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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2017, Vol. 14 ›› Issue (06) : 433 -440. doi: 10.3877/cma.j.issn.1672-6448.2017.06.008

所属专题： 文献；

头颈部超声影像学

大脑中动脉重度狭窄或闭塞性病变脑膜支代偿对颅外段颈内动脉血流动力学的影响
李响1, 杨洁1, 贾凌云1, 赵新宇1, 华扬1,†()   
  1. 1. 100053　北京，首都医科大学宣武医院血管超声诊断科
  • 收稿日期:2017-01-14 出版日期:2017-06-01
  • 通信作者: 华扬

The effect of leptomeningealanastomoseson hemodynamic changes of extracranial internal carotid artery in middle cerebral artery severe stenosis and occlusion disease

Xiang Li1, Jie Yang1, Lingyun Jia1, Xinyu Zhao1, yang Hua1,†()   

  1. 1. Department of Vascular Ultrasonography, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
  • Received:2017-01-14 Published:2017-06-01
  • Corresponding author: yang Hua
  • About author:
    Corresponding author: Hua Yang, Email:
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李响, 杨洁, 贾凌云, 赵新宇, 华扬. 大脑中动脉重度狭窄或闭塞性病变脑膜支代偿对颅外段颈内动脉血流动力学的影响[J]. 中华医学超声杂志（电子版）, 2017, 14(06): 433-440.

Xiang Li, Jie Yang, Lingyun Jia, Xinyu Zhao, yang Hua. The effect of leptomeningealanastomoseson hemodynamic changes of extracranial internal carotid artery in middle cerebral artery severe stenosis and occlusion disease[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2017, 14(06): 433-440.

目的

探讨大脑中动脉（MCA）重度狭窄或慢性闭塞性病变患侧大脑前动脉（ACA）软脑膜动脉吻合对于颅外段颈内动脉（ICA）血流动力学的影响。

方法

选取2015年1月至12月颅多普勒超声（TCD）或经颅彩色多普勒超声（TCCS）诊断为一侧MCA重度狭窄或慢性闭塞并经数字减影血管造影（DSA）证实，且对侧MCA正常及双侧颅外段ICA管径正常或狭窄率<50%的患者186例，其中，MCA重度狭窄组患者88例，MCA慢性闭塞组患者98例，根据DSA检测结果，ACA存在软脑膜动脉吻合者72例，无软脑膜动脉吻合者114例。采用TCD和（或）TCCS及颈动脉彩色多普勒超声测量并记录患侧、健侧ACA的收缩期峰值流速（PSV）、舒张期末流速（EDV）、血管阻力指数（RI）测值，患侧、健侧颅外段ICA的PSV、EDV及RI测值，采用独立样本t检验及配对t检验比较2组患侧、健侧ACA与ICA的血流动力学参数，以及软脑膜动脉吻合患侧建立与否与ACA及ICA的血流动力学参数的差异。采用线性回归分析患侧ICA及ACA血流参数间的相关性。

结果

（1）MCA慢性闭塞组患侧ICA的PSV及EDV均较重度狭窄组明显减低，RI值明显升高[（71.27±17.84）cm/s vs（78.07±14.69）cm/s，（27.00±8.38）cm/s vs（32.01±7.83）cm/s，0.625±0.056 vs 0.591±0.057]，差异均有统计学意义（t=2.820、4.243、4.099，P均<0.01）。2组患者患侧ICA的PSV及EDV测值均显著低于健侧[PSV：（78.07±14.69）cm/s vs（85.26±17.42）cm/s，（71.27±17.84）cm/s vs（83.80±22.11）cm/s；EDV：（32.01±7.83）cm/s vs （34.50±7.36）cm/s，（27.00±8.38）cm/s vs （33.22±9.97）cm/s]，差异均有统计学意义（t=2.847、5.209、2.058、5.626，P均<0.05），慢性闭塞组患侧的RI值显著高于健侧（0.625±0.056 vs 0.601±0.076），差异有统计学意义（t=2.601，P<0.05），重度狭窄组两侧的RI值比较，差异无统计学意义（P>0.05）。（2）存在软脑膜动脉吻合时，2组患者患侧ACA的PSV及EDV均较无软脑膜动脉吻合时明显升高，RI值明显减低[PSV：（164.19±22.64）cm/s vs（97.56±19.17）cm/s，（168.95±28.03）cm/s vs（96.72±21.57）cm/s；EDV：（75.68±12.53）cm/s vs（42.65±10.03）cm/s，（79.93±13.73）cm/s vs（42.30±11.95）cm/s；RI：0.540±0.036 vs 0.564±0.043，0.526±0.037 vs 0.566±0.051]，差异均有统计学意义（t=14.604、14.416、13.492、14.444、2.727、4.250，P均<0.01）。2组内患、健侧比较，存在软脑膜动脉吻合时患侧ACA的PSV及EDV均较健侧明显升高，RI值较健侧明显减低[PSV：（164.19±22.64）cm/s vs（105.19±26.95）cm/s，（168.95±28.03）cm/s vs（97.90±24.18）cm/s；EDV：（75.68±12.53）cm/s vs（44.10±13.87）cm/s，（79.93±13.73）cm/s vs（41.83±10.88）cm/s；RI：0.540±0.036 vs 0.583±0.050，0.526±0.037 vs 0.572±0.037]，差异均有统计学意义（t=10.049、15.906、10.313、16.864、4.083、6.145，P均<0.01），无软脑膜动脉吻合时，患侧ACA血流参数与健侧比较，差异均无统计学意义（P均>0.05）。（3）MCA重度狭窄患者无软脑膜动脉吻合组患侧ICA的PSV、EDV及RI与软脑膜动脉吻合组比较，差异均无统计学意义（P均>0.05）。MCA慢性闭塞患者无软脑膜动脉吻合组患侧ICA的PSV及EDV较软脑膜动脉吻合组显著降低，RI值明显升高[（65.93±13.34）cm/s vs（78.68±20.64）cm/s，（23.98±6.30）cm/s vs（31.20±9.08）cm/s，0.638±0.055 vs 0.605±0.053]，差异均有统计学意义（t=3.713、4.647、2.925，P均<0.01）。（4）MCA重度狭窄组患侧ICA与ACA的血流参数间均无相关关系（P>0.05）。慢性闭塞组中患侧ICA的PSV与患侧ACA的PSV、EDV呈线性正相关（r=0.350、0.367，P均<0.01），患侧ICA的RI值与患侧ACA的PSV及EDV呈线性负相关（r=-0.550、-0.531，P均<0.01）。

结论

MCA重度狭窄或闭塞TCD或TCCS检测患侧ACA流速升高可提示软脑膜动脉吻合存在，软脑膜动脉吻合可导致慢性闭塞患者同侧颅外段ICA流速明显下降而阻力升高，而重度狭窄患者同侧颅外段ICA血流动力学无明显改变。

关键词: 大脑中动脉, 超声检查，多普勒，彩色, 颈内动脉, 血流动力学
Objective

To investigate the influence of anterior cerebral artery (ACA) leptomeningealanastomoseson the hemodynamic changes of extracranial internal carotid artery (ICA) in patients with severe stenosis and chronic occlusion of middle cerebral artery (MCA) disease.

Methods

One hundred and eighty six cases with severe stenosis and chronic occlusion of MCA diagnosed by transcranial color-coded sonography (TCCS) and confirmed by digital subtraction angiography (DSA) were consecutively enrolled during January 2015 to December 2015. All cases were divided into two groups, including 88 cases of severe stenosis and 98 cases with chronic occlusion. According to DSA results, there were 72 cases with leptomeningeal anastomoses (LMA) and 114 cases without LMA. Transcranial Doppler (TCD) and TCCS were performed to measure and record the peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) of bilateral ACA, color Doppler ultrasound was used to measure and record PSV, EDV and RI of bilateral ICA. The ipsilateral and contralateralhemodynamic parameters of ICA and ACA were compared betweenthe two groups by means of independent-samples t test and paired-samples t test. The difference ofhemodynamic parameters between patients with LMA and without LMA were also compared. Linear regression was used to analyze the relevance between ipsilateral ICA and ACA parameters.

Results

(1) The PSV and EDV of ipsilateral ICA in MCA chronic occlusion group were significantly lower than those in MCA severe stenosis group [(71.27±17.84) cm/s vs (78.07±14.69) cm/s, (27.00±8.38) cm/s vs (32.01±7.83) cm/s, 0.625±0.056 vs 0.591±0.057; t=2.820, 4.243, 4.099, all P<0.01]. The PSV and EDV of ipsilateral ICA were significantly lower than the contralateral side in both two group [PSV: (78.07±14.69) cm/s vs (85.26±17.42) cm/s, (71.27±17.84) cm/s vs (83.80±22.11) cm/s; EDV: (32.01±7.83) cm/s vs (34.50±7.36) cm/s, (27.00±8.38) cm/s vs (33.22±9.97) cm/s; t=2.847, 5.209, 2.058, 5.626, all P<0.05]. The RI of ipsilateral ICA was higher than that of contralateral side in MCA chronic occlusion group (0.625±0.056 vs 0.601±0.076, t=2.601, P<0.05), no significantly differenceexist between the RI of two sides were in MCA severe stenosis group (P>0.05). (2) In two groups, the PSV and EDV of ipsilateral ICA with LMA were significantly higher than those without LMA, while the RI was lower [PSV: (164.19±22.64) cm/s vs (97.56±19.17) cm/s, (168.95±28.03) cm/s vs (96.72±21.57) cm/s; EDV: (75.68±12.53) cm/s vs (42.65±10.03) cm/s, (79.93±13.73) cm/s vs (42.30±11.95) cm/s; RI: 0.540±0.036 vs 0.564±0.043, 0.526±0.037 vs 0.566±0.051; t=14.604, 14.416, 13.492, 14.444, 2.727, 4.250, all P<0.01]. The PSV and EDV of ipsilateral ACA with LMA were higher than the contralateral side, and RI was lower [PSV: (164.19±22.64) cm/s vs (105.19±26.95) cm/s, (168.95±28.03) cm/s vs (97.90±24.18) cm/s; EDV: (75.68±12.53) cm/s vs (44.10±13.87) cm/s, (79.93±13.73) cm/s vs (41.83±10.88) cm/s; RI: 0.540±0.036 vs 0.583±0.050, 0.526±0.037 vs 0.572±0.037; t=10.049, 15.906, 10.313, 16.864, 4.083, 6.145, all P<0.01]. For the parameters of ACA without LMA, there was no difference between two sides (P>0.05). (3) In MCA with severestenosis group, the parameters of ipsilateral ICA between with and without LMA groupswere not significantly different (P>0.05). In MCA with chronicocclusion group, the PSV and EDV of ipsilateral ICA without LMA were significantly lower than those with LMA, and RI was higher [(65.93±13.34) cm/s vs (78.68±20.64) cm/s, (23.98±6.30) cm/s vs (31.20±9.08) cm/s, 0.638±0.055 vs 0.605±0.053; t=3.713, 4.647, 2.925, all P<0.01]. (4) In MCA with severestenosis group, no obviously correlation was found in the hemodynamic parameters of ipsilateral ICA and ACA (P>0.05). In MCA with chronicocclusion group, PSV, EDV of ipsilateral ACA had positive linear correlation with PSV of ipsilateral ICA (r=0.350, 0.367, P<0.01), and had negative linear correlation with RI of ipsilateral ICA (r=-0.550, -0.531, P<0.01).

Conclusions

In MCA with severestenosis and chronicocclusinpatients, TCD or TCCS can be used for detecting increased velocity of ACA with LMA. The hemodynamic parameters of ipsilateral ICA could beinfluenced by LMA withdecreased velocity and increased PI when MCA was occluded, but could not be influenced by LMA when MCA was severe stenosis.

Key words: Middle cerebral artery, Ultrasonography, Doppler, color, Carotid artery, internal, Hemodynamic
表1 MCA重度狭窄组与慢性狭窄组患者一般临床资料比较
组别 例数 年龄（岁，±s） 性别（例，男性/女性） 病变侧别[例（%）] 糖尿病[例（%）] 高血压[例（%）]
左侧 右侧
MCA重度狭窄组 88 56±13 74/14 40（45.5%） 48（54.5%） 22（25.0%） 51（58.0%）
MCA慢性闭塞组 98 57±12 81/17 51（52.0%） 47（48.0%） 17（17.3%） 60（61.2%）
统计值 ? t=0.825 χ2=0.069 χ2=0.805 χ2=1.639 χ2=0.206
P值 ? 0.411 0.793 0.370 0.200 0.650
组别 例数 冠状动脉粥样硬化性心脏病[例（%）] 高血脂[例（%）] 吸烟[例（%）] 临床症状[例（%）]
无症状 TIA 脑卒中
MAC重度狭窄组 88 8（9.1%） 38（43.2%） 58（65.9%） 4（4.5%） 10（11.4%） 74（84.1%）
MAC慢性闭塞组 98 12（12.2%） 40（40.8%） 67（68.3%） 7（7.1%） 13（13.3%） 78（79.6%）
统计值 ? χ2=0.515 χ2=0.107 χ2=0.127 χ2=0.779
P值 ? 0.473 0.744 0.721 0.677
表2 MCA重度狭窄组与慢性闭塞组患侧ICA血流动力学参数比较（±s）
组别 例数 PSV（cm/s） EDV（cm/s） RI
患侧 健侧 患侧 健侧 患侧 健侧
MAC重度狭窄组 88 78.07±14.69a 85.26±17.42 32.01±7.83b 34.50±7.36 0.591±0.057 0.594±0.047
MAC慢性闭塞组 98 71.27±17.84a 83.80±22.11 27.00±8.38a 33.22±9.97 0.625±0.056b 0.601±0.076
t值 ? 2.820 0.498 4.243 0.983 4.099 0.820
P值 ? 0.005 0.619 <0.001 0.327 <0.001 0.413
表3 MCA重度狭窄组软脑膜动脉吻合对ACA的血流参数影响（±s）
组别 例数 PSV（cm/s） EDV（cm/s） RI
患侧 健侧 患侧 健侧 患侧 健侧
软脑膜动脉吻合 31 164.19±22.64a 105.19±26.95 75.68±12.53a 44.10±13.87 0.540±0.036a 0.583±0.050
无软脑膜动脉吻合 57 97.56±19.17 95.04±27.30 42.65±10.03 41.72±15.68 0.564±0.043 0.570±0.070
t值 ? 14.604 1.675 13.492 0.707 2.727 0.930
P值 ? <0.001 0.098 <0.001 0.482 0.008 0.355
表4 MCA慢性闭塞组软脑膜动脉吻合对ACA的血流参数影响（±s）
组别 例数 PSV（cm/s） EDV（cm/s） RI
患侧 健侧 患侧 健侧 患侧 健侧
软脑膜动脉吻合 41 168.95±28.03a 97.90±24.18 79.93±13.73a 41.83±10.88 0.526±0.037a 0.572±0.037
无软脑膜动脉吻合 57 96.72±21.57 95.39±29.42 42.30±11.95 41.49±14.88 0.566±0.051 0.567±0.045
t值 ? 14.416 0.449 14.444 0.124 4.250 0.545
P值 ? <0.001 0.654 <0.001 0.902 <0.001 0.587
图3 大脑前动脉脑膜支代偿的多普勒图像。频谱多普勒超声测量左侧大脑前动脉流速代偿增快，PSV=165 cm/s，EDV=62 cm/s
表5 MCA重度狭窄组软脑膜动脉吻合对ICA的血流参数影响（±s）
组别 例数 PSV（cm/s） EDV（cm/s） RI
患侧 健侧 患侧 健侧 患侧 健侧
软脑膜动脉吻合 31 79.39±9.11a 84.87±17.85 32.81±4.80a 34.32±6.58 0.586±0.044a 0.591±0.050
无软脑膜动脉吻合 57 77.35±17.00 85.47±17.34 31.58±9.07a 34.60±7.81 0.594±0.063a 0.595±0.046
t值 ? 0.619 0.154 0.701 0.166 0.648 0.355
P值 ? 0.538 0.878 0.485 0.869 0.518 0.739
表6 MCA慢性闭塞组软脑膜动脉吻合对ICA的血流参数影响（±s）
组别 例数 PSV（cm/s） EDV（cm/s） RI
患侧 健侧 患侧 健侧 患侧 健侧
软脑膜动脉吻合 41 78.68±20.64a 84.10±22.51 31.20±9.08a 32.85±9.83 0.605±0.053a 0.605±0.084
无软脑膜动脉吻合 57 65.93±13.34 83.58±22.02 23.98±6.30 33.49±10.15 0.638±0.055 0.598±0.070
t值 ? 3.713 0.114 4.647 0.311 2.925 0.437
P值 ? <0.001 0.910 <0.001 0.757 0.004 0.663
图4 颅外段颈内动脉的多普勒图像。颈动脉超声频谱多普勒测量左侧ICA流速在正常范围，PSV=119 cm/s，EDV=45 cm/s，RI=0.62
图5~8 大脑中动脉慢性闭塞组患侧ACA血流参数与患侧ICA血流参数的线性回归图像。图5为ACA的PSV与颅外段ICA的PSV的线性回归图像；图6为ACA的EDV与颅外段ICA的PSV的线性回归图像；图7为ACA的PSV与颅外段ICA的RI值的线性回归图像；图8为ACA的EDV与颅外段ICA的RI值的线性回归图像
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