缺血型烟雾病脑硬膜动脉血管融通术后血管重建效果及影响因素

Efficacy and Predictive Factors of Revascularization for Ischemic Moyamoya Disease with Encephalo-Duro-Arterio-Synangiosis Procedures

目的探讨缺血型烟雾病脑硬膜动脉血管融通术(encephalo-duro-arterio-synangiosis,EDAS)后血管重建效果及影响因素。方法回顾性分析在我院接受EDAS术治疗的120例缺血型烟雾病患者的临床资料,对性别、首次手术年龄、术前脑糖代谢情况、脑梗死类型、手术侧别、颈内动脉分期、大脑后动脉分期、前后循环间代偿以及左右侧代偿与术后动脉向颅内生长情况之间进行多因素logistic回归分析。结果本组病例中102例患者接受双侧手术,18例接受单侧手术,总共手术为222例侧。术后动脉向颅内生长的有174例侧,血管重建有效率78.4%。多因素logistic回归分析显示首次手术年龄[优势比(odds ratio,OR)为1.03,95%可信区间(confidence interval,CI)1.012～1.049],大脑后动脉分期(OR=0.767,95%CI 0.601～0.977,P=0.0319),左右侧代偿(OR=0.499,95%CI 0.280～0.891,P=0.0188)及脑梗死类型与血管重建效果有关。相对于正常脑组织,皮层梗死(OR=0.275,95%CI 0.133～0.569,P=0.0005)、皮层下白质梗死(OR=0.317,95%CI 0.131～0.763,P=0.0104)和点状梗死(OR=0.392,95%CI 0.193～0.796,P=0.0096)血管重建效果更好。结论 EDAS可以有效建立颅内外血管重建。首次手术年龄越低、大脑后动脉分期越高、有左右侧代偿可以获得更好的术后血管重建;相对于正常脑组织,出现皮层梗死、皮层下白质梗死和点状梗死类型脑组织可获得更好血管重建效果。

Objective To investigate the efficacy and predictive factors of revascularization for ischemic Moyamoya disease（MMD） with encephalo-duro-arterio-synangiosis（EDAS） procedures. Methods One hundred and twenty patients with MMD admitted to our hospital were retrospectively reviewed. Clinical factors including gender, age at first operation, cerebral glucose metabolism, type of infarction, surgical side, stage of the internal carotid artery（ICA） bifurcation steno-occlusive lesion, grade of the posterior cerebral artery（PCA） lesion, compensation between anterior and posterior circulation, compensation between left and right hemisphere were retrospectively gathered. We used the logistic regression model to estimate the impact of preoperative clinical factors on the extent of revascularization.Results All the 120 patients underwent neurosurgical revascularization procedures. Since 102 of them received bilateral procedures, and 18 of them received unilateral procedures. The total procedures performed were 222. Collateral formation in the middle cerebral artery（MCA） territory from superficial temporal artery（STA） was seen in 174 hemispheres（78.38%）. A multivariate logistic regression analysis of age at first surgery（OR-1.030, 95%CI 1.012-1.049, P=0.0011）, grade of the PCA lesion（OR-0.767, 95%C1 0.601-0.977, P=0.0319）, compensation between left and right hemisphere（OR-0.499, 95%CI 0.280-0.891, P=0.0188） and certain type of infarction showed a correlation for better revascularization. Relative to normal brain tissue, cortical infarction（OR=0.275, 95%CI 0.133-0.569, P=0.0005）, subcortical white matterinfarction（OR=0.317, 95%CI0.131-0.763, P=0.0104）, dot-like infarction（OR-0.392, 95%CI 0.193- 0.796, P=0.0096） showed better revascularization. Conclusion Surgical treatment with EDAS is effective at establishing extra-intracranial revascularization. Patients with lower preoperative age, higher grade of the PCA, appearance of compensation between left and right circulation showed better revascularization. Relative to normal brain, MMD have ischemic lesions involving the cortical, subcortical and dot-like will get better revascularization results.