急性期和慢性期颈内动脉闭塞患者侧支循环类型对颅内血流灌注的影响

Effects of collateral circulation types on intracranial blood perfusion in patients with acute and chronic internal carotid artery occlusion

目的 探索急性期和慢性期颈内动脉闭塞(ICAO)患者侧支循环对颅内血流灌注的影响。方法 回顾性连续纳入2017年9月至2021年10月因脑梗死于首都医科大学宣武医院神经内科或神经外科住院的ICAO患者386例,根据患者出现临床症状到入院治疗的时间间隔,将其分为急性期组(≤4周)和慢性期组(>4周)。联合应用颈动脉彩色多普勒超声与经颅彩色多普勒超声对两组患者颅内血流动力学和侧支循环类型进行检测,同时应用血管造影检查侧支循环的开放情况,并对超声检查与血管造影的结果进行一致性检验。收集两组患者性别、年龄、身高、体质量、脑血管病危险因素(高血压病、糖尿病、高脂血症、吸烟、心房颤动、脑梗死、冠心病)及血管超声参数[管腔内径、收缩期峰值流速(PSV)、舒张期末流速(EDV)、侧支循环开放情况(侧支循环数量、开放类型)],并进行组间比较;对不同侧支(前交通动脉、后交通动脉、颈内-颈外动脉侧支)开放与否的血管超声参数进行比较。计算超声检查对不同侧支循环开放类型的敏感度、特异度、准确度。结果 (1)386例ICAO患者中,急性期组165例,慢性期组221例。急性期组ICAO男性比例低于慢性期组,冠心病比例高于慢性期组,组间差异均有统计学意义(均P<0.05)。年龄、高血压病、糖尿病、高脂血症、吸烟、心房颤动、脑梗死、体质量指数的差异均无统计学意义(均P>0.05)。(2)超声检查显示,慢性期组后交通动脉开放率高于急性期组[52.5%(116/221)比40.0%(66/165),χ^(2)=5.913,P=0.015]。急性期组侧支循环开放数量主要为1~2支,占比分别为33.3%(55/165)、52.1%(86/165);而慢性期组侧支循环开放数量主要为1~3支,占比分别为24.0%(53/221)、53.4%(118/221)、19.0%(42/221),侧支循环数量分布的组间差异有统计学意义(χ^(2)=11.394,P=0.010)。(3)超声检查显示前交通动脉、后交通动脉、颈内-颈外侧支循环开放与血管造影检查结果的一致性检验Kappa值分别为0.544(P<0.01)、0.604(P<0.01)和0.656(P<0.01)。超声检查前交通动脉的敏感度、特异度、诊断准确率分别为77.4%(236/305)、92.6%(75/81)、80.6%(311/386),超声检查后交通动脉的敏感度、特异度、诊断准确率分别为79.8%(142/178)、80.8%(168/208)、80.3%(310/386),超声检查颈内-颈外侧支循环的敏感度、特异度、诊断准确率分别为97.6%(200/205)、66.9%(121/181)、83.2%(321/386)。(4)386例ICAO患者中,前交通动脉开放者患侧大脑中动脉PSV、EDV均高于未开放者,二者差异均有统计学意义[PSV:63.00(48.00,83.00) cm/s比50.50(40.00,69.50) cm/s,Z=-4.955;EDV:35.00(27.75,46.25) cm/s比29.00(23.00,35.75) cm/s,Z=-4.804;均P<0.01];前交通动脉开放者患侧大脑中动脉搏动指数与未开放者的差异无统计学意义(P>0.05);后交通动脉开放者患侧大脑中动脉PSV、EDV、搏动指数与未开放者的差异均无统计学意义(均P>0.05);颈内-颈外动脉侧支开放者患侧大脑中动脉PSV、EDV、搏动指数与未开放者的差异均无统计学意义(均P>0.05)。结论 急性期与慢性期ICAO患者侧支循环的开放类型和数量存在差异性,超声检查与血管造影对侧支循环的检查结果的一致性较好,前交通动脉的开放对于ICAO患者颅内灌注的影响最大。

Objective To explore the effects of collateral circulation on intracranial blood perfusion in acute and chronic internal carotid artery occlusion(ICAO) patients.Methods A total of 386 ICAO patients hospitalized in the Department of Neurology or Neurosurgery of Xuanwu Hospital,Capital Medical University for cerebral infarction from September 2017 to October 2021 were retrospectively and consecutively enrolled.The patients were divided into acute stage group(≤4 weeks) and chronic stage group(>4 weeks).Carotid color Doppler ultrasound and transcranial color Doppler ultrasound were combined to detect intracranial hemodynamics and collateral circulation types of patients in the two groups.Meanwhile,the opening of collateral circulation was examined by angiography,and the consistency of ultrasound and angiography results was tested.Information including sex,age,height,body mass,and cerebrovascular disease risk factors(hypertension,diabetes,hyperlipidemia,smoking,atrial fibrillation,cerebral infarction,coronary heart disease) and vascular ultrasound parameters(lumen diameter,peak systolic velocity [PSV],end diastolic velocity [EDV],collateral circulation opening [amount and opening type]) were collected and compared between the two groups of patients.The ultrasonic parameters of different branches(anterior communicating artery [ACoA],posterior communicating artery [PCoA],internal-external carotid artery [E-I]) were compared.The sensitivity,specificity and accuracy of ultrasonic examination for different collateral circulation opening types were calculated.Results(1) Among 386 cases of ICAO,165 cases were in acute stage group and 221 cases were in chronic stage group.The proportion of male ICAO in acute stage group was lower than that in chronic stage group,and the proportion of coronary heart disease was higher than that in chronic stage group,with statistical significance(both P<0.05).There were no significant differences in age,hypertension,diabetes,hyperlipidemia,smoking,atrial fibrillation,cerebral infarction and body mass index(all P>0.05).(2) Ultrasound examination showed the rate of PCoA opening in chronic group was higher than that in acute group(52.5% [116/221] vs.40.0% [66/165],χ~2=5.913,P=0.015).The number of collateral circulation opening in acute stage group was mainly 1 to 2,accounting for 33.3%(55/165) and 52.1%(86/165),respectively.The number of collateral circulation in chronic stage group was mainly 1-3,accounting for 24.0%(53/221),53.4%(118/221) and 19.0%(42/221),respectively.There was significant difference in the distribution of collateral circulation between groups(χ~2=11.394,P=0.010).(3) The Kappa values of ultrasonography and angiography was 0.544(P<0.01),0.604(P<0.01) and 0.656(P<0.01) for detection of the opening of ACoA,PCoA,E-I.The sensitivity,specificity and diagnostic accuracy of ultrasonography examined ACoA was 77.4%(236/305),92.6%(75/81) and 80.6%(311/386),respectively.The sensitivity,specificity and diagnostic accuracy of ultrasonography examined PCoA was 79.8%(142/178),80.8%(168/208) and 80.3%(310/386).The sensitivity,specificity and diagnostic accuracy of ultrasonography examined E-I was 97.6%(200/205),66.9%(121/181) and 83.2%(321/386),respectively.(4) In 386 cases of ICAO patients,PSV and EDV of the affected middle cerebral artery in patients with ACoA were higher than those without ACoA opening,and the differences were statistically significant(PSV:63.00 [48.00,83.00] cm/s vs.50.50 [40.00,69.50] cm/s,Z=-4.955;35.00 [27.75,46.25] cm/s vs.29.00 [23.00,35.75] cm/s,Z=-4.804;all P<0.01);There was no significant difference in the pulsatile index between patients with ACoA opening and those without ACoA opening(P>0.05).There were no significant differences in PSV,EDV and pulse index between patients with PCoA opening and those without PCoA opening(P>0.05).There were no significant differences in PSV,EDV and pulsatile index between patients with E-I opening and those without(P>0.05).Conclusions There are differences in the types and quantities of collateral circulation opening between acute and chronic ICAO patients.The results of ultrasound examination and angiography on collateral circulation are consistent.The opening of ACoA has the greatest influence on intracranial perfusion in ICAO patients.