皮质脑电图与头皮脑电图同时监测在前循环颅内动脉瘤术中的应用

目的 探索一种监测前循环颅内动脉瘤术中载瘤动脉临时阻断后皮质缺血的简单、有效的方法.方法 2008年4-11月期间,对接受开颅手术治疗的52例前循环动脉瘤患者(58个动脉瘤)同时进行术中皮质脑电图和头皮脑电图临测.根据国际10/20系统将头皮电极置于O1、02、P3、P4、15和T6,用于监测麻醉深度变化;条形皮质电极置于术中可能阻断动脉的供血皮质表面,用于监测町能的皮质缺血.对临时阻断载瘤动脉后皮质脑电图出现抑制者与头皮脑电图变化进行比较,术后观察有无阻断血管相应供血区的缺血事件.结果 在58个动脉瘤中,有40个动脉瘤和41条主要动脉在术中采取了临时阻断,18例患者的19条血管临时阻断后,皮质脑电图有明显变化,而头皮脑电图无明显变化.术后仅在皮质脑电图明显变化组出现阻断血管相应供血区的缺血事件9例.麻醉深度改变对皮质和头皮脑电图影响一致.结论 同时监测皮质和头皮脑电图是监测前循环颅内动脉瘤术中皮质缺皿的一种简单、有效的方法,并可有效辨别麻醉对脑电图的影响.     

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。     

颅内外高流量搭桥治疗大脑中动脉巨大动脉瘤一例

患者男,16岁。2005年2月18日住入首都医科大学宣武医院。入院前两个月因头部轻微外伤,行头部CTMRI检查,证实为右侧大脑中动脉巨大动脉瘤,见图1。体格检查:未见神经系统阳性体征。行三维脑血管造影,显示右侧大脑中动脉M1段巨大梭形动脉瘤,豆纹动脉由动脉瘤远端发出,见图2。又行球囊闭塞试验,见图3。在闭塞右侧颈内动脉分叉部40min时,患者头痛,伴言语不清但无肢体无力;解除闭塞后,患者头痛症状缓解。闭塞时单光子射出计算机断层扫描脑血流显像(SPECT·rCBF显示,右侧大脑半球皮质[两侧脑血流比值(R/L)=0·88]及基底核区(R/L=0·69)脑血…     

颅内外高流量搭桥治疗海绵窦内动脉瘤

目的 探讨利用大隐静脉进行颅内外搭桥，治疗海绵窦内动脉瘤的疗效，并对手术指征及手术方法进行讨论。方法 利用大隐静脉进行颅内外搭桥手术治疗海绵窦内动脉瘤13例。手术中首先准备大隐静脉20～30cm，并用等渗盐水加肝素充盈。根据手术前血管造影显示的侧支循环及手术中试验性夹闭颈内动脉时的脑电图监测情况，选用颈部颈内动脉或颈外动脉，利用大隐静脉与大脑中动脉搭桥。手术后随访3～63个月，平均23个月。结果 除1例患者因术后基底核血肿造成一侧肢体轻度偏瘫外，其余12例患者均恢复良好，眼球后疼痛及三叉神经痛均消失，眼球运动功能完全恢复，也无新的脑出血或脑缺血发生。结论 在严格选择病例的前提下，利用大隐静脉行颅内外高流量搭桥，仍然为治疗海绵窦内动脉瘤的有效方法。     

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。     

吲哚菁绿血管造影在颅内动脉瘤手术中的初步应用

目的探讨吲哚菁绿（indocyanine green，ICG）脑血管造影在颅内动脉瘤手术中的作用。方法选择20例术中行ICG造影的颅内动脉瘤患者，其中16例手术直接夹闭动脉瘤，1例手术切除动脉瘤，3例行动脉瘤切除或孤立＋血管重建术。术中造影时，将即时稀释的对比剂（25mg的ICG加入到2ml注射用水中）一次性快速注入肘静脉，荧光手术显微镜下观察造影血管。术后行DSA造影。评价术中ICG造影在颅内动脉瘤手术中的作用。结果16例行动脉瘤夹闭手术患者中，1例小脑下后动脉动脉瘤患者，夹闭后ICG造影发现动脉瘤残余，经调整动脉瘤夹后再次ICG造影，证实动脉瘤夹闭完全；1例颈内动脉动脉瘤夹闭后术中造影发现颈内动脉狭窄，调整动脉瘤夹后再次造影证实无狭窄。1例大脑后动脉瘤患者，术中ICG造影发现动脉瘤内完全血栓形成，载瘤动脉近端闭塞，远端通过血管吻合支供血，遂术中决定行动脉瘤切除术。3例动脉瘤切除或孤立＋血管重建手术患者中，2例术中ICG造影证实吻合口通畅，远端血供良好；1例术中造影发现吻合口功能不良，但同侧额叶脑组织供血良好，故未进一步调整吻合口，术后患者无明显神经功能缺损症状，DSA证实同侧大脑中动脉侧支供血。16例术后行DSA检查者，均证实术中ICG造影结果。结论ICG血管造影是颅内动脉瘤术中监测动脉瘤是否残留、载瘤动脉是否狭窄及吻合血管是否通畅的重要的手段。     

不同脑功能障碍时视觉刺激引起的脑血流速度变化

适当刺激后由于代谢需要,视皮质的局部脑血流增加已被PET或MRI证实。作者应用经颅多普勒超声(TCD)观察了不同脑功能障碍视觉刺激所引起的脑血流速度的变化。 病人组28例,其中12例系动脉瘤性蛛网膜下腔出血(SAH),男4例,女8例、年龄43(19～56)岁。动脉瘤位于大脑中动脉(MCA)6例,颈内动脉2例,前交通动脉3例,基底动脉1例。12例中11例接受过动脉     

颈内动脉壁动脉瘤的诊断与治疗

目的探讨颈内动脉壁动脉瘤的诊断与治疗。方法回顾分析自2002年1月～2009年1月我科共完成的421例动脉瘤夹闭手术患者的临床资料，其中颈内动脉壁动脉瘤16例（占3．8％）共17个动脉瘤，分析其诊断与治疗经过。结果动脉瘤均发生在眼动脉和颈内动脉分叉之间的血管壁上。17枚动脉瘤均成功夹闭，共用20枚动脉瘤夹，术中动脉瘤破裂6例，均夹闭成功，14例痊愈，2例瘫痪。结论CT血管造影对颈内动脉壁动脉瘤的诊断敏感性高于数字减影血管造影。术中反复多次应用临时阻断夹及跨血管动脉瘤夹对动脉瘤的夹闭起到关键的作用。     

MRI灌注成像在烟雾病中应用的研究进展

烟雾病（moyamoya disease,MMD）又称自发性基底动脉环闭塞症,是一种以颈内动脉末端及大脑前大脑中动脉起始部动脉内膜缓慢增厚,动脉管腔进行性狭窄以至闭塞,同时伴脑底异常血管网生成及颅内外动脉的异常沟通,脑血管造影可见脑底密集成堆的小血管,酷似吸烟吐出的烟雾。     

T形支架辅助弹簧圈栓塞基底动脉尖动脉瘤一例

正患者女,59岁,因"体检时头部CT血管成像(CTA)提示基底动脉尖动脉瘤"于2015年9月20日收入第二军医大学附属长海医院神经外科。体格检查无神经系统阳性体征。头部CTA显示基底动脉尖动脉瘤及双侧颈内动脉C2段闭塞(图1)。于2015年9月24日行全脑DSA检查及动脉瘤栓塞术。在全身麻醉下,采用Seldinger技术行双侧股动脉穿刺置管,进行全身肝素化。造影证实双侧颈内动脉眼动脉起始部以远闭塞,基底动脉尖动脉瘤累及双侧大脑后动脉P1段及     

Visualization of isolated conus artery as a major collateral pathway in patients with total left anterior descending artery occlusion

To examine the existence of isolated conus artery (ICA) as a source of collateral circulation, we selectively visualized the ICA in patients with left anterior descending coronary artery (LAD) occlusion using a no. 5 French catheter. One hundred and fifty patients with a total LAD occlusion were selected from 639 consecutive patients who had diagnostic coronary angiography during an 18-month period; the ICA was found in 45 patients. Among these patients, 30 showed the ICA as a collateral vessel supplying the distal LAD. In nine of these patients, conventional left and right coronary angiography did not reveal any other significant collateral vessels, and the distal LAD was perfused mainly by the collaterals from the ICA. No serious complications such as ventricular fibrillation or myocardial infarction occurred during these procedures. These results indicate that the selective ICA visualization is clinically important when conventional left and right angiography does not demonstrate collaterals to the obstructed LAD.     

超声对单侧颈内动脉严重狭窄或闭塞时颅内动脉血流动力学变化的研究

目的:分析并评价单侧颅外段颈内动脉(ICA)严重狭窄(≥70%)或闭塞时颅内侧支循环建立的情况。方法:彩色多普勒显像(CDFI)筛选出单侧颅外段ICA严重狭窄或闭塞患者42例,应用经颅彩色多普勒(TCCD)评价颅内主要动脉的血流动力学变化,并经数字减影血管造影术(DSA)检查结果证实。结果:1.与DSA比较:TCCD探测前交通动脉(AcoA)和眼动脉(OA)具有较高的敏感性、特异性,对AcoA探测的价值最大,其次是后交通动脉(PcoA)。2.AcoA的开放与卒中的发生呈负相关。3.患侧大脑中动脉(MCA)的收缩期峰值流速(PSV)及搏动指数(PI)值均较健侧明显减低(P<0.05)。卒中组和短暂性脑缺血发作(TIA)组患侧OA的PI值明显低于健侧(P<0.05)。结论:CDFI和TCCD检测可综合分析颅内主要动脉的血流动力学变化,准确、可靠及无创地评价颅内侧支循环的情况,对单侧ICA严重狭窄或闭塞患者的治疗和预后的判断具有重要的临床价值。     

Transcranial Doppler sonography: collateral pathways in internal carotid artery obstructions

Fifty-four patients with stenoses and occlusions of the extracranial internal carotid artery (ICA) demonstrated by intravenous digital subtraction angiography (IVDSA) were studied by extracranial duplex and transcranial Doppler. Two hundred healthy volunteers served as control group. Intracranial collateralization was demonstrated in 32 patients with ICA stenoses greater than 80% and occlusions. Twelve patients with unilateral and 8 patients with bilateral ICA obstructions greater than 80% showed collateral supply via the anterior (ACA) and/or posterior cerebral artery (PCA). In 5 cases of unilateral ICA occlusion and in 7 patients with bilateral ICA stenoses greater than 80% and occlusions, the ophthalmic artery and ACA and/or PCA served as collateral vessels. Five patients with ICA occlusions showed leptomeningeal anastomoses in the region of the postocclusive middle cerebral artery (MCA). All 54 patients showed normal time-mean flow velocity in the post-obstructive MCA. In unilateral ICA stenoses greater than 80% and occlusions, the pulsatility index in the ipsilateral MCA was reduced in comparison with the contralateral side, indicating that this parameter is more sensitive to hemodynamic effects of ICA obstructions than time-mean velocity.     

The Virtues of Continuous Eeg Monitoring During Carotid Endarterectomy

Summary: The advantages of continuous EEG monitoring, during carotid endarterectomy are discussed. Observations of the types of EEG change seen when the common carotid artery is clamped are described, with the use of the EEG to indicate the adequacy of collateral circulation or the necessity for inserting a temporary shunt in the internal carotid artery.     

Collateral circulation in internal carotid artery occlusion. A study by duplex scan and magnetic resonance angiography

BACKGROUND: Clinical effects of internal carotid artery (ICA) occlusion may range from the absolute absence of symptoms to lethal hemispheric stroke. In this paper symptoms of patients with ICA occlusion have been related to the development of collateral circulation, different types of developed collateral circulation have been assessed, and the degree of sensitivity and specificity of duplex scan has been appraised. METHODS: Forty-eight patients with ICA occlusion or subocclusion, 24 males and 24 females, aged between 50 and 83 years (67.7+/-7.15), underwent duplex scan and magnetic resonance (MR) angiography. Nineteen patients were completely asymptomatic, 20 patients showed permanent neurological symptoms and 9 patients had shown transient symptoms. RESULTS: Twelve patients (25%) did not show any collateral circulation, 29 patients (60%) showed collateral circulation through homolateral external carotid artery branches and 7 patients (15%) showed collateral circulation through other circuits. Of the 20 patients with permanent symptoms only 8 showed collateral circulation. On the contrary, all the 19 asymptomatic patients and the 9 patients with transient symptoms showed collateral circulation. Eventually, duplex scan showed 78% sensitivity, 100%, specificity and 83% diagnostic accuracy. CONCLUSIONS: Our data show: 1) a clear-cut prevalence of collateral circulation through homolateral external carotid artery branches with respect to other possible collateral circulation; 2) an inverse relationship between the development of collateral circulation and the appearance of permanent symptoms; 3) a good diagnostic accuracy of duplex scan in revealing collateral circulation in the case of ICA occlusion.     

Evaluation of cerebral circulation in patients with significant carotid artery stenosis

BACKGROUND: A significant proportion of ischaemic stroke episodes are caused by atherosclerotic lesions in extracranial arteries. Assessment of haemodynamical profile of cerebral arteries in both symptomatic and asymptomatic patients with carotid artery stenosis is of clinical importance. AIM: To assess haemodynamic changes in cerebral arteries in patients with significant internal carotid artery (ICA) stenosis. METHOD: Patients (n=109) were divided into the following groups: group I (GI) - 42 subjects (64.6+/-9.0 years) with asymptomatic ICA stenosis > or =70%; and group II (GII) - 67 subjects (63.4+/-7.1 years) after stroke. The control group consisted of 30 patients (60.3+/-8.9 years) without significant stenoses of extracranial arteries on USG and angiography. In all cases ultrasonographic evaluation of flow velocities and directions in cerebral arteries within the circle of Willis and collateral flow was performed. RESULTS: The severity of ICA stenosis did not differ significantly between GI and GII. Patients in GI had flow velocity in the middle cerebral artery (MCA) increased by 15.7% and by 40.8% in the anterior cerebral artery (ACA) contralateral to the ICA stenosis (p<0.001 and p<0.001), whereas in GII no significant changes in flow velocity in these arteries were observed in comparison with the control group. Patients in the groups I and II had lower flow velocities in MCA ipsilateral to the ICA stenosis, however values for GII patients were significantly lower than in GI patients (p<0.001). The presence of collateral circulation through the anterior and posterior communicating arteries (ACoA and PCoA) was similar in GI and GII; however, the flow velocities in the ipsilateral MCA and ACA were significantly higher in asymptomatic patients (GI). The frequency of active collateral circulation through both ACoA and PCoA increased along with the increase of ICA stenosis severity (p=0.003; p<0.001). CONCLUSIONS: Collateral flow in the circle of Willis in subjects with ICA stenosis occurs equally often in symptomatic and asymptomatic patients; however, it is more efficient in patients without symptoms. The rate of development of collateral circulation depends on ICA stenosis severity. The important role in maintaining collaterals within the circle of Willis is played by ACoA, although in some patients MCA may also be supplied by PCoA.     

脑电图空间对称指数对颈动脉狭窄后侧支循环的评估

目的采用脑电图空间对称指数(sBSI)评价颈动脉狭窄患者侧支循环代偿程度。方法选取拟行数字减影血管造影(DSA)患者61例,根据代偿程度分为1级、2级和3级,并依次分为1组(6例)、2组(22例)和3组(33例)。在DSA前行16导联脑电图常规检查,计算脑电图sBSI。根据DSA结果,判断患者颈动脉狭窄程度和侧支代偿程度。对各组患者脑电图sBSI与其影响因素进行相关和回归分析。结果所有颈动脉轻度狭窄患者代偿程度均为3级,2级代偿程度出现在部分颈动脉中、重度狭窄和闭塞患者中,1级代偿程度出现在部分重度狭窄和闭塞患者中。与3组比较,1组和2组脑电图sBSI明显升高(P0.01)。1组与2组脑电图sBSI比较,差异无统计学意义。脑电图sBSI与狭窄程度呈正相关(r=0.541,P0.01),与代偿程度呈负相关(r=-0.770,P0.01)。多重回归分析显示,侧支代偿程度为脑电图sBSI独立影响因素(β=-0.029,P0.01)。结论脑电图sBSI检查作为一项无创的检查方法,在评估患者颈动脉狭窄后侧支代偿程度方面有一定的可行性。