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.     

脑-脑膜-动脉-肌肉融合术对缺血型烟雾病患者疗效的临床研究

目的 探讨脑-脑膜-动脉-肌肉融合术(EDAMS)对青少年和成年缺血型烟雾病患者的疗效.方法 选择不同年龄组患者共14 名,全部接受EDAMS 手术,术后6 个月复查DSA.根据血管造影情况和治疗效果对两组患者进行评价.结果 两组患者的侧支循环形成和术前症状都有不同程度的改善.两组之间无显著的统计学差异.结论 EDAMS 是一种治疗缺血型烟雾病的有效术式.     

烟雾病联合血管重建术后可逆性神经功能障碍的预测因素

目的探讨烟雾病患者颅内外血管联合重建术后发生可逆性神经功能障碍(RND)的预测因素。方法回顾性分析123例烟雾患者及其实施的138例颅内外血管联合重建术,记录其人口统计资料,临床表现,既往病史,RND并发症,以及手术相关资料。结果共计13例(9.42%)术后RND,发生于12名患者中。术前临床症状多次发作(多次定义为3次及以上)、一次手术双侧血管重建与术后RND密切相关(P<0.05,P<0.01)。缺血型烟雾病患者术后RND发生率(13.89%)高于出血型烟雾病患者(3.85%),但差异无统计学意义(P>0.05)。缺血型烟雾病中首发症状为TIA术后RND发生率为21.74%,首发症状为脑梗死者10.20%,二者差异无统计学意义(P>0.05)。首发症状为TIA者,术后RND发生率明显高于出血型烟雾病(P<0.05)。患者年龄,性别,手术与上一次卒中时间间隔,血管重建方式,是否单侧烟雾病,既往甲状腺、免疫疾病、高血压等病史与术后RND无明显关系。结论颅内外血管联合重建术后,首发症状TIA者比出血型烟雾病更易发生RND。但首发症状TIA与脑梗死者之间,缺血型烟雾病与出血型烟雾病之间,术后RND发生率均无明显差异。术前临床症状反复多次发作、一次手术双侧血管重建为术后RND的预测因素,因此双侧烟雾病的颅内外血管联合重建术不建议一次完成,而应分次进行。     

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.     

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.     

头颅CT灌注成像对烟雾病行间接血流重建术的疗效评价

目的研究探讨头颅CT灌注成像（CTP）技术对缺血型或出血型烟雾病（MMD）患者行间接血流重建术（indirect revascularisation）的总体疗效评价。方法 47例缺血性或出血卒中起病并由数字减影血管造影（DSA）证实的MMD患者,采用颅骨多点钻孔术（MBHT）、脑-颞肌贴敷术（EMS）、脑-颞肌-动脉贴敷术（EDAMS）、脑-硬脑膜-动脉贴敷术行间接血流重建术。并于术前、术后1周、术后3个月分别行头颅CT灌注成像检查,分别对脑血流量（CBF）、脑血容量（CBV）、达峰时间（TTP）进行定量和定性检查分析,并对手术前后及随访的CBF、CBV、TTP进行对比分析。结果 MMD患者术前与术后早期（1周）CTP各参数比较,额颞叶CBF、CBV变化无统计学差异,TTP显著降低,差异有统计学意义（P〈0.05）;术后3个月CTP与术后1周比较,额、颞叶rTTP、rCBV降低;差异有统计学意义（P〈0.05）。慢性缺血型MMD患者术后症状改善明显。结论 CT灌注成像作为一项快速简便的脑血流状况的检测技术,能反映脑微循环信息的功能成像,尤其是其TTP等时间参数对区分缺血程度具有很高的敏感性,能显示早期细微的缺血变化,MMD间接血流重建术后侧支血管的形成和脑血流的改善远早于造影上新生血管的形成,可以解释间接血流重建术后早期在造影可见的吻合血管出现之前就出现临床症状的明显改善。该检查有助于判断MMD脑缺血的部位和程度、选择手术侧别和手术方式,更为了解间接血流重建术后缺血程度是否改善提供较客观的评判依据。     

成人烟雾病治疗的相关研究进展

烟雾病（moyamoya disease,MMD）是一种慢性进行性脑血管疾病,涉及颈内动脉末端和/或其近端分支狭窄闭塞,导致侧支血管网形成。这些变化引起脑实质慢性缺血,随后发生严重的脑血管意外。成人MMD患者在未经治疗的情况下会逐渐累及认知功能,且病死率是儿童MMD患者的2倍。由于MMD发展病因的复杂性和后果的严重性,该病的治疗尤为棘手且迫切。外科血管重建术作为MMD治疗的基石,主要分为直接血管重建术、间接血管重建术和联合血管重建术三类。考虑到间接血管重建术不能降低围手术期脑卒中的发生率,直接血管重建术通常是缺血型MMD患者治疗的首选术式。若为了预防出血型MMD患者再发出血,选择直接血管重建术或联合血管重建术能够更容易建立侧支循环,促进血运重建,达到治疗的目的。当患者术后出现新发的缺血脑卒中,则优先考虑间接血管重建术。对于血流动力学不稳定的成人MMD患者,直接血管重建术或联合血管重建术则是首要选择。由于目前无逆转MMD病情进展的特效药,内科治疗仅局限于对症治疗和围手术期的管理。临床上通常使用阿司匹林抗血小板聚集,促红细胞生成素和他汀类药物等促进侧支血管发育和地塞米松促进新生血管的形成等。远隔缺血适应训练改善MMD患者的后遗症的疗效已经得到了业界的肯定。发病机制研究的深入为MMD的诊疗手段提供更多的可能性。甲硫氨酸循环异常参与了MMD的发病,提示甲硫氨酸循环相关风险评分对烟雾病风险具有良好的预测能力。此外,内皮祖细胞移植可能成为临床上治疗MMD的新策略。 [国际神经病学神经外科学杂志, 2023, 50(3): 78-83]     

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     

烟雾病外科干预的临床意义

目前病烟雾(Moyamoya病)的外科治疗意见尚不完全一致,原因是很难获得Moyamoya病患者自然病程的资料,难以进行大规模、多中心对照试验研究.有关外科治疗Moyamoya病的手术术式较多,如颅内外血管重建术、颈动脉外膜剥脱术(颈动脉周围交感神经切除)、颅骨钻孔硬膜切开蛛网膜剥脱术、颞肌贴覆术、大网膜移植贴覆术等,其中大部分由于疗效不明确风险较大已很少采用,而目前效果确切,且被广泛采用的是颅内外血管重建术,包括颅外与颅内血管的直接、间接或联合血管重建术.……     

Combined revascularization surgery for childhood moyamoya disease: STA-MCA and encephalo-duro-arterio-myo-synangiosis

We present surgical techniques for optimal revascularization in childhood moyamoya disease. During the past 10 years we performed revascularization surgery for childhood moyamoya disease using direct revascularization with superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis and indirect revascularization of encephalo-duro-arterio-myo-synangiosis (EDAMS) 43 times. Points of this surgery are as follows: (1) craniotomy and dural opening for the most extensive possible exposure of the brain surface, (2) protective manipulation of the STA, temporal muscle and middle meningeal artery, (3) STA-MCA anastomosis to the frontal branch of the MCA to improve cerebral circulation of the frontal lobe using a small branch of the STA, and (4) a small opening in the arachnoid membrane and watertight closure. Received: 1 November 1995     

Regression of rnoyamoya vessels and hemodynamic changes after successful revascularization in childhood movarnova disease

Successful revascularization improves ischemic symptoms in the pediatric patients with moyamoya disease. However, it is not clear whether the revascularization prevents future intracranial hemorrhage from the residual moyamoya vessels. The purpose of this study is to investigate perioperative morphological and hemodynamic changes in the moyamoya vessels. Four pediatric patients (age < 15 years old) with bilateral moyamoya disease were selected for this study. To quantify the number of moyamoya vessels, T1-weighted transverse images at the level of the basal ganglia and the thalamus were selected and characteristic flow voids in the lentiform nucleus were counted. Resting CBF and cerebrovascular reserve capacity (CRC) were measured pre- and 1 year after surgery using Xenon-CT CBF method with acetazolamide test. The ratio of deep CBF/kortical CBF was calculated as an index of hemodynamic stress distribution. The one-year follow-up studies showed that 1) the number of moyamoya vessels decreased on the operative side, but did not change on the nonoperative sides in all cases; 2) the ratio of deep CBFkortical CBF decreased on the operative sides, but did not change in the non-operative sides; and 3) the CRC increased on both sides. This observation suggests the possibility that revascularization surgery may be effective for preventing the future risk of intracranial hemorrhage.     

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.     

烟雾病的临床特征及外科治疗的流行病学分析

目的探讨烟雾病的性别、年龄、地区分布特点、临床表现以及外科治疗效果分析。方法回顾性分析2017-01—2019-04河南省人民医院收治的542例烟雾病患者的临床资料,包括性别、年龄、地区分布、临床表现等,分析其手术效果及预后。结果542例烟雾病患者中,男女比例为1∶1.05(男265/女277);年龄(45±12.7)岁(3~75岁),年龄分布呈现双峰形态,好发于9~11岁儿童及46~51岁成人段;河南南方地区发病率明显高于其他区域,呈区域集中现象。儿童成人均以缺血性症状为主;缺血型以头痛、头晕为主要首发症状,出血型中以脑室出血最常见。432例接收手术治疗的烟雾病患者中,行间接血管重建术66例,联合血管重建术366例,18例围手术期出现并发症,其余均恢复顺利,临床症状得到改善,随访结果良好。结论河南地区烟雾病的发病无明显性别差异,年龄呈双峰分布,成人多见,多为缺血型,纳入病例中儿童均为缺血型;豫南地区发病率明显高于其他地区;个体化脑血管重建术具有明确的疗效。     

Cerebral hemodynamics in adult ischemic-type patients with moyamoya disease compared with those of atherothrombotic middle cerebral artery occlusion]

We measured regional cerebral blood flow (rCBF) in adult ischemic-type patients with moyamoya disease and in patients with atherothrombotic middle cerebral artery occlusion (MCAO) to investigate cerebral hemodynamics in adult ischemic-type of moyamoya disease. In this study we measured rCBF and regional cerebrovascular response (rCVR) using acetazolamide by Xenon-enhanced CT. Our subjects consisted of 15 adult ischemic-type patients with moyamoya disease and 27 atherothrombotic stroke patients with proximal occlusion of the middle cerebral artery. The region of interest was conducted in the anterior cerebral artery, middle cerebral artery and posterior cerebral artery territories as well as basal ganglia regions. rCBF was preserved in all regions of patients with moyamoya disease. However, rCVR severely decreased in the anterior circulation territory in patients with moyamoya disease compared with those of MCAO. These results suggest that rCBF in the anterior circulation territory of adult ischemic-type patients with moyamoya disease is preserved by vasodilation of the cerebral arteries, while cerebral hemodynamic reserve capacity is severely reduced. The results indicated that basal moyamoya vessels are dilated. These findings may be one of the reasons why stroke occurs more frequently in adult than child patients with moyamoya disease.     

Surgical treatment of moyamoya disease in children: which is more effective procedure,EDAS or EMS?

At present, encephaloduroarteriosynangiosis (EDAS) and encephalomyosynangiosis (EMS) are the treatments of choice for moyamoya disease in children, but no attempts have been made to determine which is the more effective procedure, for the ischemic lesions in moyamoya disease. Ten patients (seven children and three adults) underwent EDAS and/or EMS: three patients EDAS on both sides; seven patients EDAS on one side and EMS on the other. These ten patients were followed up with a neurological examination and r-CBF and angiographic studies. Postoperative angiograms and r-CBF studies demonstrated more revascularization from the external carotid artery in sides treated with EDAS than with sides treated with EMS. From these results, it is concluded that the EDAS surgical procedure is superior to that of EMS for moyamoya disease.     

联合脑血运重建治疗老年烟雾病患者的临床研究

目的研究联合脑血运重建术治疗老年烟雾病患者临床效果。方法回顾性分析2017-01—2019-12河南省人民医院烟雾病诊疗中心收治的老年烟雾病患者(年龄>60岁)共52例,分为2组,联合脑血运重建组39例,保守治疗组13例,收集患者一般资料、临床特征、围术期并发症、神经功能并发症和改良Rankin量表(mRS)评分。结果长期随访后,联合脑血运重建组新发卒中5例(12.82%),保守治疗组新发卒中7例(53.84%);mRS评分改善情况:联合脑血运重建组33例(84.62%)明显改善,保守治疗组仅1例(7.69%);2组患者新发卒中事件(χ²=9.244,P=0.002)、mRS评分改善情况(χ²=4.675,P<0.001)差异均有统计学意义。结论联合脑血运重建术可明显改善老年烟雾病脑血流供应,降低mRS评分,提高老年烟雾病患者生活质量。