成人烟雾病直接脑血运重建术中侧裂周围皮质动脉血流动力学改变对术后过度灌注综合征的影响

Effects of intraoperative hemodynamics of parasylvian cortical arteries on the cerebral hyper-perfusion syndrome after direct cerebral revascularization in adults with moyamoya disease

目的基于术中微血管多普勒超声(MDU)监测的侧裂周围皮质动脉血流动力学参数,研究成人烟雾病直接脑血运重建术后过度灌注综合征(CHS)的危险因素。方法回顾性分析2020年9月至2021年5月南京大学附属鼓楼医院神经外科行颞浅动脉-大脑中动脉搭桥手术的92例(97例次手术)成人烟雾病患者的临床资料。所有患者术中均使用MDU采集侧裂周围皮质动脉的血流动力学指标,包括受体动脉的血流方向、受体动脉和搭桥血管的平均血流速度(MSV)等,计算MSV增加倍数,即术后MSV/术前MSV。根据术后有无CHS将患者分为CHS组与非CHS组,比较两组患者的临床资料及血流动力学指标。将单因素分析中P<0.1的因素纳入多因素logistic回归分析(逐步法),判断CHS的危险因素。结果97例次手术中,7例次(7.2%)术后发生CHS(CHS组),余90例次(92.8%)未出现CHS(非CHS组)。与非CHS组比较,CHS组患者Suzuki分期晚期者占比高,搭桥前受体动脉MSV低,搭桥后指向皮质和指向侧裂的受体动脉MSV增加倍数均高,差异均具有统计学意义(均P<0.05)。多因素logistic回归分析结果显示,术前Suzuki分期晚(OR=11.82,95%CI:2.05~68.19,P=0.006)和搭桥后指向侧裂的受体动脉MSV增加倍数高(OR=8.33,95%CI:2.01~34.45,P=0.003)均是术后发生CHS的危险因素。结论Suzuki分期晚期、搭桥后指向侧裂的受体动脉MSV增加倍数高的成人烟雾病患者直接血运重建术后更易发生CHS,术中MDU定量分析有助于评估血流动力学改变和预测术后CHS的发生。

Objective To explore the risk factors of cerebral hyperperfusion syndrome(CHS)based on intraoperative hemodynamics of parasylvian cortical arteries(PSCAs)measured by microvascular Doppler ultrasound(MDU)in adults with moyamoya disease(MMD)treated by direct bypass.Methods A consecutive of 92 adult patients(97 hemispheres)underwent the superficial temporal artery-middle cerebral artery(STA-MCA)bypass at the Department of Neurosurgery,Nanjing Drum Tower Hospital Affiliated to Nanjing University between September 2020 and May 2021 and were retrospectively enrolled into this research.Intraoperative MDU was performed to evaluate hemodynamics of PSCAs,including flow direction,mean systolic value(MSV)of recipient artery(RA),MSV value of bypass grafting,and MSV folds of RA.MSV folds was defined as MSVpost/MSVpre.According to the diagnosis of CHS,cases were divided into CHS group and non-CHS group.Clinical data and intraoperative hemodynamics of two groups were compared.The variable of P<0.1 in univariate analysis were included into multivariate logistic regression analysis(step by step)to explore the risk factors of CHS.Results A total of 7(7.2%)cases in 97 hemispheres satisfied the criteria of postoperative CHS(CHS group),and the other 90 cases(92.8%)had no CHS(non-CHS group).Compared to cases without CHS,those with CHS had more advanced Suzuki stage,lower MSV of RA before surgery,and higher MSV change folds of RA both directing sylvian and cortex after surgery(all P<0.05).Multivariate analysis indicated that advanced Suzuki stage(OR=11.82,95%CI:2.05-68.19,P=0.006)and high MSV change folds of RA directing sylvian(OR=8.33,95%CI:2.01-34.45,P=0.003)were significantly associated with occurrence of CHS.Conclusions Advanced Suzuki stage and high MSV change folds of RA directing sylvian are risk factors for postoperative CHS.Quantitative analysis of intraoperative MDU is useful for evaluating hemodynamics and predicting postoperative CHS.