大脑中动脉慢性闭塞患者脑血流动力学参数与脑梗死体积的相关性研究

Correlation between cerebral hemodynamic parameters and cerebral infarction volume in patients with chronic middle cerebral artery occlusion

目的探讨单侧大脑中动脉慢性闭塞(CMCAO)患者大脑中动脉(MCA)区域血流动力学参数与脑梗死体积的相关性。方法回顾性连续纳入2015年10月至2018年7月就诊于苏州大学附属第一医院神经内科、神经外科,经颅多普勒超声(TCD)确诊为单侧CMCAO的患者43例,行数字减影血管造影(DSA)评估软脑膜侧支(LMA)分级并将患者分为LMA良好组(26例,3~4级)和LMA不良组(17例,0~2级)。TCD和(或)经颅彩色多普勒超声(TCCS)检测并记录健侧(c)及患侧(i)MCA平均流速(MV),计算健侧与患侧MCA的MV比值(MVcMCA/MViMCA)。根据磁共振弥散加权成像(DWI)检查结果计算脑梗死体积,并将43例患者分为无梗死、小体积、中体积及大体积梗死组。分别比较LMA良好组与不良组之间一般资料、实验室检查、临床症状、MCA流速及脑梗死体积的差异,采用Spearman秩相关分析MCA流速与脑梗死体积的相关性。结果2组患者临床症状表现差异有统计学意义(P=0.031),LMA良好组卒中比例显著低于LMA不良组[15(57.7%)vs16(94.1%)],且无症状患者比例显著高于LMA不良组[5(19.2%)vs0(0)]。LMA良好组的MViMCA显著高于LMA不良组[(40.15±12.32)vs(20.82±6.73)],MVcMCA/MViMCA低于LMA不良组[1.38(1.12,1.65)vs2.60(2.12,3.05)],差异均有统计学意义(t=-5.900、Z=-4.434,P均<0.001)。LMA良好组无梗死及小体积梗死患者比例较高,LMA不良组中体积及大体积梗死患者比例较高,LMA良好组与不良组脑梗死体积分布差异有统计学意义(Z=-3.518,P<0.001)。脑梗死体积与MViMCA呈中度负相关(r=-0.574,P<0.001),与MVcMCA/MViMCA呈中度正相关(r=0.615,P<0.001);LMA不良组脑梗死体积与MViMCA呈中度负相关(r=-0.621,P=0.008),与MVcMCA/MViMCA呈高度正相关(r=0.721,P=0.001)。结论MCA区域流速与脑梗死体积明显相关,可以通过检测脑血流动力学变化,直接评估LMA逆向血流代偿以及MCA区域血流代偿情况,间接反映患者脑梗死病灶体积大小,从而为个体化诊疗方案的制定以及患者随访提供可靠、实时、动态的评估依据。

Objective To investigate the correlation between hemodynamic parameters in the middle cerebral artery region and cerebral infarction volume in patients with chronic middle cerebral artery occlusion (CMCAO).Methods From October 2015 to July 2018,43 consecutive patients diagnosed with unilateral CMCAO by transcranial Doppler (TCD) at the neurology and neurosurgery department were enrolled retrospectively.The leptomeningeal anastomosis (LMA) grades were assessed by digital subtraction angiography (DSA) and all patients were divided into a good LMA group (n=26,grades 3~4) or a poor LMA group (n=17,grades 0~2).TCD and/or transcranial color-coded sonography (TCCS) were used to measure and record the mean velocity (MV) of the contralateral and ipsilateral MCA,and the ratios of bilateral MV of MCA were calculated (MVcMCA/MViMCA).According to the results of magnetic resonance diffusion weighted imaging (DWI),the patients were divided into four groups,including no infarction,small volume,medium volume,and large volume of cerebral infarction.The differences in general data,laboratory tests,clinical symptoms,and MCA flow velocity between the good and poor LMA group were compared,and Spearman rank correlation analysis was used to analyze the correlation between MCA flow parameters and the cerebral infarction volume.Results The difference in the clinical symptoms of the two groups was statistically significant (P=0.031).The proportion of stroke patients in the good LMA group was significantly lower than that in the poor LMA group [15(57.7%) vs 16(94.1%)],and the proportion of asymptomatic patients was significantly higher that in the poor LMA group [5 (19.2%) vs 0 (0%)].The MViMCA in the good LMA group was significantly higher than that in the poor LMA group [(40.15±12.32) vs (20.82±6.73),t=-5.900, P<0.001],and the MVcMCA/MViMCA ratio was lower than that of the poor LMA group [1.38 (1.12,1.65) vs 2.60 (2.12,3.05),Z=-4.434,P < 0.001].The proportion of patients with no cerebral infarction or small volume infarction was significantly higher in the good LMA group,while the proportion of patients with moderate and large volume cerebral infarction was significantly higher in the poor LMA group.There was a statistically significant difference in the distribution of cerebral infarction between the two groups (Z=-3.518,P < 0.001). Cerebral infarction volume had a moderate negative correlation with MViMCA (r=-0.574,P < 0.001),and a moderate positive correlation with MVcMCA/MViMCA (r=0.615,P < 0.001).The cerebral infarction volume in the poor LMA group was moderately negatively correlated with MViMCA (r=-0.621,P=0.008),and highly positively correlated with MVcMCA/MViMCA (r=0.721,P=0.001).Conclusion The flow velocity in the MCA significantly correlates with the volume of cerebral infarction.Using TCD or TCCS to detect cerebral hemodynamic changes can directly evaluate reverse blood flow compensation like LMA and blood flow compensation in the MCA,and indirectly reflect the size of the brain infarction in patients,thus providing a reliable,real-time,dynamic assessment basis for the formulation of individualized treatment protocols and follow-up.