基于改良Suzuki分期的成人烟雾病侧枝循环特点及其临床意义

目的探讨成人烟雾病患者侧枝循环特点及其临床意义。方法收集2006~2016年在南方医科大学南方医院神经外科接受DSA检查的成人烟雾病病人资料。根据临床影像学检查分为两组（缺血组和出血组），双盲分析影像学结果，对疾病严重程度采用改良Suzuki评分（mSS）进行分级。回顾性分析患者脑血管造影图像，把侧支循环血管系统的分组分为浅部脑膜组和深部脑实质组，浅部脑膜组再分为硬脑膜血管吻合系统和软脑膜血管吻合系统；深部脑实质组分为室管膜下血管吻合系统和丘脑、纹状体内血管吻合系统。每例病人，根据侧枝循环的有无进行赋值（1表示有侧枝循环，0表示无侧枝循环）。测量和记录后交通动脉（Pcom）及颈内动脉（ICA）的内径。记录脉络膜前动脉的异常改变：（0表示没显影；1表示显影但无扩张；2表示扩张并参与代偿供血）。采用spss 22.0软件对数据进行统计学分析，比较组间差异，检验水准均为α=0.05。结果出血组与缺血组间病人mSS评分的分布没有显著差异（χ2=5.812，v=5，P=0.325）；Pcom/ICA（后交通动脉颈内动脉内径比值）比较两组差异有统计学意义（t=2.119，v=108，P=0.036）出血组Pcom/ICA值较大。Pcom/ICA在不同mSS评分的各组间的分布差异有统计学意义（f=8.924，P<0.05）mSS评分在等于3、4、5分时比值较大；两组之间脉络膜前动脉扩张的发生率的差异有统计学意义（χ2=11.79，P=0.001）；侧支循环血管系统：硬脑膜血管吻合组：两组之间硬脑膜血管吻合发生率差异没有统计学意义（χ2=0.327，P=0.567）。软脑膜血管吻合组：两组之间软脑膜血管吻合发生率差异有统计学意义（Fisher精确检验，P=0.018），出血组出现率明显高于缺血组。室管膜下血管吻合组：两组之间室管膜下血管吻合发生率差异没有统计学意义（χ2=0.011，P=0.917）。纹状体内血管吻合组：两组之间纹状体内血管吻合发生率差异有统计学意义（χ2=7.551，P=0.006），出血组出现率高于缺血组。结论侧支循环血管系统是烟雾病患者脑血流重要组成部分，其因病人不同而表现不同的模式；后交通动脉与颈内动脉内径的比值增大，脉络膜前动脉的异常扩张，发自沟动脉的软脑膜血管吻合和丘脑、纹状体内的血管吻合可能是烟雾病病人出现出血性卒中的独立危险因子。

Characteristics of collateral circulation in adult moyamoya disease based on modifiedSuzuki staging

Objective To investigate the characteristics of collateral circulation in adult moyamoya disease (MMD). Methods Theclinical data were collected from all adult patients with MMD undergoing digital subtractive angiography (DSA) in ourdepartment from 2006 to 2016. Based on the imaging findings, the patients were divided into ischemia group and bleedinggroup. A double-blind analysis was conducted of the CT or magnetic resonance imaging findings and the severity of thedisease was graded using the modified Suzuki score (mSS). We classified the anastomotic networks in MMD into thesuperficial meningeal type and deep parenchymal type. The superficial meningeal type was further classified into theleptomeningeal and the durocortical networks, and the deep parenchymal networks into subependymal networks and theinner striatal and inner thalamic networks. Results No significant difference was found in the distribution of mSS scoresbetween the hemorrhage group and the ischemic group (χ2=5.812, v=5, P=0.325), but the posterior communicating artery andinternal carotid artery diameter ratio (Pcom/ICA ratio) was significantly greater in the hemorrhage group (t=2.119, v=108, P=0.036). The Pcom/ICA ratio differed significantly among the groups with different mSS scores (f=8.924, P=0.00), higher ingroups with mSS scores of 3, 4 and 5. The incidence of anterior choroidal artery dilation differed significantly betweenhemorrhage and ischemic groups (χ2=11.79, P=0.001). The incidences of durocortical networks (χ2=0.327, P=0.567) andsubependymal networks (χ2=0.011, P=0.917) were comparable between hemorrhage group and ischemic groups, but theincidence of leptomeningeal networks (P=0.018) and inner striatal and inner thalamic networks (χ2=7.551, P=0.006) differedsignificantly between the two groups. Conclusion The collateral circulation vascular system is an important component ofcerebral blood flow in MMD patients and varies frompatient to patient. Patients with MMD exhibit increasedPcom/ICA ratio with abnormal expansion of the anteriorchoroidal artery, and the leptomeningeal networks andthe inner striatal and inner thalamic networks areindependent risk factors for cerebral hemorrhage.