微型探头血管超声在颞浅动脉-大脑中动脉搭桥术中的应用

Application of microprobe vascular Doppler in STA-MCA bypass intraoperation

目的探讨微型探头血管超声（MVD）评估单侧症状性颈内动脉闭塞（SICAO）行颞浅动脉-大脑中动脉（STA—MCA）搭桥术中吻合血管通畅的可靠性及有效性。方法回顾性纳入2012年7月至2016年5月苏州大学附属第一医院神经外科经数字减影血管造影（DSA）及CT灌注成像（CTP）确诊为SICAO的50例患者。运用MVD评估STA-MCA术中MCAM4段及STA的血流动力学参数；术后行CTP及DSA评估缺血区的灌注情况以及吻合血管的通畅性；术后6～12个月随访记录再发性卒中，并用改良Rankin量表评分（mRS）评估患者的神经功能恢复情况。结果（1）术中：MVD显示吻合后M4段血流速度增快、搏动指数升高（均P〈0．001），且吻合口近段M4血流方向逆转；STA血流速度增快、搏动指数降低（均P〈0．001），且呈“颅内动脉化”血流频谱改变。（2）术后7d：颈部血管超声显示STA起始部直径增粗且血流量增加（P〈0．05）；STA血流速度明显增快、阻力指数明显减低（P〈0．05）；CTP显示基底核区相对脑血流量升高，相对平均通过时间、相对达峰时间降低（均P〈0．05）；（3）术后6个月：DSA证实96％（48／50）的患者吻合血管通畅；（4）再发性卒中和神经功能评价：96％（48／50）的患者术后mRS评分较术前减低或不变，48例吻合通畅的患者术后无再发性卒中。结论MVD可简便、无创、实时动态地评估STA．MCA术中的血流动力学改变，STA呈“颅内动脉化”血流频谱是判断吻合血管通畅的可靠指标。

Objective To assess the reliability and efficacy of microprobe vascular Doppler（MVD） evaluating the pateney of anastomotic vessels in patients with unilateral symptomatic carotid artery occlusion （SICAO） undergoing superficial temporal artery to middle cerebral artery bypass surgery （STA-MCA bypass）. Methods Total 50 cases of SICAO patients from July 2012 to May 2016 at Department of Neurosurgery, the First Affiliated Hospital of Soochow University, confirmed by DSA and CT perfusion were treated with STA-MCA bypass surgery. The hemodynamics parameters of M4 segment of middle cerebral artery（MCA） and superficial temporal artery （STA） were evaluated by MVD intraoperation. Postoperative CTP and DSA examinations were performed to evaluate the perfusion of the isehemic area and the pateney of anastomotic vessels. Recurrent stroke was recorded 6 - 12 months after operation and neurological recovery was assessed by modified Rankin scale（mRS）. Results （ 1 ） Intraoperation： MVD revealed the blood flow velocity of MCA M4 segment and the pulsatility index（PI） increased（ all P 〈 0. 001 ） and the flow direction of M4 proximal was reversed. The blood flow velocity of STA increased but the PI sharply decreased （ all P 〈 0. 001 ） and it appeared ＂intracranial arterial spectrum＂. （ 2 ） Seven days after operation ： Carotid Doppler ultrasonography （CDU） revealed the diameter and the blood flow volume of STA anterior to the tragus obviously increased （ P 〈 0. 05 ）. CTP revealed the rCBF of basal ganglia level increased, the rMTT and rTTP decreased and the difference were statistically significant （ all P 〈 0.05 ）. （ 3 ） Six months after operation ： DSA revealed the patency of anastomotic vessels access 96% （48/50）. （4） Evaluation of recurrent stroke and neurological function： The postoperative mRS score decreased or unchanged in 96% （48/50）of the patients. No recurrent stroke was found in 48 patients with the patency of anastomotic vessels. Conclusions MVD can evaluate hemodynamic changes in STA-MCA bypass surgery in a simple, no-invasive and dynamic way. When STA showing the ＂ Intracranial arterial spectrum＂ is a reliable index to judge the patency of anastomotie vessels.