荧光造影在烟雾病颅内外血管搭桥术中的应用

Intraoperative fluorescent angiography application in intracranial-to-extracranial bypass surgery treatment for moyamoya disease

目的应用荧光造影技术于烟雾病(MMD)颅内外血管搭桥术中研究皮质脑血流动力学特点及致病机制。方法回顾性分析2019年6~12月苏州大学附属第一医院收治的28例缺血性MMD(MMD组)和16例动脉粥样硬化性脑血管疾病(ACVD组)所致烟雾综合征患者,均采用颞浅动脉-大脑中动脉(STA-MCA)搭桥术联合脑-硬膜-肌肉-动脉-颅骨周围组织血管融合术进行治疗。同时选取同期收治的5例未破裂动脉瘤患者作为对照组(均采用夹闭术进行治疗)。应用吲哚菁绿(ICG)荧光造影结合Flow 800软件分析搭桥术中吻合血管的畅通性、血流方向和“分水岭推移”现象;同时术中应用荧光素钠(NaFL)荧光造影评估NaFL外渗。比较各组患者外渗发生率及外渗程度。结果术中证实44例患者STA-MCA搭桥术的吻合口均通畅,42例为双向血流,2例为单向血流;2例MMD患者搭桥术中观测到大脑皮质“分水岭推移”现象。在对照组患者中未观察到外渗,27例(96.4%)MMD组患者和11例(68.8%)ACVD组患者搭桥术中出现NaFL外渗。MMD组患者NaFL外渗程度比ACVD组患者高,且差异有统计学意义(χ^(2)=8.92,P=0.03)。结论ICG联合Flow 800软件进行血流动力学分析有助于了解MMD患者颅内外血管搭桥术中复杂的皮质血流动力学变化,术中NaFL荧光造影证实MMD患者存在血脑屏障破坏。

Objective To investigate cortical hemodynamic characteristics and pathogenic mechanism using intraoperative fluorescent angiography after superficial temporal artery-middle cerebral artery(STA-MCA)bypass surgery in moyamoya disease(MMD).Methods The clinical data of 28 patients with MMD and 16 patients with atherosclerotic cerebrovascular disease(ACVD)were analyzed retrospectively.These patients were admitted in Department of Neurosurgery,the First Affiliated hospital of Soochow University between June 2019 and December 2019.The STA-MCA anastomosis with encephaloduro-myo-arterio-pericranio-synangiosis(EDMAPS)was used for cerebral revascularization.We used intraoperative indocyanine green(ICG)angiography with Flow 800 software to analyze check bypass patency,flow direction and the phenomenon of"watershed shift"in STA-MCA bypass surgery.The patients were divided into MMD group,ACVD group and control group(5 patients that underwent clipping for unruptured aneurysms).Sodium fluorescein(NaFL)extravasation was evaluated during videoangiography when checking for bypass patency.A grading system(0,+,++,+++)was used to define the extent of extravasation.Frequency and intensity of leakage was compared among different groups.Results During the operation,it was confirmed that the anastomosis of all the 44 cases of STA-MCA bypass surgery was patency,with 42 cases of two-way blood flow and 2 cases of one-way blood flow.The phenomenon of"watershed shift"was observed in the cerebral cortex of 2 patients with moyamoya disease during bypass surgery.NaFL extravasation was observed in none of the patients undergoing clipping for unruptured aneurysms.NaFL extravasation appeared in 27/28(96.4%)patients with MMD and in 11/16(68.7%)patients with ACVD during bypass procedures.The MMD group was characterized by a much greater intensity of NaFL extravasation(grade+++in 60.7%)than the ACVD group(grade+++in 25.0%,P<0.05).Conclusions Intraoperative ICG fluorescence angiography combined with hemodynamic parameter analysis obtained by Flow 800 software is an effective method to evaluate the complex hemodynamic characteristics after STA-MCA bypass surgery in moyamoya disease.Intraoperative NaFL fluorescence angiography confirmed the presence of blood-brain barrier disruption in moyamoya disease.It provides a new perspective to explore the pathogenic mechanism of moyamoya disease.