经颅彩色多普勒超声对重度颈动脉狭窄行颈动脉内膜切除术患者前交通动脉开放的评价

Transcranial color Doppler ultrasonography for the assessment of anterior communicating artery patency in patients with severe carotid artery stenosis

目的探讨经颅彩色多普勒超声对重度颈动脉狭窄接受颈动脉内膜切除术（CEA）治疗患者前交通动脉开放的评估价值。方法回顾性连续纳入2014年6月至2015年6月首都医科大学宣武医院神经外科症状性一侧重度颈动脉狭窄而接受CEA治疗的住院患者89例。根据DSA显示前交通动脉是否开放，分为开放组（45例）和未开放组（44例）。比较经颅彩色多普勒超声与DSA诊断前交通动脉是否开放的一致性；分析两组术中实施临时性分流率的差异及手术前后双侧大脑中动脉（MCA）、大脑前动脉（ACA）的收缩期峰值流速（PSV）、舒张期末流速（EDV）、搏动指数（PI）等血流动力学参数。结果与DSA结果比较，经颅彩色多普勒超声对89例患者术前评估前交通动脉开放的敏感度、特异度分别为91．1％（41／45）、97．7％（43／44），总符合率为94．4％（84／89）（Kappa=0．888，P〈0．01）。前交通动脉开放组患者CEA术中临时洼分流实施率[2．2％（1／45）]明显低于未开放组[20．5％（9／44）]，组间差异有统计学意义（X2=5．700，P=0．017）。两组患者术后患侧MCA的PSV、EDV、PI均较本组术前升高，差异均有统计学意义[开放组：（128±41）cm／s比（77±24）cm／s，（554-18）cm／s比（41±13）cm／s，（0．92±0．14）比（0．67±0．14）；未开放组：（139±44）cm／s比（86±31）cm／s，（59±22）cm／s比（44±16）cm／s，（0．94±0．15）比（0．71±0．16）；均P〈0．01]；开放组术后健侧ACA的PSV、EDV均较术前下降，差异有统计学意义[（125±42）cm／s比（157±57）cm／s，（55±24）cm／s比（72±34）cm／s，均P〈0．01]，手术前后健侧ACA的PI差异无统计学意义（P〉0．05）；未开放组术后健侧ACA的PSV、EDV及PI与术前的差异均无统计学意义（均P〉0．05）。结论经颅彩色多普勒超声可对一侧颈动脉重度狭窄患者前交通动脉的开放与否进行准确而客观的评价，对于CEA术中选择性分流、提高CEA的成功率具有指导意义。

Objective To investigate the evaluation value of anterior communicating artery patency for patients with severe carotid artery stenosis treated by carotid endarterectomy（ CEA） with transcranial color Doppler ultrasonography. Methods From June 2014 to June 2015,89 consecutive inpatients with unilateral symptomatic severe carotid stenosis treated with CEA at the Department of Neurosurgery,Xuanwu Hospital,Capital Medical University were enrolled retrospectively. They were divided into either a patent group（ n = 45） or a non-patent group（ n = 44） according to whether the anterior communicating artery was patent or not（ DSA findings）. Whether the anterior communicating artery was patent or not diagnosed by the transcranial color Doppler ultrasonography was compared with the consistency of the digital subtraction angiography（ DSA） results. The differences of intraoperatively implemented temporary shunt rate and the differences of hemodynamic parameters including peak velocity（ PSV）,end-diastolic velocity（ EDV）,and pulsatility index（ PI） of the preoperative and postoperative bilateral middle cerebral artery and anterior cerebral artery（ ACA） of both groups were analyzed. Results Compared with the results of DSA,the sensitivity and specificity of transcranial color Doppler ultrasonography for preoperative evaluation of the patency of anterior communicating artery were 91. 1%（ 41 /45） and 97. 7%（ 43 /44） respectively,the total accordance rate was 94. 4%（ 84 /89）（ Kappa = 0. 888,P〈 0. 01）. The temporary shunt rate（ 2. 2%[1 /45]） of patients in CEA of the anterior communicating artery patent group was significantly lower than that of the non-patent group（ 20. 5%[9 /44]）. There was significant difference between the 2 groups（ χ~2=5. 700,P = 0. 017）. PSV,EDV,and PI of the ipsilateral middle cerebral artery after procedure in both groups were higher than those before procedure. There were significant differences（ the patent group： 128 ±41 cm / s vs. 77 ± 24 cm / s,55 ± 18 cm / s vs. 41 ± 13 cm / s,and 0. 92 ± 0. 14 vs. 0. 67 ± 0. 14; the non-patent group： 139 ± 44 cm / s vs. 86 ± 31 cm / s,59 ± 22 cm / s vs. 44 ± 16 cm / s,and 0. 94 ± 0. 15 vs. 0. 71 ± 0. 16; all P〈 0. 01）. PSV and EDV of the contralateral ACA of the patent group were decreased after procedure.There were significant differences（ 125 ± 42 cm / s vs. 157 ± 57 cm / s,55 ± 24 cm / s vs. 72 ± 34 cm / s,all P〈 0. 01）. There was no significant difference in PI of contralateral ACA before and after procedure（ P〉 0. 05）. There were no significant differences in PSV,EDV and PI of the contralateral ACA in the non-patent group between after procedure and before procedure（ all P〉0. 05）. Conclusions Transcranial color Doppler ultrasonography can accurately and objectively evaluate whether the anterior communicating artery is patent or not in patients with unilateral severe carotid stenosis. It has an important clinical significance for selective shunt in CEA and improving the success rate of CEA.