经颅多普勒超声经眼窗监测脑血流动力学在颈动脉内膜切除术中的应用价值

Values of hemodynamics monitoring via ocular window with transcranial Doppler during carotid endarterectomy

目的应用经颅多普勒超声(TCD)对颞窗穿透不良的颈动脉内膜切除术(CEA)患者经眼窗监测脑血流动力学的改变,探讨该方法的有效性及可靠性。方法经眼窗监测CEA手术患者8例。采用TCD评价术前侧支循环的开放情况,并经DSA证实。于术中进行脑血流监测,记录麻醉后、颈动脉夹闭前后、转流管放置及颈动脉开放前后,不同时间点患侧眼动脉(OA)和(或)颈内动脉虹吸部(CS)的收缩期峰值血流速度(PSV)、舒张期末血流速度(EDV)、平均血流速度(MV)、血管搏动指数(PI)等参数。结果①手术监测成功7例。8例患者中有4例因交通动脉代偿不良,使用转流管。术中采用双深度监测OA及CS者3例,单独监测CS者2例(1例未成功),单独监测OA者3例。②夹闭颈动脉后与夹闭前比较,OA的PSV、MV、EDV及PI均显著下降,差异有统计学意义(P<0.05);颈动脉血流开放后,OA的PI明显升高(P<0.05);夹闭颈动脉后较夹闭前CS的PSV显著下降(P<0.05),但开放后血流与夹闭前各项参数比较,差异无统计学意义(P>0.05)。③8例患者中,有1例术后1周发生脑梗死,7例预后良好。结论经眼窗监测CEA术中脑血流改变,可有效解决颞窗穿透不良的难题。采用双深度间断监测患侧OA和CS血流参数是较理想的方式。对前交通动脉和(或)后交通动脉代偿不完全患者,建议使用转流管,可预防术中脑缺血,降低术后卒中的发生。

Objective To investigate the validity and reliability of transcranial color Doppler（TCD） via the ocular window when the temporal window pentrated poor during carotid endarterectomy（CEA）.Methods Eight patients were monitored with TCD via the ocular window during CEA.TCD was used to evaluate the patency of collateral circulation before procedure and it was confirmed by DSA.Intraoperative cerebral blood flow was monitored,the parameters such as the peak systolic velocity（PSV）,end diastolic velocity（EDV）,mean velocity（MV） and pulse index（PI） of the ipsilateral ophthalmic artery（OA） and/or carotid siphon（CS） at the different time points were record after anesthesia,before and after carotid occlusion,after shunt placement,and patency of carotid artery.Results ① 4 of 8 patients used shunt because of the adverse compensation of communicating artery.OA and CS were monitored with dual-depth monitoring in 3 patients;CS was monitored alone in 2,and OA was monitored alone in 3.②Compared to the carotid arteries before clipping,the PSV,MV,EDV and PI of OA decreased significantly after clipping.The differences were statistically significant（P0.05）.PI of OA increased significantly after the patency of carotid blood flow（P0.05）;compared to before clipping the carotid arteries,the PSV of CS decreased significantly（P0.05）,but there was no significant difference in comparing the blood flow after patency with all the parameters before clipping（P0.05）.③The surgical monitoring was successful in 7 patients.Only one patient had cerebral infarction 1 week after procedure and 7 had good prognosis.Conclusion Monitoring the cerebral blood flow changes via ocular window during CEA may effectively solve the problem of the poor temporal window penetration.Monitoring the blood flow parameters of ipsilateral OA and CS with dual-depth intermittent monitoring are the ideal ways.For patients with incomplete compensation in anterior communicating artery and/or the posterior communicating artery,the use of shunt is recommended.It may prevent intraoperative cerebral ischemia and reduce the occurrence of postoperative stroke.