微血管多普勒超声在颅内动脉瘤手术中的应用

Application of microvascular Doppler ultrasonography in the intracranial aneurysm surgery

目的评价微血管多普勒超声(MDU)技术在颅内动脉瘤手术中的监测效果。方法回顾性分析2015年3月至2016年2月14例颅内动脉瘤患者(16个动脉瘤)在开颅夹闭手术中,使用MDU 1 mm微探头检测载瘤动脉和相关穿支动脉血流动力学的改变。根据血流信号,未行动脉瘤夹调整9例;处理动脉瘤后,载瘤动脉或穿支动脉血流信号降低或消失时,改变动脉瘤夹夹闭位置5例,使载瘤动脉或穿支动脉的血流恢复至正常。对比分析动脉瘤夹调整前后,载瘤动脉的血流速度及搏动指数(PI)变化;同时将调整动脉瘤夹后的血流速度和PI与未进行动脉瘤夹调整的患者相比,并于术后1周对患者均行头部CT血管成像(CTA)或DSA复查。结果 (1)术中MDU监测显示,1例动脉瘤夹闭后分支血管闭塞,4例血管狭窄。对这5例患者调整了动脉瘤夹,MDU血流信号均恢复正常。5例患者动脉瘤夹调整前后载瘤动脉的收缩期峰值流速(PSV)分别为(19.8±5.3)cm/s和(51.0±12.0)cm/s,舒张期末流速(EDV)分别为(1.2±0.4)cm/s和(20.2±7.4)cm/s,平均流速(MV)分别为(3.6±1.5)cm/s和(26.2±8.3)cm/s,PI分别为(5.06±1.08)和(0.95±0.15),调整前后差异均有统计学意义(均P<0.01)。(2)调整动脉瘤夹5例与未进行动脉瘤夹调整的9例患者相比,调整后与未调整的PSV分别为(51.0±12.0)cm/s和(43.2±14.0)cm/s,EDV分别为(20.2±7.4)cm/s和(19.4±9.9)cm/s,MV分别为(26.2±8.3)cm/s和(26.0±10.8)cm/s,PI分别为(0.95±0.15)和(0.94±0.22),两者间差异均无统计学意义(均P>0.05)。无监测相关并发症发生。(3)术后头部CT显示一例无脑梗死。术后1周CTA或DSA复查,显示载瘤动脉及分支血管保留良好、通畅,动脉瘤消失。结论 MDU具有安全、可靠、操作简单的特点。该技术有利于发现颅内动脉瘤开颅夹闭手术中的误夹或载瘤动脉夹闭不全,以便及时调整动脉瘤夹位置,提高手术疗效。

Objective To evaluate the monitoring effect of microvascular Doppler ultrasonography（ MDU） in the intracranial aneurysm surgery. Methods From March 2015 to February 2016,fourteen patients with intracranial aneurysm（ 16 aneurysms） were analyzed retrospectively. In craniotomy clipping surgery,MDU 1 mm miniature probe was used to detect the hemodynamic changes of the parent arteries and related perforating arteries. According to the flow signals,nine patients were not conducted aneurysm clip adjustment. After the treatment of aneurysms,the changes of clipping positions of aneurysm clips were in5 cases when the blood flow of the parent arteries or perforating arteries decreased or disappeared,making the blood flow of the parent arteries or perforating arteries to normal. The changes of blood flow velocities and pulsatility indices（ PI） before and after adjustment of the clips were compared and analyzed. At the same time,the blood flow velocity and PI after adjusting aneurysm clips were compared with the patients without adjusting aneurysm clips,and the patients were performed head CT angiography（ CTA） or DSA again at 1 week after procedure. Results（ 1） The intraoperative MDU monitoring showed branch occlusion in 1 patient after aneurysm clipping. Four patients had vascular stenosis. The aneurysm clips of the above 5 cases were adjusted. The MDU flow signals returned to normal. The peak systolic velocities（ PSV） of the parent arteries in 5 cases before and after adjusting the aneurysm clips were 19. 8 ± 5. 3 cm / s and 51. 0 ± 12. 0 cm / s respectively,The end diastolic velocities（ EDV） were 1. 2 ± 0. 4 cm / s and 20. 2 ± 7. 4 cm / s respectively,the mean velocities（ MV） were 3. 6 ± 1. 5 cm / s and 26. 2 ± 8. 3 cm / s respectively,and pulsatility indices（ PI）were 5. 06 ± 1. 08 and 0. 95 ± 0. 15 respectively. There was significant difference before and after the adjustment（ all P〈0. 01）.（ 2） Compared with the 9 patients without adjusting the aneurysm clips,5 patients adjusted the aneurysm clips,the adjusted and unadjusted PSVs were 51. 0 ± 12. 0 cm / s and 43. 2 ± 14. 0 cm / s respectively,EDVs were 20. 2 ± 7. 4 cm / s and 19. 4 ± 9. 9 cm / s respectively,MVs were 26. 2 ± 8. 3 cm / s and26. 0 ± 10. 8 cm / s respectively,and PIs were 0. 9 5 ± 0. 1 5 and 0. 9 4 ± 0. 2 2 respectively. There were no significant differences between both of them（ all P〈0. 0 5）. No monitoring-related complications occurred.（ 3） Head CT after procedure revealed that all cases did not have cerebral infarction. At 1 week after procedure,CTA or DSA revealed that the parent arteries and the branch vessels were preserved well,they were patent,and the aneurysms disappeared. Conclusions MDU has the characteristics of safe,reliable,and easy to operate. This technique is helpful to find the inadvertent clipping or incomplete clipping of aneurysms in order to the timely adjustment of the positions of aneurysm clips and improving the efficacy of surgery.