脑动脉瘤术中干预性载瘤动脉暂时阻断

目的探讨脑动脉瘤术中载瘤动脉暂时阻断的时机和方式。方法１８例脑动脉瘤患者，术中采用干预性载瘤动脉暂时阻断，阻断时间１８～５５ｍｉｎ，平均２７ｍｉｎ，每间隔８～１２ｍｉｎ原位松开阻断夹１０余秒，以防血栓形成，阻断超过３０ｍｉｎ则开放载瘤动脉３～５ｍｉｎ，１０例复合性控制低血压。结果术后再出血死亡１例，出现脑梗塞１例，其余１６例恢复良好。结论干预性载瘤动脉暂时阻断能明显降低动脉瘤术中成熟破裂的发生率，大部分病人能耐受分离瘤颈，夹闭动脉瘤所需时间的阻断     

鼠大脑中动脉阻断后软脑膜微血管的动态变化

目的　观察大鼠一侧大脑中动脉阻断后同侧软脑膜小动脉和小静脉管径的变化 ,并探讨其发生的可能机制。方法　 ( 1)采用穿线法阻断大鼠一侧大脑中动脉 ,制作脑缺血模型 ;( 2 )制备一 2 5mm2 的颅窗 ;( 3 )测定大鼠大脑中动脉阻断后 5、10、 15、 2 0、 3 0、 40、 5 0min及 60min时软脑膜小动脉和小静脉管径 ;( 4 )实验数据以 ( x±s)表示 ,用t检验比较均数间的差异 ,P <0 0 5 ,有显著性差异。结果　大鼠一侧大脑中动脉阻断后 ,同侧软脑膜小动脉和小静脉管径发生变化 ,表现为小动脉和小静脉在 5min时即开始逐渐扩张 ,3 0min时达高峰 ,以后逐渐收缩 ,至 60min时其管径仍比大脑中动脉未阻断者的管径大。结论　当大鼠一侧大脑中动脉阻断后 ,这一动脉供血区微血管先扩张后收缩 ,与脑微循环障碍、O2 及葡萄糖下降有关。推测这一变化是由于缺血区乳酸增加和PH值下降     

大脑中动脉阻断大鼠软脑膜微血管的早期变化

目的：观察大脑中动脉阻断大鼠软脑膜小动脉和小静脉管径的动态变化，并探讨其发生机制。方法：采用穿线法阻断大鼠一侧大脑中动脉复制大鼠脑缺血模型；制备颅窗，应用微循环显微镜及其图像分析系统观察大鼠同侧软脑膜小动脉和小静脉管径（AD、VD）的动态变化。结果：大脑中动脉阻断大鼠同侧软脑膜小动脉和小静脉逐渐扩张，30min时达高峰，与阻断前相比管径有显著性差异，以后又逐渐收缩，1h时仍比阻断前的管径大。结论：局灶性脑缺血后脑微循环发生动态变化，其发生机制可能是因微血管内皮细胞因缺血性损伤异常分泌和释放血管活性物质调节血管张力。     

基底动脉末段动脉瘤术中基底动脉的临时阻断

目的探讨基底动脉末段动脉瘤显微外科术中采用基底动脉临时阻断(TBAO)的可行性.方法回顾性分析892例基底动脉末段(基底动脉分叉部和基底动脉-小脑上动脉)非巨大动脉瘤显微外科术中采用TBAO与非TBAO的疗效并进行比较.结果单次阻断不超过5 min比较安全,超时或重复阻断则病残和死亡率增加;TBAO应慎重地用于术前不良分级、老年和多发性动脉瘤的患者,阻断的同期使用低血压(平均动脉压<70 mmHg)应视为禁忌.结论基底动脉动脉瘤早期外科治疗中采用TBAO较非TBAO疗效好.     

显微手术治疗大脑中动脉动脉瘤

显微手术治疗大脑中动脉动脉瘤共19例,占同期手术治疗脑动脉瘤的11.7%。病情分级(Hunt 分级)Ⅰ～Ⅲ级者中无死亡;4例Ⅳ级者中,死亡1例;3例Ⅴ级者全部死亡。本文着重讨论了手术适应证及显微手术技术。     

大脑中动脉闭塞合并颅内动脉瘤

本文报告8例大脑中动脉闭塞合并颅内动脉瘤,男6例,女2例,平均年龄58岁。7例动脉瘤破裂出血之前无脑缺血症状,仅1例动脉瘤破裂前有大脑中动脉血栓形成病史。8例动脉瘤均发生于大脑中动脉闭塞同侧。动脉瘤分布部位:前交通支动脉2例,后交通动脉3例,大脑前动脉1例,大脑后动脉,颈内动脉 C_2段各1例。脑血管造影可见大脑中动脉闭塞均在中动脉起始部,大脑中动脉分布区有充分代偿供血且动脉瘤的载瘤动脉为代偿供血的主要动脉.我们认为,大脑中动脉闭塞以后可以导致其它脑血管的血流动力学改变,后者又可以加剧动脉血管壁的变性损伤,最终形成动脉瘤。     

皮质和头皮脑电监测研究前循环载瘤动脉临时阻断的安全时限

目的在皮质脑电和头皮脑电监测下,研究前循环动脉瘤术中载瘤动脉临时阻断的安全时限。方法在常温、常压下对行开颅手术的52例（58个）前循环动脉瘤病人行术中头皮脑电和皮质脑电双相监测,对术中有无临时阻断、阻断时间、术中脑电变化及术后有无阻断动脉相关缺血事件等进行综合分析。结果18例（19支血管）临时阻断后皮质脑电出现明显变化。皮质脑电重度变化在各主要血管阻断后均有出现。皮质脑电提示严重皮质缺血时,在10min内恢复脑血流者术后均未出现阻断载瘤动脉相关的缺血性并发症。结论在皮质脑电出现重度变化时,10min是最长的阻断安全时限。就个体而言,各主要血管对于临时阻断的耐受时限无区别。     

颅内动脉瘤手术中暂时阻断载瘤动脉的动物实验研究

目的探讨采用不同的颅内动脉瘤载瘤动脉阻断方法对神经功能的影响。方法82只蒙古沙土鼠,雌雄各半,随机分为正常对照组(10只)、假手术组(8只)和缺血-再灌注损伤组(实验组)。根据术中动脉阻断时间及再灌注时间的不同,实验组动物再分为8个亚组,每组8只,共64只。手术后收集脑组织间液,应用微透析仪分析其中葡萄糖、乳酸、丙酮酸、甘油水平以及乳酸/丙酮酸比值的变化,并依照Longa等的5分评分方法评定沙土鼠神经功能损伤程度,以观察缺血-再灌注损伤对脑组织间液中生化物质水平,以及各种不同阻断方式对神经功能的影响。结果实验组沙土鼠组织间液中的葡萄糖、乳酸、甘油水平及乳酸/丙酮酸比值的变化与对照组相比,差异有显著性意义(P<0.01);实验组各亚组间比较,葡萄糖、乳酸、甘油水平及乳酸/丙酮酸比值的变化差异亦有显著性意义(P<0.01);而丙酮酸水平的变化差异无显著性意义(P>0.05)。手术后72h,对各组沙土鼠的自主活动能力进行评价显示,假手术组、实验组第8、4亚组鼠神经功能受损较轻,实验组第1、2、3亚组受损较重。结论在灌注时间充足时,分次阻断载瘤动脉比一次长时间阻断对神经功能的损伤轻;在灌注时间不足时,分次阻断载瘤动脉所导致的神经功能损伤程度与一次长时间阻断相比无明显差异。故而在动脉瘤切除手术     

大鼠大脑中动脉阻断可逆性局灶脑缺血模型的研究

采用普通外科手术，以一顶端贫成光滑圆球的4—0单丝尼龙线，可逆性阻断大鼠一侧大脑中动脉（MCA）的血流，制备局灶性脑缺血及再灌注模型。通过观察动物的神经行为学、脑电生理学及病理形态学变化情况，对该模型的可靠性进行客观评价。结果表明这种改良栓线法制备的模型操作简单，与临床缺血性脑卒中的发病情况相近似，适用于局灶性脑缺血及再灌注损伤机制的研究以及治疗手段的评价。     

血管内再通术治疗症状性慢性大脑中动脉闭塞的初步临床观察

目的初步观察血管内再通术治疗症状性慢性大脑中动脉闭塞的临床疗效。方法纳入24例2019年1—12月郑州大学人民医院脑血管介入治疗中心采用血管内再通术治疗的症状性慢性大脑中动脉闭塞患者,回顾性观察血管再通的成功率、围手术期并发症的发生率及短期随访结果。结果24例患者中,20例(83.3%)血管成功再通,其中脑梗死溶栓治疗分级(TICI)2b级者6例,3级者14例;4例(16.7%)血管再通失败。共6例(25.0%)发生手术相关并发症。其中20例血管再通成功的患者中,发生蛛网膜下腔出血2例,高灌注脑出血1例,3例患者均行保守治疗,术后2周内出血均吸收,未遗留神经功能缺损症状;1例患者血管再通成功后突发心脏骤停死亡。4例血管再通失败的患者中,血管破裂1例,血管夹层1例。23例患者的术后随访时间为(5.0±1.3)个月(3~6个月)。20例血管再通成功的患者中,2例蛛网膜下腔出血者再通血管再次闭塞,末次随访时临床症状再发;其余患者无缺血症状再发,但影像学证实与术后即刻比较,1例血管狭窄率为42%,4例血管狭窄率≤10%。4例血管再通失败的患者脑缺血症状均再发。结论在严格掌握适应证的情况下,采用血管内再通术治疗症状性慢性大脑中动脉闭塞是可行的,相对安全;在短期内可改善患者的临床症状,但有再闭塞的风险;远期疗效需进一步观察。     

大脑中动脉分支闭塞表现为动脉瘤一例报告并文献复习

目的 报告1例大脑中动脉分支闭塞表现为动脉瘤的病例,以提高对此种疾病的认识.方法 患者,男,57岁.以短暂性脑缺血发作(TIA)发病,CTA及DSA显示右侧大脑中动脉起始部闭塞;左侧大脑中动脉相当于分叉部可见囊状突起,双侧大脑中动脉远端血管呈烟雾样改变.予以手术治疗,术中证实此“动脉瘤”为一动脉盲端,未予处理,仅行脑-硬膜-动脉-肌肉血管融合术(EDAMS).结果 术后患者恢复良好,随访至半年时,TIA未发作.结论 当大脑中动脉分叉部存在动脉瘤样改变,远端发生烟雾样现象并伴有缺血症状时,要考虑到动脉闭塞形成残端的可能.     

大脑中动脉夹层动脉瘤临床特点及治疗的荟萃分析

目的 综合分析有关大脑中动脉夹层动脉瘤临床报道病例的临床表现、治疗特点以及预后情况。方法 用关键词途径对1990年1月～2003年5月MEDLINE数据库进行光盘检索。对34例临床确诊为大脑中动脉夹层动脉瘤的病例报道资料进行综合分析，并进行统计学处理。结果 大脑中动脉夹层动脉瘤无明显性别和临床表现上的差异，其好发于中动脉M1段和M2段。破裂或未破裂的中动脉夹层动脉瘤的手术组预后均明显优于保守组，两者统计学差异明显。结论 大脑中动脉夹层动脉瘤是一种较为罕见的脑血管疾病。对于破裂或未破裂(尤其是M1段)的大脑中动脉夹层动脉瘤应于诊断后早期进行手术干预，改善患者预后。     

大脑中动脉瘤的显微外科治疗

报告34例大脑中动脉瘤显微外科手术的经验,其中1例有2个动脉瘤,共计35个动脉瘤.本组中大型和巨型动脉瘤14个(40%).除2个大脑中动脉主干梭形动脉瘤行动脉瘤包囊,2个巨型动脉瘤行M_1阻断伴颅内外动脉吻合外,其余(88%)均做动脉瘤颈夹闭或动脉瘤切除.无手术死亡,2例术后发生神经功能缺失.平均随访6年,优良率达93.8%.对手术入路、手术方法加以讨论.     

Outcome following occlusion of the middle cerebral artery

Outcome was studied prospectively in 28 consecutive patients with occlusion of the middle cerebral artery (MCA). They comprise a subgroup of 101 consecutive patients with TIA or stroke less than or equal to 75 years of age, admitted within 72 h after the stroke. Cerebral angiography and CT-scan were performed within 1-2 days of admission. CT-scan was repeated 6 months later. Functional status on admission, 3 and 6 months after the stroke was evaluated using the Rankin disability scale (score 1-2: independent of others care, score 3-5: dependent on others care). The degree of hemiparesis was measured using the Medical Research Council's score. Thirteen had infarcts with a diameter less than or equal to 3 cm (mean 2.5 +/- 0.9 cm); 15 had infarcts greater than 3 cm (mean 6.3 +/- 1.4 cm); 10 had trunk occlusions; 18 had branch occlusions. MCA occlusions with large infarcts and severe hemiparesis on admission carried a poor outcome. Eleven (85%) of 13 patients with the case in only 1 (7%) of the 15 with infarcts greater than 3 cm, the remaining 14 (93%) had either died (40%) or were dependent (53%) (p less than 0.00005). Eleven (85%) of 13 patients with mild hemiparesis on admission were independent, while 13 (87%) of 15 with moderate or severe hemiparesis on admission had either died (40%) or were dependent on others' care (47%) 6 months after the stroke (p less than 0.0004). Type of occlusion (branch trunk) was a poor predictor of outcome.     

Surgical strategies using cerebral revascularization in complex middle cerebral artery aneurysms

Objectives

To describe surgical strategies using cerebral revascularization for complex middle cerebral artery aneurysms unsuitable to microsurgical clipping.

Materials and methods

In this study, the clinical features, case management, and results in 9 consecutive patients who underwent 10 cerebral revascularization procedures between January 1999 and April 2008 were retrospectively analyzed. The patient population consisted of 6 men and 3 women whose ages ranged from 15 to 71 years (mean, 42.4 years). The size of the aneurysms ranged from 12 to 35 mm (mean, 24.3 mm). Treated aneurysms were located in the M1 segment in 2 patients, the middle cerebral artery (MCA) bifurcation in 3 patients, the distal M3 segment in 3 patients, and the anterior temporal artery (ATA; the early cortical branch of the M1 segment) in 1 patient. A total of 10 revascularizations were performed. Three aneurysms were saccular and six aneurysms were fusiform. For the fusiform aneurysms of the M1 segment in 2 patients, superficial temporal artery (STA) trunk–saphenous vein (SV)–MCA bypasses followed by trapping were performed. For the large saccular MCA bifurcation aneurysms in 3 patients, STA–MCA bypasses followed by complete neck clipping, including the revascularized branch with the preservation of the flow of the other branch, were performed in 2 cases, and a STA trunk–SV–MCA bypass secondary to direct neck clipping with the preservation of both M2 branches was performed in 1 case. For the fusiform distal MCA aneurysms, STA–MCA bypasses in 2 patients and in situ MCA–MCA bypasses in 2 patients were performed. In one case involving distal MCA fusiform aneurysm, STA–MCA bypass and MCA–MCA bypass were performed simultaneously. In a case involving fusiform ATA aneurysm, primary reanastomosis after aneurysm excision was performed in 1 patient.

Results

The post-operative 3-month Glasgow outcome scales were good recovery in 6 patients, severe disability in 1 patient, a vegetative state in 1 patient, and death in 1 patient. A follow-up angiography was performed in 6 patients and revealed a patent bypass in 5 patients. In one case treated by direct neck clipping secondary to cerebral revascularization, the angiography obtained 2 weeks later showed graft occlusion, but there were no neurologic symptoms. Among the unfavorable outcomes of 3 patients who did not undergo follow-up angiography, surgery-related morbidity secondary to cerebral infarction was due to the size discrepancy between the donor and recipient vessels in 1 patient with severe disability. In the other 2 patients, the preoperative conditions were Hunt and Hess grade V.

Conclusions

Cerebral revascularization is a safe and effective technique of treatment for selective cases of complex large or giant aneurysms and unclippable fusiform aneurysms in the MCA.     

Regional cerebral blood flow after occlusion of the middle cerebral artery

Occlusions of the middle cerebral artery (MCA) are mostly of embolic origin (appr. 80%) and give rise to about one third of all ischemic strokes, most of these being major strokes. MCA occlusions lasting for less than 1/2 h are tolerated without occurrence of permanent tissue damage. Occlusions lasting between 1/2 h to 4-8 h lead to permanent tissue damage and neurological deficits that are proportional to the duration of occlusion. Maximal tissue damage is obtained after 4-8 h occlusion. A cerebral blood flow of 8-23 ml/100 gr/min is sufficient for cellular viability but insufficient for normal tissue function ("ischemic penumbra"). Cellular function is completely abolished in the interval 8-16 ml/100 gr/min and flow at that level is tolerated only for 1-3 h before neuronal death ensues. In the interval 18-23 ml/100 gr/min there is some functional activity although it is reduced. Experimental and clinical evidence suggests that flow in this interval may be tolerated for several days, months or even longer ("chronic ischemic penumbra"). After MCA occlusion the blood flow falls below 8 ml/100 gr/min in most cases and permanent MCA occlusion always leads to relatively large areas of frank infarction. The ischemic infarcts may be surrounded by collaterally perfused areas where the blood flow is pressure-dependent (impaired autoregulation) and quite commonly insufficient for normal neuronal function (below 23 ml/100 gr/min). Such collaterally perfused areas may include a "chronic ischemic penumbra". Emboli causing MCA occlusions commonly disintegrate and/or migrate more peripherally within the first few weeks post stroke. This leads to reperfusion and changes of ischemic infarcts into hyperemic infarcts where flow is severely increased. The vascular reactivity is completely abolished in hyperemic infarcts and the hyperemic state lasts for about two weeks. Probably, anemic infarcts are equivalent to ischemic infarcts while the hemorrhagic variety is equivalent to hyperemic infarcts. The "partial infarct" with selective neuronal necrosis occurs in experimental animals after MCA occlusions of less than four h but not after permanent MCA occlusion. The significance of partial infarction in human stroke is not clarified. The extent of irreversible tissue damage can be reduced only if therapy sets in within 4-8 h after the occlusion. If a "chronic penumbra" exists the extension of reversible tissue damage can be reduced if therapy aimed at increasing the blood flow in the penumbra sets in within weeks or even months after the stroke.(ABSTRACT TRUNCATED AT 400 WORDS)     

两种局灶性脑缺血再灌注模型的比较

目的比较两种大鼠大脑中动脉闭塞(middle cerebral artery occlusion,MCAO)局灶性脑缺血再灌注模型,寻找一种更加理想、稳定和可靠的模型。方法将22只SD大鼠随机分为颈外动脉插线组和颈总动脉插线组,采用线栓法建立大鼠脑缺血再灌注模型,MCAO2h再灌注24h,采用TTC染色和NF-κB免疫组化染色,并分别测定脑梗死体积和NF-κB表达量。结果两种插线方法都能造成大鼠局灶性脑梗死,颈外动脉插线组再灌注状态优于颈总动脉插线组,且脑梗死体积和NF-κB表达量均高于颈总动脉插线组。结论颈外动脉插线闭塞大脑中动脉是一种较为理想和可靠的大鼠MCAO局灶性脑缺血再灌注模型制作方法。     

大脑中动脉瘤的显微手术治疗

目的探讨大脑中动脉瘤的显微手术治疗。方法回顾分析13例大脑动脉瘤的临床表现,影像学特点,手术治疗方法及随访结果。结果动脉瘤颈夹闭10例,夹闭＋包裹2例,瘤体切除1例。其中恢复正常或轻残10例,生活不能自理3例。结论大脑中动脉瘤往往以出血为首发症状,一旦确诊,尽早手术。术中注意防止动脉瘤破裂出血及脑血管痉挛。     

Intraluminal spindle-shaped-head suture induced occlusion of middle cerebral artery in the rats

Objective: This study aimed to introduce a modified animal model of middle cerebral arterial occlusion (MCAO) through placement of intraluminal spindle-shaped head suture by comparing the traditional MCAO model.

Methods: A total of 60 male Spraque-Dawley (SD) rats were divided into two groups and MCAO was induced using spindle-shaped head suture or round head suture. The mortality, infarct volume, neurological function, success rate of the surgery, and stability of modeling were examined to evaluate the effectiveness of this model.

Results: Our results showed the success rate was 90.0% in spindle-shaped head group and 83.3% in round head group showing no significant difference; spindle-shaped head achieved a better establishment of MCAO model as shown in neurological examination. The infarct volume was 31.99 ± 5.44% in spindle-shaped head group and was significantly higher than in round head group (24.59 ± 7.17%; p < 0.05), and the coefficient of variation of infarct volume in spindle-shaped head group was lower than in round head group.

Conclusion: Our findings indicate that the modified suture induces a more reproducible and stable ischemic stroke following MCAO in SD rats.