直接脑血运重建手术治疗儿童烟雾病

Direct Revascularization for Treatment of Pediatric Moyamoya Disease

目的探讨直接脑血运重建手术治疗儿童烟雾病的效果。方法对首都医科大学附属北京天坛医院神经外科自2007年7月至2009年2月收治的儿童烟雾病患者20例进行回顾性分析,男10例,女10例,年龄4～15岁(中位年龄9岁)。根据Suzuki的分期标准,Ⅰ期3例,Ⅱ期8例,Ⅲ期7例,Ⅳ期2例。以缺血为首发症状者19例,出血为首发症状者1例。20例患者均行颞浅动脉与大脑中动脉(superficial temporal artery-middle cerebral artery,STA-MCA)搭桥术或STA—MCA搭桥术联合应用脑-硬脑膜-动脉贴敷术(encephalo-duro-arterio synangiosis,EDAS),术中均采用脑血管吲哚菁绿荧光造影以确定重建血管通畅程度,术后随访记录患者症状改善情况,并采用全脑数字减影血管造影(digital subtraction angiography,DSA)、经颅多普勒(transcranial doppler sonography,TCD)、单光子发射断层扫描(emission computed tomography,ECT)等影像学检查观察重建血管血流及侧枝循环形成情况。结果患者行直接脑血运重建手术15例,直接血运重建联合间接血运重建术5例。术中吲哚菁绿荧光血管造影(indocyanine green angiography)显示吻合口血流通畅19例(95%),吻合血管血流缓慢1例(5%)。患者随访时间为术后3～22个月,平均(12.5±4.5)个月,术后症状完全缓解11例(55%),症状明显改善8例(40%),症状改善不明显1例(5%)。本组患者无手术死亡,无术后颅内出血及脑缺血事件发生。术后随访行DSA、计算机断层扫描血管成像(computed tomography angiography,CTA)或磁共振血管成像(magnetic resonance angiography,MRA)检查的17例患者均出现颈外动脉向大脑中动脉供血的情况。行ECT检查的4例(20%)患者患侧血流灌注均较术前有所改善。结论直接脑血运重建手术治疗儿童烟雾病能够早期迅速增加脑血运,改善脑缺血症状和神经系统功能缺损,术中吲哚菁绿荧光血管造影在手术中具有重要作用。

Objective To evaluate the role of direct revascularization for the treatment of pediatric Moyamoya disease. Methods There were 20 total patients （age range： 4-15 years; mean age： 9 years）. All patients underwent superficial temporal artery to middle cerebral artery （STA-MCA） anastomosis or combined with encephalo-duro-arterio-synangiosis （EDAS）. The postoperative results were evaluated following surgery in terms of the angiographic revascularization and the clinical outcome. Results The mean period of follow-up after surgery was 12.54-4.5 months, with a range of 3-22 months. The ischemic symptoms disappeared in 11 patients, relieved significantly （≥90%） in 8 patients, only one patient with big preoperative infarction had no obvious change. There was no recurrence of cerebral hemorrhage or infarction on follow up. Spontaneous revascularization from the superficial temporal artery were found in all 17 （85%） followed up cases by digital subtract angiography （DSA）, computed tomography angiography （CTA） or magnetic resonance angiography （MRA）. Conclusion With the use of indocyanine green angiography in operation, STA-MCA bypass surgery for treatment of pediatric Moyamoya disease can achieve a satisfactory result.