两种手术方法治疗低皮质微血管密度成人烟雾病患者的疗效比较

Outcome of Encephalo-duro-arterio-synangiosis and Combined Bypass Surgery for Adult Moyamoya Disease Patients with Low Cortical Microvascular Density

目的探讨低皮质微血管密度的成人烟雾病患者行脑-硬脑膜-动脉血管融通术(encephalo-duro-arterio-synangiosis,EDAS)与联合血管重建术(combined bypass surgery,CBS)的治疗效果。方法采用前瞻性研究方法,选取中国人民解放军第307医院神经外科自2009年6月～2012年8月间收治的行CBS治疗的50侧例低皮质微血管密度的成人烟雾病患者(CBS组),以2002年11月～2008年11月间行EDAS治疗的37侧例低皮质微血管密度患者作为对照组(EDAS组)。CBS组所有患者均行单侧或双侧EDAS及颞浅动脉-大脑中动脉(superficial temporal artery-middle cerebral artery,STA-MCA)分支吻合术联合手术治疗,术中根据皮质血管照片分析皮质微血管密度,根据皮质微血管密度等级确定手术方案。术前、术后6个月行经颅多普勒超声(transcranial Doppler,TCD)和数字减影血管造影(digital subtraction angiography,DSA)检查评估脑血流状况和手术血管重建情况。结果两组患者间在临床表现类型、术前分期方面差异无显著性。EDAS组患者手术后6个月颞浅动脉的平均流速(STAVm)较术前比较差异具有显著性[(42.18±12.68)cm/svs(28.34±7.28)cm/s,P=0.041];STA的搏动指数(pulsationindex,PI)较术前比较差异具有显著性[(1.62±0.62)vs(2.42±0.87),P=0.043]。CBS组术后6个月STAVm较术前比较差异具有显著性[(53.67±11.48)cm/svs(26.83±8.46)cm/s,P=0.032];STAPI较术前比较差异具有显著性[(1.24±0.58)vs(2.61±0.91),P=0.039]。术后6个月,CBS组的STAVm较EDAS组比较差异具有显著性[(53.67±11.48)cm/svs(42.18±12.68)cm/s,P=0.042],CBS组的STAPI较EDAS组比较差异具有显著性[(1.24±0.58)vs(1.62±0.62),P=0.047]。EDAS组患者术后6个月手术血管重建评估≥Ⅱ级占37.8%,CBS组患者术后6个月手术血管重建评估≥Ⅱ级占48.0%,两组间差异具有显著性(P=0.033)。结论 EDAS与CBS均能改善低皮质微血管密度的成人烟雾病患者的脑血流情况,均可发生手术血管重建,但CBS效果优于EDAS术,有助于患者术后脑血流的改善。

Objective To compare the efficacy of encephalo-duro-arterio-synangiosis （EDAS） and combined bypass surgery （CBS） for adult moyamoya disease patients with low cortical microvascular density. Methods A prospective study was conducted. Collect the data of 50 hemispheres who had been performed combined bypass surgery （CBS group）. These adult patients with moyamoya disease had low cortical microvascular density and admitted to 307 Hospital of Chinese People＇s Liberation Army from Jun 2009 to Aug 2012. The control group was 37 hemispheres of low cortical microvascular density patients treated with EDAS from Nov 2002 to Nov 2008 （EDAS group）. All patients in the CBS group were performed with unilateral or bilateral EDAS and superficial temporal artery-middle cerebral artery （STA-MCA） branch anastomosis combined surgery. Analyse the cortical microvascular density according to the cortical photo, and determine the operation method. The improvement of cerebral blood flow was evaluated by transcranial Doppler （TCD）,and postoperative revascularization was evaluated by digital substraction angiography （DSA）. Results In the EDAS group, the mean flow velocity of superficial temporal artery （STA Vm） increased obviously after operation （[42.18±12.68] cm/s vs [28.34±7.28] cm/s, P=0.041）. The pulsation index （PI） of STA obviously declined after operation （[1.62±0.62] vs [2.42±0.87], P=-0.043）. In the CBS group, the STA Vm increased obviously after operation （[53.67±11.48] cm/s vs [26.83±8.46] cm/s, P=0.032）. The STA PI obviously declined after operation （[1.24±0.58] vs [2.61±0.91], P=0.039）. After 6 months, the STA Vm of the CBS group were higher than that of the EDAS group （[53.67±11.48] vs [42.18±12.68], P-0.042）, the STA PI of the CBS group were lower than that of the EDAS group （[1.24±0.58] vs [1.62±0.62], P=0.047）. In the postoperative revascularization assessment, the hemispheres that reached grade ≥Ⅱ in the CBS group was more than the EDAS group （48% vs 37.8%, P=0.033）. Conclusion For low cortical microvascular density of adult patients with moyamoya disease, both EDAS and CBS can improve the cerebral blood flow and surgery vascular remodeling, but CBS is better than EDAS. So for low cortical microvascular density of adult patients with moyamoya disease, we can take CBS in order to further improve the prognosis of patients.