血管重建术对不同类型烟雾病患者卒中复发及功能预后的影响

Effects of revascularization surgery on stroke recurrence and functional outcomes in different types of moyamoya diseases

目的探讨血管重建术对不同类型烟雾病(moyamoya diseases,MMD)患者卒中复发及功能预后的影响,并分析影响卒中复发及功能预后的因素。方法纳入2010年1月至2016年6月于复旦大学附属华山医院神经外科住院诊治的MMD患者,收集基本临床资料,电话随访卒中复发情况、生存情况、随访时mRS评分等。将所有烟雾病患者分为缺血型及出血型两组,并根据治疗方法分别分为手术组及保守组。采用Cox回归分析血管重建术对不同类型MMD患者卒中复发及功能预后的影响。结果共435例患者完成随访,中位随访时间为21个月(4~88个月)。缺血型MMD患者共265例(手术组221例),出血型共170例(手术组151例)。缺血型手术组卒中复发率明显低于保守组(P=0.011);出血型手术组与保守组之间卒中复发率无明显差异(P=0.966);出血型手术组脑出血复发率较缺血型手术组患者更高(P<0.001)。Cox多因素回归分析提示发病年龄与卒中复发风险相关(P=0.019)。缺血型及出血型手术组随访时mRS评分较基线均有所改善(P<0.001);但相比缺血型,出血型手术组mRS评分改善更明显(P=0.001)。COX多因素回归分析发现发病年龄、糖尿病、基线mRS评分及卒中复发与功能预后不良相关。结论缺血型MMD患者行血管重建术可减少卒中复发;出血型MMD患者血管重建术后脑出血复发率较高,但功能预后改善明显。发病年龄可影响卒中复发风险;发病年龄、糖尿病、卒中复发及基线mRS评分可影响缺血型和出血型MMD患者的功能预后。

Objective To assess the effects of revascularization surgery on stroke recurrence and outcomes in patients with different types of moyamoya diseases （MMD） and analyze the prognostic factors. Methods Consecutive patients with MMD admitted to Huashan Hospital from Jan., 2010 to Jun. , 2016 were reviewed in current study. Baseline clinical data were collected. Follow-up was conducted via telephone reviews to gather information about stroke recurrence, survival, modified Rankin Scale （mRS） score, etc. All the patients were divided into ischemic group and hemorrhagic group according to stroke types, and separately divided into bypass and conservative group according to treatment. The effects of revascularization on stroke recurrence and functional outcomes among different types of MMD patients were analyzed using Cox regression. Results Follow-up was completed among 435 patients. The median follow-up time was 21 months （4-88 months）. The ischemic MMD group comprised 265 patients, of which 221 cases underwent revascularization; The hemorrhagic group comprised 170 cases with 151 cases surgically treated. Postoperative stroke recurrence rate of ischemic MMD patients in bypass group （2. 6%） was lower than that in conservative group （13. 6%） （P=0. 011）. While no statistical difference of postoperative stroke recurrence rate was found between bypass and conservative group of hemorrhagic MMD patients （P=0. 966）; bypass group in hemorrhagic MMD patients had a higher cerebral hemorrhage recurrence rate than those in ischemic MMD patients （P〈0. 001）. Multivariate Cox regression showed that onset age was an independent risk factor for stroke recurrence （P=0. 019）. It demonstrated that mRS score definitely improved at follow-up in both groups （P〈0. 001）; compared with ischemic MMD patients, the mRS score had a more significantly improvement in the bypass group of hemorrhagic MMD patients （P=0. 001）. Multivariate Cox regression showed that onset age, diabetes, baseline mRS score and stroke recurrence were significantly associated with poor function outcome. Conclusions Revascularization surgery can significantly reduce stroke recurrence for ischemic MMD patients. Hemorrhagic MMD patients have a higher cerebral hemorrhage recurrence rate after revascularization but show an improvement in functional outcome. Onset age can influence the risk of stroke recurrence; Onset age, diabetes, baseline mRS score and stroke recurrence are prognostic factors among ischemic and hemorrhagic MMD patients after surgical treatment.