儿童缺血型烟雾病合并后循环病变与脑梗死的关系研究

Study on the relationship between post-circulatory lesions and cerebral infarction in children with ischemic moyamoya disease

目的探讨儿童缺血型烟雾病合并后循环病变与脑梗死的关系及其预后。方法回顾性纳入2010年1月至2018年12月天津医科大学总医院神经外科收治的44例儿童缺血型MMD患者,根据是否合并脑梗死将其分为脑梗死组(15例)和非脑梗死组(29例);其中3例行脑-颖肌贴敷术(EMS),5例行颛浅动脉-大脑中动脉(STA-MCA)吻合术,36例行EMS + STA-MCA吻合术。术后对所有患儿行门诊或电话随访,包括询问患儿临床症状的改善情况、判断是否有脑梗死事件发生,行改良Rankin量表评分(mRS)评估预后。比较两组患儿疗效,进一步通过单因素和多因素logistic回归分析影响患儿发生脑梗死的临床因素。结果44例患儿的手术均成功。术后12例(27. 3%, 12/44)出现并发症,两组并发症发生率的差异无统计学意义[脑梗死组为40. 0%(6/15),非脑梗死组为28. 7%(6/29),P =0.615]。44例患儿的随访时间为(7.2± 1.5)个月(6~12个月)。随访期间,无一例患儿发生新发脑梗死;35例(79.5%)预后良好,9例(20.5%)预后不良;两组患儿预后良好率的差异无统计学意义[脑梗死组为66. 7%(10/15),非脑梗死组为86. 3%(25/29),P =0. 130]。单因素分析结果显示,合并大脑中动脉、大脑后动脉狭窄及术前出现短暂性脑缺血发作是患儿发生脑梗死的影响因素(均P<0.05),进一步多因素logistic回归分析结果显示,合并大脑后动脉狭窄是患儿发生脑梗死的独立危险因素(0R=5.465,95% CI:l.224 - 24.400,P=0.026)c结论缺血型烟雾病患儿合并大脑后动脉狭窄是发生脑梗死的独立危险因素,出现脑梗死对患儿预后无明显影响。

Objective To explore the relationship between post-circulatory lesions and cerebral infarction in children with ischemic moyamoya disease ( MMD ). Methods A total of 44 children with ischemic MMD who were admitted to Department of Neurosurgery, Tianjin Medical University General Hospital from January 2010 to December 2018 were retrospectively enrolled into this study. All of them were divided into cerebral infarction group ( 15 cases) and non-cerebral infarction group (29 cases) according to whether they had cerebral infarction or not. Three cases were treated with encephalo-myosynangiosis (EMS), 5 cases with superficial temporal artery-middle cerebral artery anastomosis bypass ( STA-MCA bypass) and 36 cases with EMS + STA-MCA. All children were followed up by outpatient visits or telephone and were asked about the improvement of clinical symptoms and whether there were any cerebral infarction events. The outcome was assessed by the modified Rankin scale score ( mRS). The clinical efficacy was compared between the 2 groups of children. The clinical factors affecting the children with cerebral infarction were further analyzed by single factor and multiple factor logistic regression. Results All 44 patients underwent successful operation. Postoperative complications occurred in 12 cases (27. 3%, 12/44). There was no statistically significant difference in the incidence of complications between 2 groups [40. 0%(6/ 15) vs. 2& 7%(6/29), P = 0. 615 ]. The follow-up duration of 44 cases was 7. 2 ±1.5 months (6 - 12 months). During the follow-up period, none of the children had cerebral infarction. Among the 44 cases,35 (79. 5%) had good outcomes and 9 (20. 5%) had poor outcomes. There was no statistically significant difference in the favorable prognosis rate between the 2 groups [66. 7%( 10/15) vs. 86. 3%( 25/29 ), P =0. 130]. Single factor analysis showed that MCA stenosis, PCA ( posterior cerebral artery) stenosis and transient ischemic attack before operation were the influencing factors of cerebral infarction in children ( all P < 0. 05). Further multiple factor analysis showed that PCA stenosis was an independent risk factor for cerebral infarction in children ( OR = 5. 465 , 95% C/: 1.224 - 24. 400, P = 0. 026). Conclusion In children with ischemic MMD, PCA stenosis is an independent risk factors for cerebral infarction, and whether there is cerebral infarction has no significant effect on the prognosis of those children.