颈内动脉内膜剥脱术治疗症状性颈内动脉狭窄临床研究

目的探讨颈内动脉内膜剥脱术在症状性颈内动脉狭窄治疗中的临床应用价值。方法对2012年6月~2014年6月间在我院行颈内动脉内膜剥脱术的症状性颈内动脉狭窄病人的23例临床资料进行回顾性研究并随访。结果术后出现暂时性声音嘶哑1例,术侧多发小梗塞灶1例,颈部血肿保守治疗后恢复2例,未见肢体瘫痪、神志不清等严重并发症;术后CTA、DSA检查示颈动脉通畅;随访6月~2年未见血管再狭窄、严重脑缺血表现。结论颈内动脉内膜剥脱术治疗症状性颈内动脉狭窄是一种简单、安全、有效的治疗方法。     

颈动脉内膜斑块剥脱术治疗颈内动脉狭窄(附16例报告)

目的探讨颈动脉内膜斑块剥脱术的手术适应证、操作要点和麻醉方法。方法回顾性分析2004年11月至2009年12月经颈动脉内膜斑块剥脱术治疗的16例颈内动脉狭窄患者的临床资料。16例患者均有临床症状,其中颈内动脉中度狭窄者2例,重度狭窄者14例。均采用经气管内插管全身麻醉,术中应用诱导性高血压,应用显微外科技术剥除颈动脉内膜斑块,所有病例均未应用术中转流术。结果术后均行多普勒超声检查,结果示颈动脉血流量较术前明显增加。12例反复发作一过性脑缺血的患者术后随访6个月均未再发作。1例糖尿病合并高血压有脑卒中史者死亡,其余患者随访6个月至2年脑缺血症状明显改善。结论颈内动脉内膜斑块剥脱术是颈动脉狭窄安全有效的治疗方法。     

颈动脉内膜切除术的手术技巧与疗效简

目的探讨颈动脉内膜切除术治疗颈动脉狭窄的手术技巧,提高手术疗效,降低术中不良事件及术后并发症发生率。方法共53例颈动脉狭窄患者,右侧狭窄26例、左侧15例、双侧12例;中度狭窄（30％～69％）35例、重度狭窄（70％～99％）16例、完全闭塞2例。结果其中50例单纯行颈动脉内膜切除术、2例行颈动脉内膜切除术联合动脉瘤夹闭术、1例颈动脉支架成形术后管腔狭窄者行颈动脉内膜切除术并支架取出术。术后颈部CTA及灌注成像提示颈动脉血管形态良好、血流通畅,脑组织灌注不同程度改善。随访3～24个月,1例因心肌梗死死亡、2例术侧颈部皮肤麻木、1例声音嘶哑、3例仍有轻度短暂性脑缺血发作,无脑卒中病例。结论颈动脉内膜切除术是治疗颈动脉狭窄性病变安全、有效的外科方法,正确选择手术适应证及娴熟的手术技巧是保证手术成功、提高疗效的关键。     

颈动脉内膜切除与支架置入治疗症状性颈动脉狭窄的疗效比较

目的 探讨颈动脉支架置入术与颈动脉内膜切除术治疗颈动脉狭窄的近期疗效及安全性.方法 195例症状性颈动脉狭窄(≥60％)患者,随机分为颈动脉内膜切除术组(CEA组,97例),颈动脉支架组(CAS组,98例).CEA组在全麻下行颈动脉内膜切除术,CAS组采用自膨式镍钛合金支架治疗.分别评价两组术中、术后7d、30 d和90 d内终点事件发生率(卒中/死亡)及治疗相关的并发症,术中、术后7d、术后30 d及90d行颈动脉超声,头颅CT/MRI、NIHSS评分.结果 CAS组术后7d内死亡1例,卒中2例,发生率3.1％.CEA组术后7d死亡1例,2例卒中,发生率为3.1％,两组差异无统计学意义(P＞0.05).术中及术后7 d CEA组术后并发脑神经损伤较CAS组高(P＜0.05),卒中/死亡、急性颈动脉闭塞、高灌注综合征、局部血肿形成,两组差异无统计学意义(P＞0.05).CAS组与CEA组神经功能缺失表现均明显改善,两组差异无统计学意义(P＞0.05).术后7d、30 d、90 d两组头颅CT/MRI差异无统计学意义(P＞0.05).结论 CAS及CEA在治疗症状性颈动脉狭窄,预防卒中复发方面具有相似的近期效果,但其远期效果有待于进一步研究.     

Effects of uncomplicated carotid endarterectomy on cognitive function and brain perfusion in patients with unilateral asymptomatic severe stenosis of the internal carotid artery by comparison with unoperated patients

Objective: The purpose of the present exploratory study was to evaluate the effects of uncomplicated carotid endarterectomy (CEA) on cognitive function and brain perfusion in patients with unilateral asymptomatic severe stenosis of the internal carotid artery (ICA) by comparison with unoperated patients.

Methods: Patients with age ≤75 years and unilateral asymptomatic severe stenosis (≥70%) of the cervical ICA underwent CEA with antiplatelet therapy (surgically treated group: 116 patients) or antiplatelet therapy alone or neither (medically treated group: 45 patients). For the surgically treated group, neuropsychological testing and brain perfusion measurement using single-photon emission computed tomography were performed within one month before surgery and one month after surgery. For the medically treated group, the same testing and measurement were performed twice at an interval of 1 to 2 months.

Results: None of the operated patients developed new major ischemic events after surgery or intraoperative cerebral hyperperfusion. None of the patients in the medically treated group experienced neurological deficits including transient ischemic attacks during the study period. The incidence of patients with interval cognitive improvement was significantly greater in the surgically treated group (11 patients: 9%) than in the medically treated group (0%) (p = 0.0352). The incidence of patients with interval brain perfusion improvement in the ipsilateral cerebral hemisphere was significantly greater in the surgically treated group (24 patients: 21%) than in the medically treated group (0%) (p = 0.0003).

Conclusions: Uncomplicated CEA may improve cognitive function and brain perfusion in patients with unilateral asymptomatic severe stenosis of the ICA when compared with unoperated patients.     

内膜斑块剥脱术与支架置入术治疗颈动脉狭窄的Meta分析

目的 探讨颈动脉内膜斑块剥脱术（CEA）与颈动脉支架置入术（CAS）治疗颈动脉狭窄的疗效。方法 计算机检索Pubmed、Embase数据库,收集CEA与CAS治疗颈动脉狭窄的随机对照研究,应用Stata软件进行统计分析。结果 共纳入12项研究,共7 401例患者。Meta分析结果显示:术后30 d,CAS组卒中和死亡联合事件发生率（OR=1.51,95% CI为1.23~1.84;P<0.001）、任意卒中事件发生率（or ci为1.18~1.83;P<0.001）均明显高于cea组;而心肌梗死发生率（or ci为0.28~0.75;p="0.002）、颅神经损伤发生率（OR=0.08,95%" ci为0.04~0.14;P<0.001）均明显低于cea组。两组致残性卒中和死亡联合事件发生率（or ci为0.93~1.77;p="0.13）、病死率（OR=1.52,95%" ci为0.96~2.41;p="0.07）、致残性卒中发生率（OR=1.16,95%" ci为0.79~1.71;p="0.46）无明显差异。结论 CAS治疗颈动脉狭窄短期安全性和有效性与CEA类似。     

TCD对无症状性颈动脉狭窄患者微栓子检测的临床研究

目的应用经颅多普勒(TCD)检查微栓子以识别无症状性(ACS)颈动脉狭窄患者中需要治疗的高危患者。方法收集本院神经内科常规体检人员,经多普勒超声检查发现颈动脉狭窄≥50%,而未发生缺血症状或至少在12个月内无症状者,应用TCD检查微栓子,每月1次,连续随访2a。结果入选213例患者,23例(10.8%)初次检查发现微栓子(TCD+),190例(89.2%)没有发现微栓子(TCD-)。随访1a,TCD+组2例(17.4%)发生卒中,而TCD-组5例(2.6%)发生卒中;2a时TCD+组1例(4.5%)发生卒中,TCD-组3例(1.6%)发生卒中。结论对无症状性颈动脉狭窄患者,TCD检查微栓子阳性者卒中发病率高,应给予药物或相应的手术治疗,预防卒中发生。     

高龄颈动脉狭窄患者颈动脉内膜切除术和颈动脉支架成形术的安全性比较简

目的回顾接受颈动脉内膜切除术和颈动脉支架成形术的高龄（≥70岁）颈动脉狭窄患者的临床资料,分析手术安全性。方法共691例颈动脉狭窄患者,121例行颈动脉内膜切除术、570例行颈动脉支架成形术,分析两组患者危险因素、临床特征和术后并发症发生率,评价两种手术方法之安全性。结果术后30d时,两组患者病死率（0．83％对1．05％,P=1．000）、脑卒中（4．13％对1．93％,P=0．258）和心肌梗死（0．83％对0,P=0．175）发生率差异均无统计学意义;但颈动脉内膜切除术组患者术后心脏不良事件（8．26％对1．05％,P=0．000）和脑神经损伤（4．96％对0,P=0．000）发生率高于颈动脉支架成形术组,而窦性心动过缓或低血压发生率低于颈动脉支架成形术组（0对7．54％,P=0．002）。结论高龄患者接受颈动脉内膜切除术或颈动脉支架成形术均有较高的安全性,术前应全面评价患者基础情况,以减少术后并发症发生率。     

颈动脉内膜剥脱术治疗中重度颈动脉狭窄的临床研究

目的以颈动脉支架置入术(CAS)为对照,分析颈动脉内膜剥脱术(CEA)在治疗中重度颈动脉狭窄的临床价值。方法将100例颈动脉狭窄患者按手术方法不同分为观察组(CEA)和对照组(CAS),记录2组围术期手术相关并发症;记录手术用时、住院时间、治疗费用;随访12个月,记录2组包括死亡在内的不良反应发生率及改良Rankin评分情况。结果观察组与对照组在围术期手术相关并发症、住院时间、术后6个月不良反应发生率及改良Rankin评分比较均无明显差异(P均0.05)。但观察组治疗经费低于对照组(P0.05)。结论颈动脉支架置入术治疗中重度颈动脉狭窄效果良好,术后近期和远期疗效及治疗安全性与颈动脉内膜剥脱术相当,但颈动脉内膜剥离术费用成本较低,并发症少。     

The impact of pre-operative symptoms on carotid endarterectomy Outcomes: Analysis of the ACS-NSQIP carotid endarterectomy database

Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes.     

颈动脉内膜剥脱术和颈动脉支架的疗效分析

目的回顾分析颈动脉内膜剥脱(carotid endarterectomy,CEA)及颈动脉支架(carotid artery stenting,CAS)治疗颈动脉粥样硬化性狭窄的近期和中期临床效果。方法比较北京协和医院血管外科2010年1月-2014年12月行CEA及CAS患者的临床资料,分析两种术式的安全性及1年内出现再狭窄及再发卒中的情况。结果研究期间共收治颈动脉粥样硬化性狭窄患者572例,其中456例行CEA,116例行CAS。两组患者术前一般资料、临床症状、伴随疾病等因素均无显著性差异。CEA组和CAS组手术相关死亡(0.2%vs 0)、术后30 d内缺血性卒中(1.1%vs 1.7%)、急性心肌梗死(0.7%vs 1.7%)、局部血肿(0.4%vs 0.8%)、植入物感染(0.4%vs 0)、颅外神经损伤(1.1%vs 0)、过度灌注发生率(5.7%vs 3.4%)均无显著差异。CAS组术后持续低血压发生率显著高于CEA组(12.9%vs 1.1%,P0.01)。1年随访结果显示,CAS组出现治疗侧颈动脉再狭窄(﹥50%)显著高于CEA组(6.9%vs 2.6%,P=0.026),但两组术后重度狭窄(﹥70%)(2.5%vs 1.1%)及同侧卒中发生率(0.9%vs 0.4%)上没有显著性差异。结论 CEA和CAS都是治疗颈动脉粥样硬化性狭窄安全有效的措施,但CAS组术后持续低血压及治疗侧颈动脉1年再狭窄发生率高于CEA组。     

颈动脉粥样斑块性狭窄内膜切除手术前后脑灌注的初步研究

目的 应用动态磁敏感对比灌注成像(DSC-MRI)测量方法研究有症状和无症状颈动脉狭窄患者脑灌注的改变,以此评估颈动脉内膜切除术(CEA)对改善脑循环的作用.方法 选取35例重度颈动脉狭窄患者,在行CEA前、术后1周及术后6个月,分别行DSC-MRI检查来评估对比分析脑灌注的变化情况.结果 随时间的进展,有症状的颈动脉狭窄患者组脑循环改善的趋势更大,尤其在平均通过时间(MMT)值上显示明显,两组相比差异有统计学意义,P＜0.05.结论 通过在术前和术后行DSC-MRI检查,发现有症状和无症状的颈动脉狭窄的患者在接受CEA术后脑灌注改变明显不同.     

Cognitive performance following endarterectomy in asymptomatic severe carotid stenosis

Cognition and the effects of carotid endarterectomy (CEA) were evaluated in 22 non-demented subjects with vascular risk factors (VRF) and asymptomatic severe carotid artery stenosis (ASCAS), 14 volunteers with VRF but without stenosis, and 24 healthy controls (HC) without VRF. Non-demented subjects with VRF, with or without carotid stenosis scored inferior to HC. It is concluded that carotid stenosis is not a primary cause of cognitive deterioration and CEA does not improve cognition in patients with ASCAS.     

Association between asymptomatic carotid stenosis and cognitive function: A systematic review

Background

Asymptomatic carotid stenosis (CS), traditionally considered clinically silent, may be an independent risk factor for a cognitive impairment.

Methods

To determine whether an association exists between asymptomatic CS and cognitive function, we systematically reviewed the literature in the Cochrane Library, MEDLINE, EMBASE and the China National Knowledge Infrastructure databases.

Results

A total of 8 cross-sectional studies and 2 community-based cohort studies were included, comprising 763 participants in the CS group and 6308 participants in the non-CS group. All but one study supported the association between asymptomatic CS and cognitive impairment. Pooled analysis identified older age (2 studies) and cerebral hypoperfusion (2 studies) as additional factors in patients with asymptomatic CS that may linked to cognitive decline.

Conclusions

These results suggest that rather than being clinically silent, asymptomatic CS may be associated with cognitive impairment, and this should be further investigated in high-quality studies.     

颈动脉内膜斑块剥脱术中颈动脉阻断对局部脑氧饱和度的影响

目的 观察颈动脉内膜斑块剥脱术（CEA）中患侧颈动脉阻断对局部脑氧饱和度的影响。方法 2014年2月至2015年2月择期行CEA治疗重度颈动脉狭窄52例,麻醉诱导前及颈动脉阻断前后监测局部脑氧饱和度。以芬太尼、异丙酚、罗库溴铵诱导,气管插管术后以异丙酚和瑞芬太尼维持麻醉。术中连续监测并记录心率（HR）、平均动脉压（MAP）、脑电双频指数（BIS）、局部脑氧饱和度等。结果 HR在颈动脉阻断前后均无明显变化（P>0.05）;MAP在颈动脉阻断后明显增高（P<0.05）,而在阻断开放后逐渐恢复到术前水平;bis在颈动脉阻断前后均无明显变化（>P>0.05）;患侧局部脑氧饱和度在颈动脉阻断后呈下降趋势,但是无统计学差异（P>0.05）,在阻断开放后逐渐恢复,开放后30 min明显高于术前水平（P<0.05）。>结论 CEA术中患侧颈动脉阻断对患者局部脑氧饱和度没有影响;CEA术可以改善患侧局部脑供氧。     

颈内动脉狭窄血管成形及支架置入术临床探讨

目的 分析颈动脉狭窄血管成形及支架置入术的围手术期治疗,总结操作经验,评价长期临床效果.方法 总结32例颈动脉狭窄患者,均经影像学诊断确诊,行DSA再证实,局麻下行血管成形及支架置入术,3例患者由于不配合改用全麻,6例患者由于高度狭窄,术前PWI评价脑灌注,行分次治疗,在支架置入2周后局麻下行球囊扩张术.结果 32例患者支架覆盖斑块良好,术后残余狭窄＜10%,1例患者同侧肢体偏瘫,经治疗6 h后恢复.术后8例低血压,经多巴胺静脉维持后好转,7例一过性心动过缓,经对症治疗后好转.经1 a随访,未出现脑卒中再发作,2例发生再狭窄行球囊扩张.结论 术前综合评价、术中轻柔操作、防止低血压为手术成功和降低并发症的关键,分次治疗可降低高度狭窄病人术后高灌注综合征的发生几率.     

无症状性ICA患者行颈动脉支架置入术对认知功能的影响

目的 探讨颈动脉支架置入术对无症状性颈动脉高度狭窄患者认知功能的影响。方法 以本院2012年2月～2014年2月治疗的96例行颈动脉支架置入术的无症状性颈动脉高度狭窄患者为研究组,以同期90例行常规内科治疗的无症状性颈动脉高度狭窄患者为对照组,分别在治疗前3 d和治疗后3个月采用连线测验(TMTa、TMTb)、简易智能量表(MMSE)、阿尔茨海默病评估量表认知部分(ADAS-Cog)评估患者的认知功能。结果 研究组患者治疗前3 d颈动脉狭窄为(79.51±6.02)%,治疗后3个月残余狭窄为(13.52±6.01)%,治疗后3个月狭窄程度较治疗前3 d有明显改善(P<0.05); 治疗后研究组狭窄程度显著低于对照组(P<0.05)。与治疗前3 d相比,研究组治疗后3个月患者的MMSE评分明显增加(P<0.05),TMTa、TMTb和ADAS-Cog评分均明显降低(P<0.05); 治疗3个月研究组各指标均显著优于对照组(P<0.05)。结论 颈动脉高度狭窄可能造成患者认知功能损伤,即使是无症状的此类患者,行颈动脉支架置入术对患者的认知功能也具有一定的改善作用,并且可降低颈动脉狭窄程度。