脑硬脑膜颞浅动脉血管融通术治疗出血型烟雾病的疗效及其影响因素分析

Efficacy and its influencing factors of encephalo-duro-arterio-synangiosis for treatment of hemorrhagic moyamoya disease

目的探讨脑硬脑膜颞浅动脉血管融通术(EDAS)治疗出血型烟雾病的疗效及其影响因素。方法回顾性分析85例2002年12月—2011年12月在解放军第三○七医院行双侧EDAS治疗、术后采用DSA随访的出血型烟雾病患者的临床资料。分析项目包括性别、首次手术年龄,术前出血次数、脑代谢情况(正电子发射断层扫描,PET)评估、脑出血类型、是否合并脑缺血症状、烟雾病分期、大脑后动脉是否受累及是否有并发症(高血压、高血脂、高血糖任意一项),这些因素对血管重建效果的影响。结果①对85例(170侧大脑半球)术后6～43个月进行了随访,平均随访时间(13±8)个月。170侧大脑半球血管重建有效率为50.6%(86/170)。2例在随访期发生再出血,DSA显示颅外血管已向颅内大量代偿。②单因素分析显示,随着年龄的增大,EDAS的有效率逐渐降低(P=0.003);出血前有缺血症状(P=0.000 1)、术前脑代谢降低或缺损者(P=0.000 1)及术前多次出血者(P=0.057)血管重建的效果更好。③多因素Logistic回归分析显示,高龄(OR=1.919,95%CI:1.163～3.167,P=0.011)是影响出血型烟雾病患者手术效果的独立危险因素,出血前有缺血症状(OR=0.252,95%CI:0.067～0.952,P=0.042)、脑代谢降低或缺损(OR=0.016,95%CI:0.004～0.060,P=0.000)是影响手术效果的保护性因素。结论年龄越低、出血前有缺血症状、脑代谢障碍者的血管重建效果更好。

Objective To investigate the efficacy and its influencing factors of encephalo-duro-ar- terio-synangiosis （EDAS） in the treatment of hemorrhagic moyamoya disease. Methods The clinical da- ta of 85 patients with hemorrhagic moyamoya disease, who admitted to the 301st Hospital of PLA for bilater- al EDAS treatment and were followed up with DSA after procedure, were analyzed retrospectively. The effects of gender, age at first operation , preoperative bleeding frequency, cerebral glucose metabolism （positron emission tomography [ PET ] ） evaluation, types of intracerebral hemorrhage, having cerebral ischemic symptoms or not, stages of moyamoya disease, affecting posterior cerebral artery or not, having complications （ hypertension, heperlipemia or hyperglycaemia ） or not on the result of revascularization （ DSA evaluation）. Results （1）85 patients （ 170 sides） were followed up for 6 to 43 months by DSA after procedure. The mean follow-up time was 13 ± 8 months. The effective rate of revascularization of 170 hemispheres was 50.6% （86/170）. Two patients had rebleeding during the follow-up period. DSA showed that the extracranial vessels had large number of intracranial compensation. （2）Univariate analysis showed that the effective rate of EDAS decreased gradually with the increase of age （ P = 0. 003 ）. The efficacy of vascu- lar reconstruction was even better in patients who had ischemic symptoms before bleeding （ P = 0. 000 1 ） , preoperative reduced or defective brain metabolism （ P = 0. 000 1 ） and multiple attacks of bleeding before procedure （ P = 0. 057 ）. （3） Multivariate logistic regression analysis showed that advanced age （ OR = 1. 919, 95% CI 1. 163 to 3. 167 ;P = 0.011 ） was an independent risk factor for affecting the surgical effect in patients with hemorrhagic moyamoya disease. Having ischemic symptoms before bleeding （ OR = 0. 252, 95% CI O. 067 to O. 952 ; P = O. 042 ） and decreased or defects of cerebral metabolism （ OR = O. 016, 95%CI0. 004 to 0. 060; P = 0. 000） were the protective factors for affecting the surgical effect. Conclusion The younger the age, the patients with ischemie symptoms and cerebral metabolic disturbance before procedure, the better effect of revascularization will obtain.