一期直接血管重建与单纯药物治疗缺血性烟雾病的对比研究

COMPARISON OF ONE-STAGE DIRECT REVASCULARIZATION AND MEDICINE THERAPY FOR TREATMENT OF ISCHEMIC MOYAMOYA DISEASE

目的比较一期直接血管重建与单纯药物治疗缺血性烟雾病的临床效果。方法2002年3月-2008年3月,收治18例缺血性烟雾病患者。男12例,女6例;年龄9～33岁。均以缺血性卒中为首发症状。11例脑梗死,7例短暂性脑缺血发作。采用国人缺血性心血管病风险评估量表评定,除1例中危外余均为低危患者。DSA检查示均存在不同程度颈内动脉分支闭塞及异常侧支吻合。单光子发射型计算机断层仪检查示14例单侧及4例双侧脑血流量低灌注。11例接受颞浅动脉-大脑中动脉吻合手术,7例接受抗血小板聚集剂联合钙通道阻滞剂治疗。结果手术治疗患者切口均Ⅰ期愈合,围手术期无卒中发生。2例术后5d吻合血管痉挛;1例术后2周出现缺血区域高灌注;均经对症治疗后恢复。患者均获随访,随访时间13～32个月,平均18个月。治疗12个月内药物治疗患者发生6例11次卒中,手术患者6例6次;两组卒中频次差异有统计学意义(P<0.05)。治疗后12个月内药物治疗患者85.7%再次卒中,手术治疗患者为54.5%。治疗6个月后DSA或CT血管造影显示:6例药物治疗患者异常侧支增生,血管闭塞并向远端进展;7例手术患者异常侧支增生,但血管闭塞未加重;其余4例无变化。涉及双侧病变2次手术者及药物治疗后延期手术者,卒中频次无改善。治疗后12个月采用修订Rankin身体机能评分,药物治疗者2例2分,5例0～1分;手术治疗者1例3分,6例2分,4例0～1分;两组比较差异无统计学意义(P>0.05)。结论首次卒中并确诊为缺血性烟雾病后,应予一期直接血管重建治疗,相比药物治疗或延期手术可能降低复发卒中风险,减缓疾病进展。

Objective To compare the therapeutic effect of one-stage direct revascularization and medicine therapy for the treatment ofischemic moyamoya disease. Methods From March 2002 to March 2008, 18 patients with ischemic moyamoya disease （12 males and 6 females） were treated, aged 9 to 33 years old. Eighteen patients presented with ischemic stroke, including 11 cases of cerebral infarction and 7 cases of transient ischemic attack. According to Chinese ischemic cardiovascular diseases evaluation tools, 17 patients were classified as low risk ischemic stroke and 1 as modernte risk ischemic stroke. Different levels of occlusion branch of the intracranial carotid arteries and pathosis collaterals were identified by DSA. Fourteen patients and 4 patients were showed unilateral and bilateral hypoperfusion of cerebral blood flow by single photon emission computed tomography, respectively. Eleven patients received superficial temporal artery-middle cerebral artery anastomosis and 7 patients received medicine （anti-PLT agglutinin and calcium channel blocker）. Results All incisions healed at stage I. There was no stroke events during perioperation. Anastomosis vessel vasospasm occurred in 2 patients 5 days after operation; and hyperperfusion syndrome in 1 patient 2 weeks after operation. All patients were followed up 13-32 months （mean 18 months）. In 11 anastomosis patients, 6 underwent 6 stroke events within 12 months; in 7 medicine patients, 6 underwent 11 stroke events within 12 months; and showing a significant difference （P 〈 0.05）. The stroke recurrence rate was 85.7% in medicine patients and 54.5% in anastomosis patients 12 months after therapy. DSA showed pathosis collaterals in 7 anastomosis patients and 6 medicine patients 6 months after therapy. After 12 months according to modified Rankin scale, the scores of anastomosis patients were 3 points in 1 case, 2 points in 6 cases and 0-1 point in 4 cases, and the scores of medicine patients were 2 points in 2 cases and 0-1 point in 5 cases; showing no significant difference （P 〉 0.05）. Conclusion As long as onset of stroke occurred and ischemic moyamoya disease is diagnosed, one-stage direct revascularization should be performed, which can reduce the rate of stroke recurrence risk and slow down the progression of disease.