脑血运重建术在脑血管疾病治疗中的临床应用

发布时间：2018-07-05 16:33

本文选题：血运重建术 + 颅内外血管搭桥　；参考：《山东大学》2016年硕士论文

【摘要】：背景：目前对于烟雾病患者,保守治疗疗效不佳,治疗主要依赖于脑血运重建术。对于粥样硬化性颈动脉狭窄/闭塞的患者首选药物治疗,但部分患者最佳药物治疗后仍有频繁缺血发作,这部分患者可从脑血运重建术中获益。另外,对于颅内复杂动脉瘤等脑出血性疾病,虽然近年来显微神经外科和神经介入技术飞速发展,但仍有部分复杂动脉瘤患者无法通过手术夹闭或介入栓塞的方式得到治疗,脑血运重建术在这部分患者的治疗中也扮演着不可替代的作用。目的：探讨不同术式的脑血运重建术在烟雾病、慢性症状性ICA/MCA闭塞、颅内复杂动脉瘤的患者中的临床应用价值。方法：回顾性分析2013年7月至2016年2月至山东大学齐鲁医院神经外科就诊的99例行脑血运重建术的患者资料。其中烟雾病患者70例,给予症状侧STA-MCA搭桥术联合脑-硬脑膜-肌肉-血管融合术(EDMS);慢性症状性ICA/MCA闭塞患者17例,给予STA-MCA搭桥术；颅内复杂动脉瘤患者12例,根据不同动脉瘤特点分别给予个体化的血运重建术。并对所有患者的病例特点、治疗方法、围术期并发症进行了统计分析。另外,有48例慢性脑缺血的患者(36例烟雾病患者、12例慢性症状性ICA/MCA闭塞患者)和11例颅内复杂动脉瘤患者完成了中期随访,对随访患者的吻合血管通畅性、脑血流动力学改变、患者神经功能改变及动脉瘤改变情况进行了统计分析。结果：1、烟雾病和慢性症状性ICA/MCA闭塞：①术后6-12个月随访DSA提示44例／48例(92%)患者吻合血管通畅。其中烟雾病患者22例／36例(61%)颞肌下有不同程度的新生血管网形成并向皮层供血。②40例／48例(83%)患者CTP检查与术前相比rCBF得到改善,6例／48例(13%)rCBF不变,2例/48例(4%)rCBF恶化。③45例/48例(94%)未再发生与吻合侧半球相关的脑缺血或脑出血发作。20例/48例(42%)患者的mRs评分较术前降低,25例/48例(52%)患者的mRs评分与术前一样(包括12例0分的患者),3例/48例(6%)患者术后mRs评分较术前升高。④87例慢性脑缺血的患者中9例(10.3%)出现了不同形式的围术期并发症。2、复杂动脉瘤：①术后3-6个月随访DSA/CTA示10例/11例(91%)吻合血管通畅性良好。② DSA/CTA示所有(100%)随访的复杂动脉瘤均无复发和残留。③所有随访患者(100%)术后3-6个月内无新发神经功能损害的症状和体征。7例患者mRs评分下降,2例保持不变,2例由于围术期并发症mRs评分升高。④12例复杂动脉瘤患者中3例(25%)发生了围术期并发症。结论：1、STA-MCA搭桥+EDMS对成人烟雾病患者有良好的疗效,可改善其脑灌注和神经功能,预防卒中事件再发生。2、在伴有血流动力学障碍的慢性症状性ICA/MCA闭塞患者中,STA-MCA搭桥术可改善其脑灌注和神经功能,降低其潜在的卒中发生率。3、根据复杂动脉瘤的位置、形态、大小等特点进行个体化的血运重建术是一种治疗复杂动脉瘤的有效方法。
[Abstract]:Background: for moyamoya disease patients, conservative treatment is not good, the treatment mainly depends on cerebral revascularization. For patients with atherosclerotic carotid artery stenosis / occlusion, the first choice of drug treatment, but some patients still have frequent ischemic attacks after the best drug treatment, this part of patients can benefit from cerebral blood revascularization. In addition, although microneurosurgery and neurointerventional techniques have developed rapidly in recent years, some complicated aneurysms can not be treated by surgical clipping or interventional embolization. Cerebral revascularization also plays an irreplaceable role in the treatment of these patients. Objective: to evaluate the clinical value of different types of cerebral revascularization in patients with moyamoya disease, chronic symptomatic ICA / MCA occlusion and complicated intracranial aneurysms. Methods: from July 2013 to February 2016, the data of 99 patients undergoing cerebral revascularization in Qilu Hospital of Shandong University were analyzed retrospectively. Seventy patients with moyamoya disease were treated with symptomatic STA-MCA bypass grafting combined with brain-dural musculovascular fusion (EDMS), 17 patients with chronic symptomatic ICA / MCA occlusion and 12 patients with complicated intracranial aneurysms. Individual revascularization was performed according to the characteristics of different aneurysms. The characteristics, treatment methods and perioperative complications of all patients were analyzed statistically. In addition, 48 patients with chronic cerebral ischemia (36 patients with moyamoya disease and 12 patients with chronic symptomatic ICA / MCA occlusion) and 11 patients with complex intracranial aneurysms completed a mid-term follow-up. The changes of nerve function and aneurysm were analyzed statistically. Results after 6 to 12 months follow-up DSA showed that 44 / 48 (92%) patients with moyamoya disease and chronic symptomatic ICA / MCA / MCA: 1 had patency. Among them, 22 / 36 (61%) patients with moyamoya disease had varying degrees of neovascularization in the subtemporal muscle, and 240 / 48 (83%) patients had cortical blood supply. The CTP examination of patients with moyamoya disease was improved in 6 cases, 48 cases (13%) in 6 cases (13%), 2% in 48 cases. (4%) .345 cases of rCBF deterioration. 48 cases (94%) had no recurrence of cerebral ischemia or cerebral hemorrhage associated with anastomosing side hemispheres. 20 / 48 (42%) patients had the same MRS score as before operation (including 12 cases 0%), 25 cases / 48 cases (52%) had the same MRS score as before operation (including 12 cases 0%). MRS scores of 3 / 48 (6%) patients were higher than those before operation. Of the 487 patients with chronic cerebral ischemia, 9 (10.3%) had different forms of perioperative complications. 10 patients with complex aneurysms were followed up 3-6 months after operation with DSA-CTA. 11 cases (91%) with good vascular anastomosis. 2 DSA / CTA showed no recurrence of all (100%) complicated aneurysms and 3% (100%) all patients followed up without symptoms and signs of new neurological impairment within 3 to 6 months after operation. The score decreased in 2 cases and remained unchanged in 2 cases. Among 412 patients with complex aneurysms, 3 cases (25%) developed perioperative complications due to increased score of mRS in perioperative complications. Conclusion the EDMS graft with 1: 1 + STA-MCA has a good curative effect on adult moyamoya disease patients, and can improve the cerebral perfusion and nerve function of adult moyamoya disease patients. In patients with chronic symptomatic ICA / MCA occlusion with hemodynamic disorders, STA-MCA bypass grafting can improve cerebral perfusion and neurological function, and reduce the potential incidence of stroke by 0.3, depending on the location and shape of complex aneurysms. Individualized revascularization is an effective method for the treatment of complex aneurysms.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R651.12

【相似文献】