颈内动脉内膜剥脱术围手术期脑、颈动脉超声的综合评估

目的分析颈内动脉内膜剥脱术（carotid endarterectomy，CEA）围手术期的脑、颈动脉超声的综合评估。方法选取60例接受CEA治疗病人，并于围手术期采取经颅多普勒超声（transcranial Doppler，TCD）+颈动脉超声检查法，详细记录术前、术中与术后检查结果，术前以数字减影血管造影（digital subtraction angiography，DSA）为"金标准"，分析颈动脉超声检查颈动脉狭窄率的准确性，比较DSA与TCD对侧支循环开放检出率、围手术期颈动脉超声与TCD检查指标。结果颈动脉超声检查50%~69%狭窄率灵敏度66.67%（6/9），特异度100.00%（51/51），准确性95.00%（57/60），Kappa值=0.77；TCD对前交通动脉开放检出率为91.07%，后交通动脉开放检出率为85.96%，颈内-颈外动脉开放检出率为87.50%；术前颈动脉超声显示狭窄部位管径明显变窄，并且血流速度较正常者升高，手术解除狭窄后通过颈动脉超声检查发现术侧血管狭窄有效解除，同时上下切缘内膜获得良好固定效果，管腔之中无内膜漂浮等异常，血流通畅；颈动脉开放时与术后1周收缩期峰值流速（PSV）、舒张期末流速、颈内动脉狭窄段PSV/颈总动脉PSV比值均明显低于术前（P < 0.01），狭窄部位内径明显大于术前（P < 0.01）；TCD检查显示，病人颈动脉开放时与术后1周患侧PSV、舒张期末流速、平均流速、脉动指数均明显高于麻醉后5~10 min（P < 0.01），且均恢复至正常水平，其中2例大脑中动脉血流速度在基础水平200%以上，为避免过度灌注，对狭窄近端颈总动脉进行重新夹闭，减小血压值10~30 min，最后流速恢复。结论TCD+颈动脉超声可在CEA术前检查、术中监测与术后疗效评估中提供准确有效客观依据，对病人手术顺利进行具有较高应用价值。

Comprehensive evaluation of brain and carotid ultrasound in perioperative period of carotid endarterectomy

ObjectiveTo analyze the comprehensive evaluation of brain and carotid ultrasound in perioperative period of carotid endarterectomy(CEA).MethodsThe transcranial Doppler(TCD) and carotid ultrasound in 60 patients treated with CEA were examined during the perioperative period.The results of preoperative, intraoperative and postoperative examination were recorded.Using preoperative digital subtraction angiography(DSA) as the golden standard, the accuracy of carotid artery stenosis detected by carotid ultrasound was analyzed.The detection rate of collateral circulation opening was compared between DSA and TCD, and the perioperative indicators were compared between carotid ultrasound and TCD.ResultsThe sensitivity, specificity, accuracy and Kappa value of carotid ultrasound in the detection of 50% to 69% stenosis were 66.67%(6/9), 100.00%(51/51), 95.00%(57/60) and 0.77, respectively.The detections rates of TCD for anterior communicating artery opening, posterior communicating artery opening and internal-external carotid artery opening were 91.07%, 85.96% and 87.50%, respectively.The preoperative carotid ultrasound showed that the diameter of the stenosis narrowed, and the blood flow velocity was higher than that of normal people.Carotid ultrasound found that the vascular stenosis on the operative side was effectively relieved after the stenosis was removed by operation.The intima of upper and lower margins was well fixed, there was no intimal floating in lumen, and the blood flowing was smooth.The PSV, EDV and PSVICA/PSVCCA at carotid artery opening and after 1 week of operation were significantly lower than those before surgery(P < 0.01), and the internal diameter of stenosis was significantly larger than that before surgery(P < 0.01).TCD examination showed that the PSV, EDV, MV and PI at carotid artery opening and after 1 week of operation were significantly higher than those after 5 to 10 minutes of anesthesia(P < 0.01), and all indictors returned to the normal level.The blood flow velocity of middle cerebral artery in 2 cases were more than 200% above the basal level.To avoid excessive perfusion, the proximal common carotid artery was clamped again, the blood pressure value decreased for 10 to 30 minutes, and the flow rate was restored in the end.ConclusionsTCD combined with carotid artery ultrasound can provide the accurate and effective objective basis for preoperative examination, intraoperative monitoring and postoperative evaluation of CEA, which has great application value in successful operation of patients.