不同手术方法治疗成人蛛网膜下腔出血型烟雾病效果分析

Different surgical methods for adult subarachnoid hemorrhagic moyamoya disease

目的比较成人蛛网膜下腔出血型烟雾病患者采用不同手术方式治疗的效果及安全性,探讨适宜的手术方式。方法成人蛛网膜下腔出血型烟雾病患者60例,行颞浅动脉-大脑中动脉吻合术20例为直接手术组,行脑-硬脑膜-肌肉血管融合术16例为间接手术组,行颞浅动脉-大脑中动脉吻合联合脑-硬脑膜-肌肉血管融合术24例为联合手术组。比较3组烟雾病家族史、合并症以及入院时SUZUKI分期等临床资料;分别于术前3 d及术后3个月评定3组改良Rankin量表(modified Rankin scale,mRS)评分;分别于术前及术后3个月行头颅CT灌注成像检查,记录3组脑皮质灌注相对脑血流量(relative cerebral blood flow,rCBF)、相对脑血流容量(relative cerebral blood volume,rCBV)、平均通过时间(mean transit time,MTT);比较3组术后脑高灌注综合征、脑梗死、颅内再出血、癫痫、伤口愈合不良等并发症发生情况。结果3组年龄,SUZUKI分期,男性、有烟雾病家族史、吸烟、嗜酒及合并糖尿病、高血压比率比较差异均无统计学意义(P>0.05)。直接手术组、间接手术组、联合手术组术后3个月mRS评分[(0.450±0.082)、(1.438±0.459)、(0.458±0.078)分]均低于术前3 d[(2.000±0.589)、(2.000±0.789)、(1.833±0.659)分](P<0.05),直接手术组、联合手术组低于间接手术组(P<0.05)。直接手术组、间接手术组、联合手术组术后3个月rCBF[(1.11±0.16)、(1.06±0.51)、(1.13±0.11)mL/(min·100 g)]均高于术前[(0.79±0.12)、(0.80±0.32)、(0.81±0.10)mL/(min·100 g)](P<0.05),MTT[(4.34±0.48)、(4.70±0.38)、(4.31±0.50)s]均低于术前[(6.28±0.38)、(6.33±0.54)、(6.31±0.48)s](P<0.05);直接手术组、联合手术组术后3个月rCBF均高于间接手术组(P<0.05),MTT均低于间接手术组(P<0.05);3组术前及术后3个月rCBV比较差异均无统计学意义(P>0.05)。直接手术组、联合手术组术后脑高灌注综合征发生率(40.0%、41.7%)高于间接手术组(6.3%)(P<0.05)、颅内再出血发生率(5.0%、8.3%)低于间接手术组(37.5%)(P<0.05),直接手术组与联合手术组比较差异无统计学意义(P>0.05);3组术后脑梗死、癫痫、头皮愈合不良发生率比较差异均无统计学意义(P>0.05)。结论成人蛛网膜下腔出血型烟雾病患者行颞浅动脉-大脑中动脉吻合术、颞浅动脉-大脑中动脉吻合联合脑-硬脑膜-肌肉血管融合术可改善神经功能,增加脑血流量,降低术后颅内出血率,但脑高灌注综合征发生率增高。

Objective To compare the outcome and safety of different surgical methods in the treatment of subarachnoid hemorrhagic moyamoya disease(MMD),and to explore the appropriate surgical method.Methods In 60 adult patients with subarachnoid hemorrhagic MMD,20 received superficial temporal artery-middle cerebral artery anastomosis(STA-MCA)(direct surgery group),16 received encephaloduromyosynangiosis(EDMS)(indirect surgery group),and 24 received STA-MCA+EDMS(combined surgery group).The family history of MMD,complications and SUZUKI stage at admission were compared among three groups.The modified Rankin scale(mRS)scores of three groups were assessed 3 d before surgery and 3 months after surgery,respectively.Cerebral CT perfusion imaging was performed before and 3 months after surgery,respectively.The relative cerebral blood flow(rCBF),relative cerebral blood volume(rCBV)and mean transit time(MTT)were recorded,and the postoperative incidences of complications such as cerebral hyperperfusion syndrome,cerebral infarction,intracranial rehemorrhage,epilepsy and poor wound healing were compared among three groups.Results There were no significant differences in the age,SUZUKI stage,and percentage of male patients and patients with family history of MMD,smoking,alcohol addiction,diabetes mellitus and hypertension among three groups(P>0.05).The mRS scores in direct surgery group,indirect surgery group and combined surgery group were lower 3 months after surgery(0.450±0.082,1.438±0.459,0.458±0.078)than those 3 d before surgery(2.000±0.589,2.000±0.789,1.833±0.659)(P<0.05),and were lower in direct surgery group and combined surgery group than those in indirect surgery group(P<0.05).The rCBFs were greater 3 months after surgery in direct surgery group,indirect surgery group and combined surgery group[(1.11±0.16),(1.06±0.51),(1.13±0.11)mL/(min·100 g)]than those before surgery[(0.79±0.12),(0.80±0.32),(0.81±0.10)mL/(min·100 g)](P<0.05),and greater in direct surgery group and combined surgery group than those in indirect surgery group 3months after surgery(P<0.05).The MTTs were shorter 3 months after surgery in direct surgery group,indirect surgery group and combined surgery group[(4.34±0.48),(4.70±0.38),(4.31±0.50)s]than those before surgery[(6.28±0.38),(6.33±0.54),(6.31±0.48)s](P<0.05),and shorter in direct surgery group and combined surgery group than those in indirect surgery group 3 months after surgery(P<0.05).There were no significant differences in rCBV among three groups both before surgery and 3 months after surgery(P>0.05).The incidence of cerebral hyperperfusion syndrome was higher in direct surgery group(40.0%)and combined surgery group(41.7%)than that in indirect surgery group(6.3%)(P<0.05),the incidence of intracranial rebleeding was lower in direct surgery group(5.0%)and combined surgery group(8.3%)than that in indirect surgery group(37.5%)(P<0.05),and there were no significant differences between direct surgery group and combined surgery group(P>0.05).There were no significant differences in the incidences of cerebral infarction,epilepsy and poor scalp healing among three groups(P>0.05).Conclusion Both STA-MCA and STA-MCA+EDMS can improve the nerve function,increase cerebral blood flow,and reduce the incidence of postoperative intracranial hemorrhage in the treatment of adult subarachnoid hemorrhagic MMD,but the incidence of cerebral hyperperfusion syndrome is high.