5例肺动脉血栓内膜剥脱术后神经系统障碍的临床特点及原因

The clinical features of neurological disorders after pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension

目的总结5例肺动脉血栓内膜剥脱术治疗慢性肺动脉血栓栓塞症术后神经系统障碍的患者的临床表现特点，并尝试分析其原因。方法回顾2002年至2010年，26例因慢性血栓栓塞性肺动脉高压症行肺动脉血栓内膜剥脱术的患者围手术期资料。总结术后生泵患者中5例出现神经功能障碍并发症者的临床与影像学特点，分析其与无并发症患者的手术前、手术中的资料，寻找可能的影响因素。结果26例中围手术期死亡4例，22例生存者心功能改善，生活质量明显提高。5例围手术期出现神经系统障碍表现者中，3例表现为嗜睡、谵妄、记忆力障碍，颅脑CT未见异常发现，治疗后症状1周内消失，2周内完全恢复；另2例患者除上述症状外，还表现为共济失调、步态不稳、舞蹈样动作，症状持续时间长，其中1例经高压氧治疗后1个月症状好转，颅脑CT未见异常发现，颅脑MRI显示双侧中脑，基底节区异常信号，治疗8周症状基本好转出院，6个月症状完全消失，复查颅脑MRI异常信号消失；1例颅脑CT未见异常发现，12周出院，恢复较差，生活部分自理。术后出现神经系统障碍患者Jamieson手术分型Ⅲ型、Ⅳ型比例较多（P=0．024），手术中停循环时间较长（P=0．034）。结论肺动脉血栓内膜剥脱术后早期神经系统障碍多表现为弥漫性脑皮层与对称性基底节区神经功能障碍，颅脑MRI相应区域异常信号，多数患者症状在2—8周内消失，6个月内颅脑MRI异常信号可以消失。出现神经系统功能障碍的患者多手术操作难度大，停循环时间较长，推测考虑与术中脑缺血缺氧有关。

Objective Investigate the clinical features of the neurological disorders in patients after pulmonary thromhoendarterectomy （PTE） for chronic pulmonary thromboembolism , analyze the factorial. Methods A retrospective study was made of 26 patients who underwent PTE between 2002 and 2010 in Beijing Chao-Yang hospital. The symptom of neurological system disorders occurred in the survivors were been investigate. The preoperative conditions and the perioperative conditions of all survivors were investigated. Compared the differences between the groups with neurological system disorders and the groups without. Results There were 22 patients of 26 survived after the surgery. Cardiac function of the survivors improved, and the quality of life improved significantly. 5 cases of the 22 survivors had symptoms of neurological system disorders. 3 patients showed lethargy, delirium, memory disorders, brain CT found no abnormal, symptoms recovered within 2 weeks. The fourth patient showed ataxia, unsteady gait, dance-like movements symmetry, in addition to the above symptoms, brain CT no abnormal showed, brain MRI showed bilateral abnormal signal in the midbrain, basal ganglia, symptoms improved and discharged after 8 weeks, the symptoms completely disappeared 6 months, and the abnormal signals in brain in MRI disappeared. The fifth patient with similar symptoms to the fourth, brain CT no abnormal found, be discharged 10 weeks after the operation, recovery is poor, living part of themselves. The postoperative neurological disorders occurred in the patients of Jamieson surgery type Ⅱ type, IVtype of larger proportion, （ P = 0. 024）, longer circulatory arrest surgery （ P = 0. 034 ）. Conclusion The neurological disorders postoperative PTE often showed diffuse symmetric cerebral cortex and basal ganglia nerve dysfunction, brain MRI showed abnormal signal corresponding region, the majority of symptoms disappeared in 2 - 8 weeks, abnormal signal in brain MRI could disappeared after 6 months. Neurological dysfunction occurs in patients with more difficult surgical procedure, longer circulatory arrest, suggesting that with the surgery cerebral ischemia and hypoxia related.