烟雾病患者。观察两组术式的术后疗效、手术并发症及其远期预后。结果 对于梗死型及出血型烟雾病患者,联合手术术后血管造影评分优于间接手术(P=0.009)。进一步对有症状组患者进行ROC曲线分析提示,当年龄>49.5岁时行联合手术对术后血管新生能力差具有一定预测作用(P <0.001)。当年龄> 42.5岁时行间接手术,对于术后血管新生能力差具有一定预测作用(P=0.046)。新生血管能力在各铃木分级、梗死型烟雾病、出血型烟雾病及无症状组均无统计学意义(P> 0.05)。结论 本中心研究提示联合手术对于术后血管的新生能力效果要优于间接手术,对于烟雾病患者应当尽早诊断尽早进行干预治疗。     

联合血管重建术治疗成人缺血型烟雾病14例临床分析

烟雾病(moyamoya disease)主要是双侧颈内动脉远端或大脑前动脉、大脑中动脉近端狭窄或闭塞,伴脑底部和软脑膜烟雾状细小血管形成,表现为脑缺血或出血的临床症状。烟雾病的治疗以外科手术为主。2003-07—2012-01作者采用联合血管重建术治疗成人缺血型烟雾病14例,现报告如下。     

Anesthesia for cerebral revascularization for adult moyamoya syndrome associated with sickle cell disease

We report the anesthetic management of an adult patient undergoing cerebral revascularization surgery for moyamoya syndrome complicating sickle-cell disease (SCD). We present a 25 year-old male of African ethnicity with homozygous SCD who was experiencing worsening ischemic neurologic symptoms culminating in intraventricular hemorrhage from rupture of moyamoya vessels. Despite an extracranial-intracranial superficial temporal artery-middle cerebral artery bypass that was angiographically patent postoperatively, he subsequently required an intracranial omental transplant to improve cerebral blood flow to the anterior cerebral artery territory. Prior to both cerebral revascularization procedures, the patient had continued with his regularly scheduled red blood cell exchange transfusion. The importance of normothermia, normocarbia, normotension, and normovolemia is emphasized in the neuroanesthetic management. We conclude that the safe and efficacious operative treatment of moyamoya disease, using both direct and indirect revascularization procedures, is being increasingly described, and therefore anesthesiologists are likely to encounter similar cases in the future and need to be aware of the surgical procedures and perioperative implications. The overall principles of safe anesthesia (normotension, normocarbia, good oxygenation, normothermia, normovolemia) for patients with SCD also applies to patients with moyamoya. During a craniotomy, certain deviations from these are needed (hyperventilation and mannitol diuresis for brain volume reduction, induced hypothermia or manipulations of arterial blood pressures) but they can be safely used with careful monitoring of the patient.     

烟雾病间接血流重建术后早期CT灌注评价

目的 探讨CT灌注成像对烟雾病间接血流重建术后早期疗效的评估价值.方法 回顾性分析47例经DSA证实的烟雾病的临床资料,其中出血型29例,缺血型18例,均行间接血流重建术.手术前后行头部CT灌注成像检查,分别对脑血流量(CBF)、脑血容量(CBV)、达峰时间(TIP)行半定量和定性分析,对比手术前后症状改善情况.结果 烟雾病手术前后CT灌注成像各参数比较,TTP绝对值(TTP值)和相对值(rTTP值)差异均有统计学意义(均P<0.05),余参数值差异均无统计学意义(均P >0.05).缺血型烟雾病术后症状明显改善9例(50%).症状改善者,手术前后TTP值和rTTP值差异均有统计学意义(均P<0.05);症状未改善者,手术前后TTP值差异显著((P<0.05),而rTTP值差异无统计学意义(P >0.05).结论 烟雾病间接血流重建术后侧支血管形成和脑血流改善早于造影可见新生血管形成,CT灌注成像为术后早期临床症状明显改善提供合理解释.     

Clinical features and outcomes in 154 patients with haemorrhagic moyamoya disease: comparison of conservative treatment and surgical revascularization

Abstract

Objectives:

Rebleeding is an unsatisfactory outcome for patients with haemorrhagic MMD. This study mainly investigated clinical features and outcomes in haemorrhagic MMD.

Methods:

A retrospective review was performed on a total of 154 patients with haemorrhagic MMD comprising 126 surgically treated and 28 conservatively treated patients.

Results:

There were 102 female and 52 male patients with a mean age at the initial bleeding of 33.95?years. Preoperative rebleeding occurred in 37 patients, and multivariate Cox regression analysis demonstrated that age at the time of initial bleeding (P?<?0.001, HR?=?1.093) was a risk factor for preoperative rebleeding. Of 124 patients with surgical revascularization, perioperative ischaemic stroke occurred in five (4.03%) and intracranial bleeding in four (3.23%). The mean follow-up period was 36.12?months. Recurrent bleeding occurred in six (10.17%) of 59 patients treated with direct revascularization, seven (20.69%) of 34 patients treated with indirect revascularization, two (6.45%) of 31 patients treated with combined revascularization and six (21.43%) of 28 patients treated conservatively. Kaplan–Meier analysis revealed no statistical differences in preventing rebleeding between direct, indirect and combined revascularization and conservative treatment (P?=?0.311).

Conclusions:

Age at the initial bleeding is a risk factor for rebleeding in haemorrhagic MMD. Although surgical revascularization show the tendency to decrease the rebleeding rate, there is no statistical difference between direct revascularization, indirect revascularization, combined revascularization and conservative treatment in preventing rebleeding. Further study is needed to determine whether surgical revascularization is effective in select population or with certain techniques.     

Clinical outcomes after revascularization for pediatric moyamoya disease and syndrome: A single-center series

Moyamoya is a progressive cerebrovascular arteriopathy that affects children of any age. The goal of this study was to determine imaging and clinical outcomes as well as complication rates in a pediatric cohort undergoing either a combined direct/indirect or indirect-only revascularization approach. Patients with moyamoya disease or syndrome ≤ 18 years of age at the time of initial surgery were identified, and clinical data were collected retrospectively. Over a 12-year period, 26 patients underwent revascularization procedures on 49 hemispheres with a median follow-up of 2.6 years from surgery. Median age at surgery was 7.3 years (range 1.4–18.0 years). Thirty-three hemispheres (67.3%) underwent combined revascularization with a direct bypass and encephalomyosynangiosis, and sixteen hemispheres (32.7%) underwent indirect-only revascularization. The rate of 30-day perioperative complication was 10.2%, and the rate of postoperative clinical stroke by end of follow-up was 10.2% by hemisphere. There was a 5.7% rate of intraoperative bypass failure requiring conversion to an indirect revascularization approach. On follow-up imaging, 96.9% of direct bypasses remained patent. On multivariate analysis, higher preoperative Pediatric Stroke Outcome Measure (PSOM) scores were associated with lower rates of good clinical outcome on follow-up (unit OR 0.03; p = 0.03). Patients with age < 5.4 years had lower rates of good clinical outcome on follow-up. In this North American cohort, both combined direct/indirect and indirect only revascularization techniques were feasible. However, younger children < 5.4 years of age have worse outcomes than older children, similar to east Asian cohorts.     

颅内外血管吻合结合间接血管重建治疗烟雾病

目的 探讨颅内外血管吻合结合间接血管重建治疗烟雾病的疗效.方法 65例烟雾病中,缺血型49例,出血型16例,均接受颞浅动脉-大脑中动脉分支吻合与脑-硬膜-肌肉血管融合术相结合的手术治疗,其中15例行同侧颞浅动脉两个分支吻合,9例行双侧手术.术后采用CTA、TCD、CT灌注成像和DSA评价手术效果.结果 采用该术式后,患者手术侧血流均有立即改善,随访效果好.结论 颞浅动脉-大脑中动脉分支直接吻合术结合脑-硬脑膜-肌肉血管融合术治疗烟雾病效果良好.     

Determinants of intellectual outcome after surgical revascularization in pediatric moyamoya disease: a multivariate analysis

Objects The aim of this study was to clarify predictors for poor intellectual outcome in pediatric moyamoya disease.Methods Fifty-two pediatric patients were included. Clinical diagnosis was transient ischemic attacks (TIA) in 35 and completed stroke in 17. Ten patients underwent indirect synangiosis through small craniotomy, whereas the other 42 underwent superficial temporal artery (STA)–middle cerebral artery (MCA) anastomosis and indirect synangiosis through large craniotomy. Full-scale IQ (FSIQ) was measured using the Wechsler intelligence scale for children (WISC) after surgery. Multivariate logistic regression models were applied to test the effect of clinical factors on intellectual outcome.Results and conclusion Eight patients revealed mentally impaired status (FSIQ<70). Multivariate analysis revealed that completed stroke and small craniotomy surgery were significantly associated with poor intellectual outcome. Odds ratios of each factor were 33.4 (95% CI, 2.4–474) and 19.6 (95% CI, 1.8–215) respectively. Early diagnosis and the revascularization procedure over as wide an area as possible may be essential to improve their intellectual outcome.     

Five-year experience of 101 adult patients with moyamoya disease at a single institution in Eastern China

This retrospective study included 101 adult moyamoya disease (MMD) patients of whom 58 were females and 43 were males in Wenzhou, China. Clinical and diagnostic features, surgical treatment, follow-up information and outcomes constitute this review. The modified Rankin Scale (mRS) was used to determine the neurological functional outcome. The Kaplan–Meier method was used to estimate recurrent stroke and mortality risk based on drug treatment alone or in combination with revascularization. The mean age at symptom onset was 43.3 (range, 18–64) years. The initial symptom was either hemorrhage, ischemia or transient ischemic attack (TIA) in 90, 6 and 5 patients, respectively. The median follow-up time in 84 patients was 26.5 (range, 6–62) months. Ten patients were treated with revascularization. In the remaining drug-treated group, the 5-year risk of recurrent stroke and death was 8% following onset of initial symptoms, while it was 25% in the revascularization group. However, the difference between these two groups was not significant (p > 0.05). There was also no difference in mRS between these two groups upon patient discharge, but in the revascularization group was lower than that in the drug-treated group at their last follow-up (p < 0.05). Adult MMD patients were most ikely to present with hemorrhage and had a better neurological functional outcome after revascularization than from medical therapy. However, revascularization did not decrease the recurrent stroke incidence or mortality risk. These results are different from those reported by other Chinese and foreign institutions.     

Arteriovenous malformation associated with moyamoya disease

The first case of a child with an arteriovenous malformation (AVM) associated with moyamoya disease is reported. The patient presented ischemic symptoms and underwent isdirect bypass surgery on both sides when she was 5 years old. Four years later she suffered from headache, and a small AVM of the left frontal lobe associated with the moyamoya vessels was detected. Single photon emission computed tomography (SPECT) was performed at age 11 and demonstrated low local cerebral blood flow (CBF) in the left frontal lobe and right temporal lobe, although the revascularization after the bypass surgery seemed to be effective, as judged on pancerebral angiography. We feel that brain ischemia due to the moyamoya disease may have played a causative role in the development of the AVM.