七氟醚-瑞芬太尼麻醉对缺血型烟雾病脑血管重建术患者脑氧供需平衡的影响

目的 评价七氟醚-瑞芬太尼麻醉对缺血型烟雾病脑血管重建术患者脑氧供需平衡的影响.方法 择期行颞浅动脉-大脑中动脉分支吻合术的缺血型烟雾病患者40例,性别不限,年龄19～ 59岁,BMI 19～ 25 kg/m2,ASA分级Ⅰ或Ⅱ级,Suzuki分期≥3.采用随机数字表法,将患者随机分为2组(n=20):异丙酚-瑞芬太尼组(PR组)和七氟醚-瑞芬太尼组(SR组).麻醉诱导:靶控输注异丙酚,血浆靶浓度5 μg/ml,静脉注射芬太尼3 μg/kg和罗库溴铵0.6 mg/kg.气管插管后行机械通气,麻醉维持:SR组吸入七氟醚(呼气末浓度1.0％ ～ 1.7％),PR组TCI异丙酚,血浆靶浓度3～4 μg/ml,2组均TCI瑞芬太尼,血浆靶浓度3.5 ng/ml,维持BIS值40 ～ 60,间断静脉注射罗库溴铵0.3 mg/kg.分别于麻醉诱导前(T0)、血管阻断前10 min (T1)、血管阻断后10 min (T2)、血管吻合-开放后10 min (T3)时记录局部脑氧饱和度(rSO2).结果 与T0时比较,PR组T3时术侧rSO2升高,SR组T1-3时术侧和非术侧rSO2升高(P＜0.05或0.01);与PR组比较,SR组T1时术侧rSO2升高(P＜0.05),非术侧rSO2差异无统计学意义(P＞0.05).结论 对于缺血型烟雾病脑血管重建术患者,七氟醚复合瑞芬太尼麻醉可维持良好的脑氧供需平衡状态,且与异丙酚复合瑞芬太尼麻醉的效果相似.     

多层螺旋CT血管成像在烟雾病诊断中的应用

目的探讨多层螺旋CT血管成像（MSCTA）在烟雾病诊断中的价值以及应用前景。方法回顾性分析10例烟雾病患者的MSCTA及数字减影血管造影（DSA）的影像学资料。结果MSCTA可清晰显示狭窄、闭塞以及异常增多的脑血管。容积重建有利于显示病变血管与周围结构的空间关系,综合最大密度投影法重建和多曲面重建图像分析可清晰显示异常增多的脑血管,即烟雾状血管。MSCTA对狭窄及闭塞血管的检出率为66．2％（53/80）;DSA对狭窄及闭塞血管的检出率为67．5％（54／80）,两者比较差异无统计学意义（P〉0．05）。MSCTA对颅底异常血管网的显示及分布情况与DSA大致相似。结论MSCTA诊断烟雾病的灵敏度高,是早期诊断烟雾病的重要依据,早期诊断、及时治疗是改善烟雾病患者预后的有效方法。     

烟雾病的临床研究进展

烟雾病是颈内动脉末端进展性狭窄、闭塞及脑底出现异常血管扩张网所致的脑出血性或缺血性疾病,伴脑底部异常血管网形成为其特点。此病在临床上主要有脑缺血和出血两类表现,成年患者经常表现为出血症状,而儿童患者多表现为短暂缺血发作或中风。数字减影血管造影（DSA）仍是诊断该病的金标准。血管重建手术是目前该病的主要治疗方法。     

成人出血型烟雾病54例DSA诊断与分析

目的分析成人出血型烟雾病的数字减影血管造影的影像学特点。方法 54例成人出血型烟雾病患者经股动脉穿刺插管行DSA血管造影。结果 54例患者中累及大脑前动脉31例,累及大脑中动脉19例,同时累及大脑前动脉、大脑中动脉18例,其中82.76%闭塞,7例累及大脑后动脉,6例出现基底动脉异常,7例合并动脉瘤。结论出血型烟雾病血管病变不仅累及大脑前、中动脉,大脑后动脉及基底动脉亦可累及,动脉闭塞多于狭窄,可出现于单侧型烟雾病,可合并动脉瘤,DSA检查是诊断烟雾病的最主要的手段。     

儿童烟雾病血供重建的远期随访(附226例报告)

目的报告施行改进的颅外颅内动脉吻合及脑肌血管连通融合相结合的血供重建术,治疗１５岁以下儿童烟雾病２２６例的远期治疗作用。方法术后经８年（平均１５５年）以上随访,经脑血管造影复查及ＭＲＩ、头颅ＣＴ扫描、经颅多普勒超声（ＴＣＤ）颅内多条血管探测检查,以及对临床神经系统症状与术前对比、格拉斯哥预后测评（ＧＯＳ）、Ｔａｆｔ智商测定。结果２２６例中,６４例（２８％）神经系统症状完全恢复,６９例（３１％）显著进步,４６例（２０％）轻度进步,４３例（１９％）无变化,４例（２％）死亡,有效率７９％。结论改进的颅外颅内动脉吻合及脑肌血管连通融合相结合的方法,对改善儿童烟雾病脑缺血状态有明显作用,研究发现预后结果与术前脑血管损害程度分期有相关性,损害程度较轻的Ⅰ～Ⅲ期预后好,智商高,损害严重的Ⅳ～Ⅴ期预后差,智商低     

目标导向液体治疗对缺血型烟雾病患者脑血管重建术后谵妄的影响

目的探讨目标导向液体治疗对缺血型烟雾病患者脑血管重建术后谵妄(POD)的影响。方法择期行颞浅动脉-大脑中动脉分支吻合术的缺血型烟雾病患者40例,男24例,女16例,年龄18～59岁,BMI 18.5～24.0 kg/m~2,ASAⅡ或Ⅲ级,Suzuki分期≥3,MMSE评分24分。采用随机数字表法将其分为两组(n=20):常规补液组(R组)和目标导向液体治疗组(G组)。R组采用常规4-2-1补液原则,维持CVP 5～10 cmH_2O;G组采用目标导向液体治疗,维持每搏量变异度(SVV)10%。两组维持MAP波动幅度在基础值20%以内,MAP下降幅度超过基础值20%以上时,静脉注射麻黄碱6～10 mg或输注去甲肾上腺素0.01～0.03μg·kg~(-1)·min~(-1)。记录麻醉诱导前即刻(T_0)、血管阻断前10 min(T_1)、阻断后10 min(T_2)、血管开放后10 min(T_3)时的局部脑氧饱和度(rSO_2)、MAP、HR、BIS值、鼻咽温。于T_1—T_3时采集动脉血样1 ml,行血气分析,并测定Hct和PaCO_2。于术后3 d,采用CAM量表评估患者POD的发生情况。结果两组不同时点MAP、HR、鼻咽温、BIS值、Hct和PaCO_2差异无统计学意义;与T_0时比较,T_1—T_3时G组患者两侧rSO_2明显升高,T_3时R组患侧rSO_2明显升高(P0.05);与R组比较,T_1—T_3时G组患者两侧rSO_2明显升高(P0.05)。与R组比较,G组患者补液量明显减少,POD发生率明显降低(P0.05)。结论目标导向液体治疗可降低缺血型烟雾病患者脑血管重建术后POD的发生率,其机制可能与改善rSO_2有关。     

脑氧饱和度监测下磷酸肌酸钠对腰椎手术患者术后早期恢复质量的影响

目的 探讨脑氧饱和度(rSO₂)监测下磷酸肌酸钠对腰椎手术患者术后早期恢复质量的影响。方法 选择2021年10月至2022年1月全麻下拟行腰椎体融合术的患者118例,男51例,女67例,年龄18～64岁,BMI<30 kg/m²,ASAⅡ或Ⅲ级。将患者随机分为两组：磷酸肌酸钠组(P组)和对照组(C组),每组59例。术中监测rSO₂并维持下降幅度不超过基线值的20%。手术开始后30 min内,P组静脉滴注磷酸肌酸钠1.0 g(溶于生理盐水100 ml);C组静脉滴注生理盐水100 ml。于术前1 d、术后1、3 d采用恢复质量量表(QoR-15)评估患者恢复质量。记录术中rSO₂降低次数及处理措施、术中麻醉药物用量、手术时间、麻醉时间、出血量、输液量、拔管时间、麻醉复苏室(PACU)停留时间、术后首次肛门排气时间、术后首次下床活动时间和术后住院时间。记录术后低血压、便秘、术后恶心呕吐(PONV)、谵妄和心律失常发生情况。结果 与术前1 d比较,术后1、3 d两组QoR-15评分明显降低(P<...     

局部脑氧饱和度监测在老年患者术中应用的研究进展

背景 局部脑氧饱和度(regional cerebral oxygen saturation,rSO2)监测是一种新型无创监测脑氧平衡的方法,老年患者术中实时监测rSO2可以优化老年患者围手术期的管理,降低术后神经系统并发症的发生. 目的 为rSO2监测的相关研究和临床应用提供参考. 内容 主要介绍rSO2的基本原理、影响因素及rSO2在老年患者心脏手术、神经外科手术、胸外科、腹外科及骨科中的应用. 趋向 积极探索rSO2在老年患者中的应用价值,减少老年患者术后并发症.     

成人烟雾病患者颅内外血运重建术后早期神经系统并发症的危险因素

目的筛选成人烟雾病患者颅内外血运重建术后早期神经系统并发症的危险因素。方法回顾性收集2017年1月至2019年6月于本院行颅内外血运重建术烟雾病患者的病例资料, 性别不限, 年龄18～65岁, ASA分级Ⅱ或Ⅲ级。根据患者是否发生术后早期神经系统并发症, 分为术后早期神经系统并发症组和未发生术后早期神经系统并发症组。收集患者年龄、性别、术前临床症状、既往高血压病史、糖尿病病史、冠心病病史、ASA分级、麻醉方式、手术方式、麻醉时间、手术开始时间、手术时间、术中尿量、术中血管活性药使用次数和麻醉后观察室(PACU)停留时间等因素。采用logistic回归分析筛选发生术后早期神经系统并发症的危险因素。结果最终共纳入行颅内外血运重建术的成人烟雾病患者510例, 术后早期神经系统并发症发生率为9.0%。logistic回归分析结果显示, 术前缺血、术中血管活性药物使用>3次和PACU停留时间>90 min是术后神经系统并发症发生的危险因素(P<0.05)。结论术前缺血、术中血管活性药物使用>3次和PACU停留时间>90 min是成人烟雾病患者颅内外血运重建术后早期神...     

脑氧饱和度监测下控制性降压对老年高血压患者术后谵妄的影响

目的 探讨脑氧饱和度(rSO₂)监测下控制性降压对老年高血压患者术后谵妄（POD）的影响。方法 择期全麻下行鼻泪道手术的老年高血压患者110例,男53例,女57例,年龄65~85岁,ASA Ⅱ或Ⅲ级,高血压Ⅰ或Ⅱ级,采用随机数字表法分为两组：rSO₂监测组（S组）和对照组（C组）,每组55例。两组均采用乌拉地尔联合艾司洛尔控制性降压,维持MAP≥基础值的70%,且MAP≥55 mmHg;当S组rSO₂<基础值的80%或rSO₂最低值<基础值的50%,并且持续时间大于10 s,则逐步提升血压直至rSO₂恢复至≥基础值的80%或绝对值＞50%。C组rSO₂监护仪施行遮盖处理。记录入室后吸氧5 min（T0）、控制性降压15 min（T1）、30 min（T2）、控制性降压结束后5 min（T3）、拔管后10 min（T4）的HR、MAP、rSO₂;记录rSO₂基础值、术中最低值及较基础值下降的最大百分比;术后1、2、3 d采用谵妄评定方法 中文修订版（CAM-CR量表）对患者进行POD评估。结果 与T0时比较,T1—T2时两组MAP明显下降（P<0.05）,C组rSO₂明显下降（P<0.05）,T3—T4时逐渐回升至术前水平。T1—T2时S组rSO₂明显高于C组（P<0.05）,术中rSO₂最低值明显高于C组（P<0.05）,rSO₂较基础值下降的最大百分比明显低于C组（P<0.05）。术后1 d S组POD发生率明显低于C组（P<0.05）。结论 rSO₂监测下控制性降压能减少老年高血压患者鼻泪道手术后谵妄的发生,提高围术期安全性。     

Minimally invasive cerebral revascularization in moyamoya disease in adult patients

BackgroundMoyamoya disease (MMD) affects young patients, is generally progressive, and results in strokes or cerebral hemorrhages for which medical management is not effective.ObjectiveTo determine the effectiveness of surgical management with minimally invasive cerebral revascularization in MMD.Material and MethodsWe conducted a retrospective cohort study of patients undergoing extracranial-intracranial microsurgical revascularization surgery with mini-craniotomy, analyzing the epidemiological, clinical, neuroimaging, postoperative evolution, and complications. We describe the technique in detail. Key outcomes included graft patency, complications, and recurrence of ischemic or hemorrhagic stroke.ResultsFrom September 2017 to December 2020, 12 brain revascularization procedures for MMD were performed in eight patients (four bilateral), and all 12 grafts were classified as patent. The main complication was contralateral cerebral infarction identified by postoperative neuroimaging in a patient without clinical symptomatology. There was no case of scalp ischemia or necrosis when performing the minimally invasive approach with linear incision.ConclusionsThe results of this study suggest that the minimally invasive extracranial-intracranial cerebral revascularization procedure for MMD in adults is effective, with graft patency in all cases and minimal morbidity.     

Contralateral cerebral hemodynamic changes after unilateral direct revascularization in patients with moyamoya disease

Direct revascularization has been used successfully to prevent strokes by improving regional cerebral blood flow (rCBF) to the affected hemisphere faster in patients with moyamoya disease (MMD). Since most literatures have focused on the rCBF changes of operative hemisphere, we evaluated the hemodynamics of nonoperative side by xenon-enhanced computed tomography (Xe-CT) and acetazolamide challenge test in patients with MMD during a short time follow-up. Fifteen MMD patients with unilateral ischemic presentations who received direct revascularization on the symptomatic hemispheres with complete hemodynamic evaluations by Xe-CT and acetazolamide challenge test were enrolled. Hemodynamic evaluations were performed 1, 3, and 6 months, postoperatively. The postoperative rCBF and cerebral vascular reserve (CVR) were recorded and correlated with clinical outcome. Angiography was performed if the patient had neurological deterioration or deficits. The average follow-up time was 8.5 ± 3.5 months. Three months after the ipsilateral direct revascularization, the CVR of nonoperative hemispheres (25.8 ± 8.1%) began to decrease significantly (P = 0.003). Six months later, the rCBF showed a downward trend in nonoperative hemispheres (47.4 ± 8.0 ml·100 g⁻¹ min⁻¹) than the preoperative status, but the difference was not significant (P = 0.053). Three patients presented with decreased rCBF and impaired CVR in the nonoperative hemispheres. Among them, two patients were symptomatic. Unilateral direct revascularization in symptomatic hemisphere for MMD patient could induce CVR impaired in primary asymptomatic hemisphere during the short term after the surgery. Therefore, critical follow-up, especially the hemodynamic follow-up in the asymptomatic hemispheres should be performed in patients with MMD.     

Cerebral revascularization for moyamoya disease in children

Ninety-four patients with moyamoya disease (56 in the pediatric age group and 38 adults) were treated by revascularization surgery in the past 21 years (1979--2000). Combined surgery of the superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and indirect revascularization of encaphalo-duro-arterio-myo-synangiosis (EDAMS) was performed. Ischemic attacks disappeared in most patients within 1 year (mean) after surgery in pediatric cases. No morbidity or mortality was experienced in the pediatric group. Some children with cerebral infarction before the surgery, however, had mild mental retardation even after the surgery. Early diagnosis and proper prophylactic surgical treatment is indispensable for pediatric patients with moyamoya. MR angiography is an important diagnostic modality for the screening and longitudinal follow-up of moyamoya disease.     

Cerebral revascularization for moyamoya disease in adults

Moyamoya disease is a rare entity that results in progressive occlusion of the arteries of the circle of Willis. In adults, this most commonly leads to intraventricular hemorrhage and less frequently to symptoms of ischemia. Without treatment, there is progressive deterioration of neurologic function and re-hemorrhage. Direct superficial temporal artery to middle cerebral artery bypass is considered the treatment of choice, although it's efficacy, particularly for hemorrhagic disease, remains uncertain.     

Cranial burr hole for revascularization in moyamoya disease

Currently, superficial temporal artery-middle cerebral artery (MCA) anastomosis, encephalomyosynangiosis (EMS), and encephalo-duro-arterio-synangiosis are used to treat moyamoya disease and are reported to effectively improve ischemic symptoms. All are methods of reversing the flow of blood from the external carotid artery system into the cortical branches of the MCA. As moyamoya disease advances, these operations alone will predictably not correct the deterioration in blood flow in the territory of the anterior cerebral artery. It was noted in a case of moyamoya disease with intraventricular hemorrhage that a burr hole, made in the frontal region for drainage purposes, induced marked neovascularization. Since then, similar frontal burr holes have been made in five juvenile cases of moyamoya disease; this procedure involved making a burr hole in both frontal bones and incising both the dura and the arachnoid membrane. In two cases a frontal burr hole in both frontal bones and incising both the dura and the arachnoid membrane. In two cases a frontal burr hole was placed simultaneously with EMS, and in the others the frontal burr hole was made following EMS. The clinical symptoms improved after the frontal burr hole was made, and dynamic computerized tomography revealed improved circulation in the frontal regions. Together with conventional surgical therapy for juvenile cases of moyamoya disease, this operation is considered beneficial both to the circulation in the frontal region and for the protection of frontal brain function.     

Anesthetic management of revascularization for moyamoya disease

Anesthetic management during 85 STA-MCA anastomoses with or without encephalo-myosynangiosis for 64 patients with Moyamoya disease was evaluated retrospectively. Anesthetic agents included nitrous oxide-NLA (GONLA), nitrous oxide-halothane (GOF), nitrous oxide-enflurane (GOE), and their combinations. Slight hypercarbia (40 mmHg less than PaCO2 less than 50 mmHg) was essential to avoid cerebral ischemia. Several procedures to control heart rate by beta blockade or to control hypertension by nitroglycerin were required, because tachycardia and hypertension interfered with fine surgical procedure. During microsurgery HR of GONLA anesthetized patients was significantly lower. Postoperatively the patients anesthetized by GOE showed significantly lower PaCO2 compared with the GONLA anesthetized patients. So we recommend GONLA for anastomosis in patients with Moyamoya disease.