颈动脉支架置入后致命性再灌注性脑出血

高灌注综合征为颈动脉内膜切除术后的一种并发症。 1981年Ｓｕｎｄｔ等用“高灌注综合征”这一术语报道了颈动脉内膜切除术后的三联征 :典型的偏头痛、短暂的局灶性癫痫发作和脑出血。其特点是脑血流增多 ,收缩压无明显变化。多在术后 5～ 7天出现 ,通常先发生单侧头痛。迄今为止 ,关于颈动脉支架置入后的高灌注综合征尚无报道。作者报道 1例 68岁血压正常的男性患者。 5个月前曾发生左大脑半球缺血性卒中 ,血管造影显示左颈内动脉狭窄 95%。住院后血压、血液学、生化、血小板计数、凝血功能检查均正常 ,头颅ＣＴ提示中度脑白质变性 ,无出血…     

CEA术中经颅局部脑氧饱和度监测预测术后过度灌注综合征

过度灌注综合征是颈动脉内膜切除术(CEA)后的一种少见而又十分严重的并发症。最近,Neurosurgery报道利用近红外光谱分析(nea-infared spectroscopy)进行术中经颅局部脑氧饱和度(rSO_2)监测能够可靠地预测术后发生过度灌注综合征的危险性。 Ogasawara等对50例同侧颈内动脉狭窄(≥70％)患者CEA治疗时进行术中rSO_2监测,同时在术前和术后即时通过SPECT评价患者的脑血流(CBF)。结果发现,6例CEA术后出现过度灌注(定义为与术前相比     

脑高灌注综合征

<正>脑高灌注综合征(CHS)是指颈动脉内膜剥脱术(CEA)后没有发生脑缺血的患者,在临床上出现血压升高、术侧头痛、癫痫和短暂性局灶神经功能缺损的症候群。Bouri等[1]提出,诊断CEA后CHS需要满足下列条件:(1)发生在CEA后30d内;(2)有脑高灌注存在的证据:经颅多普勒超声(TCD)、单光子发射计算机体层摄影(SPECT)或CT/MRI支持,或者收缩压>180mm Hg(1mm Hg=0.133     

颈动脉内膜切除术预防和治疗缺血性卒中的疗效分析

目的：评估颅外段颈内动脉重度狭窄患者颈动脉内膜切除术预防和治疗缺血性卒中的临床价值。方法：22例患者均由经颅多普勒(TCD)筛选、数字减影血管造影(DSA)或CT血管造影(CTA)检查证实为颈内动脉重度狭窄，其中21例为有症状颈动脉狭窄。22例患者住院期间接受24侧次颈动脉内膜切除术，术后随访并行TCD检查。结果：21例(23侧次)手术过程顺利，随访2～30个月，未再发TIA或脑梗死，19例症状减轻或缓解。1例术后死于脑栓塞和肺部感染。随访期复查TCD1～2次，20例未发现明显再狭窄。结论：颈动脉内膜切除术对治疗重度颈内动脉狭窄，预防TIA和缺血性卒中有效。TCD可作为对重度颈内动脉狭窄的筛选、术中监测和术后随访的重要手段。     

颈动脉内膜剥脱术后不同抗凝抗栓治疗对早期并发症的影响

目的:分析颈动脉内膜剥脱术(CEA)后抗凝等内科治疗对围术期并发症发生情况的影响。方法:回顾2010年5月至2012年7月,于我院行颈动脉内膜剥脱术患者144例临床资料,根据术后不同处理分为肝素组(H组,n=52)和低分子右旋糖酐复合阿司匹林组(DA组,n=90),观察两组患者一般状况,比较不同术后治疗患者围术期并发症情况。结果:肝素组及低分子右旋糖酐组患者并发症的发生例数和发病率分别为:伤口血肿4例(7.7%)和4例(4.4%);高灌注综合征5例(9.6%)和3例(3.3%);围术期脑卒中1例(1.9%)和2例(2.2%);术后高血压36例(69.2%)和68例(75.6%);术后低血压4例(7.7%)和3例(3.3%);围术期急性冠状动脉综合征1例(1.9%)和3例(3.3%),两组间比较差异无统计学意义(P>0.05)。结论:在严格控制血压条件下,颈动脉内膜剥脱术后应用肝素和低分子右旋糖酐复合阿司匹林两种治疗,对患者术后恢复安全性的影响无明显区别,应密切观察患者颈部伤口情况及新发神经定位体征情况。     

多模态监测下颈动脉内膜剥脱术治疗颈内动脉重度狭窄

目的探讨多模态监测下颈动脉内膜剥脱术治疗颈内动脉重度狭窄的临床疗效。 方法回顾性分析常德市第一人民医院神经外科自2018年1月至2021年9月实施颈动脉内膜斑块剥脱术治疗的15例颈内动脉重度狭窄患者的基本资料、术后并发症和复查情况。 结果1例患者在预阻断时，多普勒提示血流下降50%，但电生理未提示异常，提高血压，未予以术中转流；3例患者电生理及多普勒同时提示低灌注，予以术中转流后均好转。术后所有患者无明显并发症，术后复查未见再狭窄。 结论多模态监测下颈动脉内膜剥脱术治疗颈内动脉重度狭窄安全有效。     

颈动脉内膜切除术中应用临时转流管的疗效探讨

目的探讨颈动脉内膜切除术中应用颈动脉临时转流管的指征和经验方法对42例颈动脉狭窄患者行颈动脉内膜切除术，术中使用经颅多普勒超声监测大脑中动脉血流速度，8例患者阻断术侧颈内动脉后，大脑中动脉血流速度低于阻断前的60％，对此8例患者使用颈动脉临时转流管，术后随访1～24个月。结果使用颈动脉临时转流管的8例患者，未出现与阻断颈内动脉有关的围手术期并发症；随访期内无再次脑缺血事件发生；颈部B超检查显示颈动脉通畅，无再狭窄发生。结论颈动脉内膜切除术中有选择性地使用颈动脉临时转流管，可预防与阻断术侧颈内动脉有关的术中脑缺血事件的发生。     

高灌注综合征的诊断及治疗策略

高灌注或高灌注状态（hyperperfusion state）是由于颈动脉高度狭窄被解除后，同侧脑血流量（eerebralblood flow，CBF）成倍增加超出脑组织的代偿能力所致，是一个病理生理学概念。高灌注综合征（hyperperfusion syndrome，CHS）多指继发于颈动脉内膜切除术（carotid endarterectomy，CEA）后出现头痛、神经缺损、癫痫发作或脑出血等症状群。CHS症状可有轻重，     

应用经颅多普勒超声指导颈动脉内膜切除术中脑血流的调节

目的探讨颈动脉内膜切除术中，经颅多普勒超声（TCD）对血压与脑血流调节指导作用。方法回顾性分析颈动脉重度狭窄患者52例，在全身麻醉下行颈动脉内膜切除术，术中应用TCD监测大脑中动脉（MCA）血流参数，根据脑血流参数的变化调控血压，并决定术中是否应用临时转流管。应用临时转流管（转流组）16例，未用36例（非转流组）。结果①52例患者术后，完全恢复且无脑缺血发作50例，因过度灌注脑出血死亡2例。②颈动脉阻断前，转流组、非转流组平均动脉压（MAP）为（111±9）、（97±15）mmHg，两组比较差异有统计学意义，P〈0．01；MCA平均血流速度（MCA Vm）为（40±12）、（39±13）cm／s，差异无统计学意义。③阻断后，转流组、非转流组MAP为（118±8）、（106±9）mmHg，较阻断前差异均有统计学意义（P〈0．01）；MCA Vm为（14±8）、（33±16）cm／s，较阻断前均下降，平均血流速度变化率为（66±6）％、（15±5）％，P〈0．01。④转流组转流中，MAP（110±13）mmHg，接近阻断前水平；MCA Vm为（44±15）cm／s，MCA Vm较阻断前提高（10±2）％。⑤开放后两组MAP为（90±12）、（93±11）mmHg；MCA Vm为（55±19）、（54±23），较阻断前提高，平均血流速度变化率为（36±3）％、（37±4）％。差异均有统计学意义，P〈0．05。⑤术中转流组、非转流组呼气末二氧化碳分压为（31．0±2．5）、（31．8±2．2）mmHg，差异无统计学意义。结论颈动脉内膜切除术中应用TCD监测，可评价脑血流灌注情况，指导血压的调控及术中转流管的选择。     

颈动脉狭窄患者CEA术后并发症分析

目的分析颈动脉狭窄患者颈动脉内膜剥切除术（CEA）后并发症的发生情况。方法对145例颈动脉狭窄患者的临床资料作回顾性分析。结果本组出现并发症35例,包括大面积脑梗死1例、偏瘫4例、高灌注表现15例、声音嘶哑10例、伤口血肿4例、切口感染1例,经对症处理,死亡1例,余明显好转。术后随访1～25个月,患者未发生颈动脉再狭窄。结论术前严格筛选评估,术中严密操作,术后积极治疗,可有效减少CEA术后并发症的发生。     

Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: risk factors, prevention, and treatment

OBJECTIVES: The study defined the incidence of cerebral hyperperfusion syndrome and intracranial hemorrhage (ICH) and the risk factors for their development following carotid artery stenting (CAS). BACKGROUND: Hyperperfusion syndrome and ICH can complicate carotid revascularization, be it endarterectomy or CAS. Although extensive effort has been devoted to reducing the incidence of ischemic stroke complicating CAS, little is known about the incidence, etiology, and prevention strategies for hyperperfusion and ICH following CAS. METHODS: We retrospectively reviewed the prospective database of 450 consecutive patients who were treated with CAS in our department to identify patients who developed hyperperfusion syndrome and/or ICH. RESULTS: The mean age of the patients was 72.7 +/- 10.9 years, and the mean diameter narrowing was 84 +/- 12.8%. Five (1.1% [95% confidence interval 0.4% to 2.6%]) patients developed hyperperfusion. Three (0.67%) of the five developed ICH. Two of these patients died (0.44%). Symptoms developed within a median of 10 h (range, 6 h to 4 days) following stenting. All five patients had correction of a severe internal carotid stenosis (mean 95.6 +/- 3.7%) with a concurrent contralateral stenosis >80% or contralateral occlusion and peri-procedural hypertension. These same risk factors are involved in cerebral hyperperfusion following carotid endarterectomy. The use of platelet glycoprotein IIb/IIIa receptor blockers did not appear to increase the risk ICH. CONCLUSIONS: The hyperperfusion syndrome occurs infrequently following CAS, and ICH occurs in 0.67% of patients. Patients with severe bilateral carotid stenoses may be predisposed to ICH, particularly if there is concurrent arterial hypertension. Patients with these factors may require more intensive hemodynamic monitoring after CAS, including prolongation of hospitalization in some cases.     

Early recognition of cerebral hyperperfusion syndrome after carotid stenting--a case report

The hyperperfusion syndrome is a recognized complication of carotid endarterectomy. Reports of cerebral hyperperfusion injury following internal carotid artery angioplasty and stenting are few We report a case of 76-year-old hypertensive man who was admitted to our hospital for assessment 2 years after experiencing an ischemic stroke of right hemisphere. Angiography confirmed 60% stenosis of left internal carotid artery (ICA). Percutaneous transluminal stenting of left internal carotid artery was performed without any immediate complications. Two hours after the procedure, the patient suddenly deteriorated. Computed tomography (CT) of the brain revealed extensive intracerebral hemorrhage and he died 5 days later. There was precipitating migranous headache, and his blood pressure was moderately elevated at the time of deterioration. Sentinel headache could solely indicate the early sign of hyperperfusion injury after carotid stenting, especially in the presence of arterial hypertension. Patients with sentinel headache after angioplasty should be recognized early and they deserve intensive study for other features of cerebral hyperperfusion injury and prompt early management.     

颈动脉狭窄血管重建术后过度灌注综合征

随着颈动脉狭窄血管重建术 (包括颈动脉内膜切除术、颈动脉成形术和支架置入术 )的开展 ,术后过度灌注综合征已引起广泛重视。对于其发生机制、临床监测和治疗方法等问题尚在研究探索中。     

Cerebrovascular resistance and blood flow velocity changes after carotid endarterectomy

BACKGROUND: To study the pattern of cerebral blood flow velocity and cerebral resistance changes after carotid endarterectomy. PATIENTS AND METHODS: In 81 patients (mean age +/- SD, 64 +/- 8 years) with unilateral carotid endarterectomy (CEA) the systolic, diastolic and mean blood velocities, and the pulsatility index (PI) were recorded in both middle cerebral arteries preoperatively and repetitively postoperatively with the use of transcranial Doppler ultrasound (TCD). RESULTS: In the middle cerebral artery ipsilateral to CEA mean blood velocity was increased 6 hours (64 +/- 25 cm/sec; p < 0.005) and 7 days (54 +/- 15 cm/sec; p < 0.05) after CEA and had returned to the preoperative level (49 +/- 11 cm/sec) after 3 months. Compared to preoperatively (0.86 +/- 22), the PI was significantly increased at 6 hours examination (1.03 +/- 23, p < 0.005), and remained increased thereafter. A pathologically increased mean blood velocity (> 83 cm/sec) 6 hours after CEA occurred in 11 patients, two of them developed a slight hyperperfusion syndrome. In the contralateral middle cerebral artery, only the diastolic blood velocity showed significant changes (preoperatively, 35 +/- 12 cm/sec; 3 months after CEA, 33 +/- 8 cm/sec; p < 0.05). CONCLUSIONS: Using TCD, hemodynamic changes occur predominantly in the middle cerebral arteries ipsilateral to CEA. Early postoperative TCD studies may be of help to identify patients at risk to develop a hyperperfusion syndrome.     

颈动脉支架置入术围手术期血压调控的探讨

目的探讨粥样硬化性颈动脉狭窄患者,经皮血管内支架置入血管成形术(PTAS)围手术期血压调控的必要性及初步经验。方法回顾性分析293例粥样硬化性颈动脉狭窄患者经全脑数字减影血管造影术诊断后,采用自膨式支架经股动脉入路行PTAS,围手术期对血压严密监控,并根据血压的高低采取综合措施及时进行调整,以避免发生高灌注性脑病或心、脑缺血。结果 293例患者中支架置入成功292例(99.7%)。术前狭窄率70%～95%平均(82.0±13.1)%,术后残余狭窄率为0～20%,平均(9.2±6.8)%,术后患者脑缺血症状及体征均有明显改善。有1例患者在术中及术后血压控制不理想,发生了高灌注性脑出血而死亡。通过采取综合措施调节血压后未再发生高灌注性脑病,血压降至90～120/60～90 mm Hg(1 mm Hg=0.133 kPa)后,所有患者均未发生心、肾、脑等脏器缺血。结论 PTAS微创安全有效,但术中及术后调整血压非常必要,围手术期有效地调控血压是减少术后高灌注性综合征发生的重要手段之一。     

脑动脉瘤破裂出血的急诊栓塞治疗

目的探讨脑动脉瘤破裂急性出血期经血管内栓塞治疗的效果。方法对出血后3天内的51例脑动脉瘤急诊行全脑血管造影,在确认责任动脉瘤后即用可脱螺旋圈栓塞。同时重视控制体循环血压,防治脑血管痉挛等措施。结果50例栓塞手术成功;4例术中动脉瘤出血和血管痉挛加重于术后遗留有不全偏瘫。2例因术前Hunt-Hess计分5级,术后病情未缓解5天内死亡。48例经随访6个月~3年未发生再出血情况。结论脑动脉瘤破裂出血后可以尽快栓塞治疗,应用降压和扩血管等相关措施有助于改善治疗效果。     

Assessment of flow changes in the circle of Willis after stenting for severe internal carotid artery stenosis.

PURPOSE: To assess flow velocities in the cerebral arteries after carotid artery stenting (CAS) in patients with unilateral versus bilateral lesions and analyze velocities in patients with neurological complications after CAS. METHODS: Ninety-two patients (68 men; mean age 63.2 +/- 8.4 years, range 44-82) with internal carotid artery (ICA) stenoses were divided according to unilateral (group I, n = 72) or bilateral (group II, n = 20) disease. Fifty age- and gender-matched patients without lesions in the extra- or intracranial arteries served as a control group. Transcranial color-coded Doppler ultrasound was performed prior to and within 24 hours after CAS in the test groups; systolic velocities were assessed ipsilateral (i) and contralateral (c) to the CAS site in the middle cerebral artery (MCA) and anterior cerebral artery (ACA). RESULTS: Collateral flow via the anterior communicating artery (ACoA) was found in all group-II patients and 90% of group-I patients. After CAS, collateral flow through the ACoA ceased, and the velocity increased by 26% in the iMCA in group I compared to controls (p < 0.001). In group II, iMCA flow increased by 30% (p < 0.001) and flow via the ACoA (p < 0.001) increased, resulting in normalization of cMCA velocities (p = 0.928). In 89 (96.7%) subjects, CAS was uncomplicated. Hyperperfusion syndrome occurred in 2 (2.2%) patients, both with bilateral ICA stenoses; 1 (1.1%) transient ischemic attack was seen in a patient with unilateral disease. In the patients with hyperperfusion syndrome, the MCA velocities were 2.7- and 7.4-fold higher, respectively, versus before CAS and 2-fold higher than in controls. CONCLUSION: Uncomplicated CAS results in an iMCA velocity increase >25% compared to controls. MCA velocities in hyperperfusion syndrome were greatly increased versus before CAS and in controls.     

颈动脉内膜剥脱术对缺血性脑卒中的防治效果分析

目的总结颈动脉内膜剥脱术对防治缺血性脑卒中的经验。方法对196例患者进行颈动脉内膜剥脱术,均为单侧。术中应用颈动脉转流管47例,阻断血流149例。术前均经颈动脉造影检查,选择颈内动脉狭窄〉70％者133例,〉95％者63例。71例患者并存冠状动脉病变,17例同台行冠状动脉搭桥。结果术后临床症状改善满意191例,术后1周内出现脑出血3例,经开颅止血引流,痊愈1例,死亡2例。出现颈部切口内血肿12例,再手术清创止血获愈。随访6～60个月,获得随访166例,失访28例,死于其他疾病或灾祸38例,元脑缺血症状再发作128例。结论颈动脉内膜剥脱术是治疗颈动脉重度狭窄的一种有效、安全术式。