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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） ›› 2019, Vol. 16 ›› Issue (09) : 676 -683. doi: 10.3877/cma.j.issn.1672-6448.2019.09.007

所属专题： 文献；

头颈部超声影像学

微型探头血管超声在烟雾病患者搭桥术中的血流动力学评估
张白1, 惠品晶1,†(), 颜燕红1, 丁亚芳1, 王润川1, 张翌1, 黄亚波2, 胡春洪3, 方琪4   
  1. 1. 215006　苏州大学附属第一医院颈脑血管超声
    2. 215006　苏州大学附属第一医院神经外科
    3. 215006　苏州大学附属第一医院影像科
    4. 215006　苏州大学附属第一医院神经内科
  • 收稿日期:2019-01-28 出版日期:2019-09-01
  • 通信作者: 惠品晶
  • 基金资助:
    江苏省干部保健科研项目(BJ17010); 苏州市民生科技示范工程项目(SS201714，SS201859); 江苏省科技厅社会发展项目-重点病种规范化诊疗项目(BE2016670); 江苏省医学创新团队（领军人才）(CXTDA2017026); 科技部十三五重大专项：数字化诊疗示范应用及脑卒中临床解决方案(2017YFC0114302); 江苏数字创新诊疗装备应用示范研究(2017YFC0114300)

Microprobe vascular Doppler for assessing vascular patency in patients undergoing superficial temporal artery to middle cerebral artery bypass for Moyamoya disease

Bai Zhang1, Pinjing Hui1,†(), Yanhong Yan1, Yafang Ding1, Runchuan Wang1, Yi Zhang1, Yabo Huang2, Chunhong Hu3, Qi Fang4   

  1. 1. Department of Ultrasound, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
    2. Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
    3. Department of Image, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
    4. Department of Neurology, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
  • Received:2019-01-28 Published:2019-09-01
  • Corresponding author: Pinjing Hui
  • About author:
    Corresponding author: Hui Pinjing, Email:
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引用本文：

张白, 惠品晶, 颜燕红, 丁亚芳, 王润川, 张翌, 黄亚波, 胡春洪, 方琪. 微型探头血管超声在烟雾病患者搭桥术中的血流动力学评估[J]. 中华医学超声杂志（电子版）, 2019, 16(09): 676-683.

Bai Zhang, Pinjing Hui, Yanhong Yan, Yafang Ding, Runchuan Wang, Yi Zhang, Yabo Huang, Chunhong Hu, Qi Fang. Microprobe vascular Doppler for assessing vascular patency in patients undergoing superficial temporal artery to middle cerebral artery bypass for Moyamoya disease[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2019, 16(09): 676-683.

目的

前瞻性研究微型探头血管超声（MVD）评估烟雾病（MMD）患者颞浅动脉-大脑中动脉（STA-MCA）搭桥术吻合血管通畅性的可行性及可靠性。

方法

选取2012年7月至2017年12月在苏州大学附属第一医院神经外科经数字减影血管造影（DSA）确诊为烟雾病患者68例（83例次，其中15例为先后双侧手术）。术中应用MVD检测并分析供血动脉即STA顶支或额支、受血动脉即MCA分支M4在吻合前、后的血流动力学参数。设定吻合后STA脉动指数（PI）≤1.10为吻合血管通畅（即通畅组，57例），STA的PI值>1.10为血管通而不畅（即不通畅组，17例），STA仅为"单峰"收缩期血流信号，则血管不通（即不通组，9例）。手术前、后均行颈部血管超声（CDU）、CT灌注成像（CTP）、CT血管造影（CTA）和DSA检查。比较吻合前后STA、吻合前M4与吻合后M4近心段、吻合前M4与吻合后M4远心段血流动力学参数采用配对t检验，比较吻合后M4近心段与远心段血流动力学参数采用独立样本t检验，比较吻合后STA通畅组、不通畅组及不通组3组血流动力学参数的差异采用F检验，有统计学意义的组间采用LSD-t检验。

结果

吻合前后STA：吻合后STA Vm、Vs、Vd明显升高且PI值明显减低，差异均有统计学意义（t=-5.32、-4.62、-5.68、8.96，P均<0.001），频谱呈"颅内动脉化"改变；吻合后3组之间比较，通畅组Vm、Vs、Vd最高且PI值最低，差异均有统计学意义（Vm：t=6.15，Vs：t=5.81、6.95，Vd：t=7.32，PI：t=-11.99、-15.31，P均<0.001），不通组Vs最低且PI值最高，差异均有统计学意义（Vs：t=4.15，PI：t=-6.08，P均<0.001）。所有吻合不通畅或不通的患者均经调整修正后再次检测，STA频谱均呈"颅内动脉化"改变。吻合前后M4：吻合后M4近心段及远心段Vm、Vs、Vd均明显升高且远心段PI值明显增高，差异均有统计学意义（近心段：t=-6.64、-7.73、-5.63，远心段：t=-4.35、-4.51、-3.99、-3.96，P均<0.001）；吻合后近心段Vm、Vs、Vd高于远心段，PI值低于远心段，差异均有统计学意义（t=2.58、2.31、2.69、2.49，P均<0.05），且近心段血流方向逆转（表明吻合通畅）。预后：所有患者术后4~7 d行CDU检查，95%（79/83）的患者STA频谱仍呈"颅内动脉化"改变，表明吻合血管通畅，与CTA结果一致，且CTP证实脑灌注改善；术后6个月~1年，行DSA检查，证实96%（80/83）吻合血管通畅。

结论

MVD在MMD患者行STA-MCA搭桥术中可实时评估吻合血管的通畅性，且吻合后STA的PI值≤1.10可作为判断术中吻合血管通畅的可靠指标。

关键词: 超声检查，多普勒, 烟雾病, 血流动力学, 显微外科手术
Objective

To prospectively assess the feasibility and reliability of using microprobe vascular Dopple (MVD) to assess the vascular patency in patients undergoing superficial temporal artery to middle cerebral artery (STA-MCA) bypass procedure for Moyamoya disease (MMD).

Methods

From July 2012 to December 2017, 68 consecutive patients (totally 83 cases, including 15 cases who underwent bilateral surgeries) at Department of Neurosurgery, the First Affiliated Hospital of Soochow University, were confirmed to have MMD by digital subtraction angiography (DSA) and treated with STA-MCA bypass surgery. Before and after surgical revascularization, the hemodynamics parameters of the STA and the M4 segment of the MCA were evaluated by MVD. According to the STA pulsation index (PI) after the anastomosis, the patients were divided into three groups: patency group (n=57), PI≤1.10; poor patency group (n=17), PI>1.10; and obstruction group (n=9), the STA exhibited the "single peak" systolic blood flow signal. All patients underwent carotid Doppler ultrasonography (CDU), CT perfusion imaging (CTP), CT angiography (CTA), and DSA before and after surgery. The paired t-test was used to compare the hemodynamic parameters between the STA before and after anastomosis, between the M4 before anastomosis and the M4 proximal segment after anastomosis, and between the M4 before anastomosis and the M4 distal segment after anastomosis. The independent sample t-test was used to compare the hemodynamic parameters between the M4 proximal and distal segments after anastomosis. The differences of STA hemodynamic parameters among the patency group, the poor patency group, and the obstruction group were compared by the F test, and the statistically significant groups were further analyzed by the LSD-t test.

Results

After the anastomosis, the blood flow velocity (Vm, Vs, and Vd) of the STA increased significantly and the PI decreased significantly (t=-5.32, -4.62, -5.68, 8.96, all P<0.001), and it showed an ″intracranial arterial spectrum″. When comparing among the three groups, the patency group had the highest blood flow velocity (Vm, Vs, and Vd) and the lowest PI (Vm: t=6.15; Vs: t=5.81, 6.95; Vd: t=7.32; PI: t=-11.99, -15.31; all P<0.001). The STA of all cases in the poor patency group and obstruction group were adjusted and corrected until the STA returned to an ″intracranial arterial spectrum″. After the anastomosis, the blood flow velocity (Vm, Vs, and Vd) of the MCA M4 proximal and distal segments increased significantly, and the PI of the distal segment increased significantly (proximal segment: t=-6.64, -7.73, -5.63; distal segment: t=-4.35, -4.51, -3.99, -3.96; all P<0.001). The blood flow velocity (Vm, Vs, and Vd) was significantly higher and the PI was significantly lower in the proximal segment than in the distal segment (t=2.58, 2.31, 2.69, 2.49, all P<0.05), and the blood flow direction in the proximal segment was reversed (indicating anastomotic patency). All patients underwent CDU in 4 to 7 days after surgery, and 95% (79/83) patients still presented an ″intracranial arterial spectrum″ in the STA, indicating that the anastomotic vessel was patent. This result was consistent with CTA findings, and CTP confirmed cerebral perfusion improvement as well. Between 6 months to 1 year after anastomosis, DSA confirmed that 96% (80/83) of anastomotic vessels were patent.

Conclusion

In STA-MCA bypass surgery, MVD can be ued to evaluate the patency of anastomotic vessels in real time, and PI≤1.10 can be used as a reliable indicator for judging vascular patency after STA anastomosis.

Key words: Ultrasonography, Doppler, Moyamoya disease, Hemodynamics, Microsurgery
表1 吻合前后颞浅动脉血流动力学变化（±s）
组别 例数 Vm（cm/s） Vs（cm/s） Vd（cm/s） PI
吻合前 83 5.17±2.88 12.25±5.19 1.83±1.30 2.12±0.52
吻合后 83 31.16±11.65 45.42±18.27 23.33±12.98 0.72±0.16
t值 ? -5.32 -4.62 -5.68 8.96
P值 ? <0.001 <0.001 <0.001 <0.001
表2 吻合后颞浅动脉通畅组、不通畅组及不通组血流动力学变化（±s）
组别 例数 Vm（cm/s） Vs（cm/s） Vd（cm/s） PI
通畅组 57 38.88±16.75 55.89±22.53 28.31±12.41 0.73±0.19
不通畅组 17 13.23±7.79a 27.58±17.28a 6.01±3.64a 1.60±0.28a
不通组 9 0 3.33±1.80bc 0 9.47±5.41bc
F值 ? 15.04 81.02 135.81 137.33
P值 ? <0.001 <0.001 <0.001 <0.001
图1 病例1，男性，36岁，因左侧肢体乏力一周入院，大脑中动脉诊断为烟雾病，行右侧颞浅动脉-大脑中动脉搭桥术中的STA血流动力学及频谱形态改变。图a为微型探头血管超声（红色箭头所示）探测吻合后STA（白色箭头所示）；图b为吻合前STA呈"高阻型"血流频谱（Vm=2 cm/s，Vs=6 cm/s，Vd=0 cm/s，PI=3.6）；图c为吻合后STA呈"低阻型"血流频谱（Vm=19 cm/s，Vs=26 cm/s，Vd=13 cm/s，PI=0.71），即频谱呈"颅内动脉化"改变
图2 病例2，女性，42岁，因右侧基底节区出血入院，大脑中动脉确诊为烟雾病，行右侧颞浅动脉-大脑中动脉搭桥术。图a骨瓣复位后探测STA，PI值>1.10（PI=2.2），提示吻合血管通而不畅，考虑血管痉挛，遂使用罂粟碱。图b再次探测STA，仅探及微弱"单峰"血流信号，表明吻合不通畅，查找原因，发现吻合口内膜撕裂，遂重新选择M4吻合
表3 吻合前后M4血流动力学变化（±s）
组别 例数 Vm（cm/s） Vs（cm/s） Vd（cm/s） PI
吻合前 83 5.47±2.32 6.68±3.55 4.10±2.32 0.55±0.19
吻合后 ? ? ? ? ?
? 近心段 83 41.57±20.69a 57.94±22.94a 32.19±19.18a 0.65±0.21
? 远心段 83 22.69±17.70bc 35.50±23.97bc 16.55±11.92bc 0.85±0.24bc
? F值 ? 8.93 10.90 7.76 12.35
? P值 ? 0.001 <0.001 0.002 <0.001
图3 病史同病例1，行右侧颞浅动脉-大脑中动脉搭桥术中的M4血流动力学及频谱形态改变。图a吻合前探测M4呈"低搏动性"代偿血流频谱（Vm=15 cm/s，Vs=18 cm/s，Vd=12 cm/s，PI=0.47）；图b吻合后M4近心段血流方向逆转，血流速明显升高且PI值略增高（Vm=38 cm/s，Vs=52 cm/s，Vd=31 cm/s，PI=0.54）；图c微型探头血管超声探测吻合后M4近心段（箭头所示）；图d吻合后M4远心段血流速及PI值均明显增高（Vm=29 cm/s，Vs=49 cm/s，Vd=22 cm/s，PI=0.93），且远心段PI值高于近心段；图e微型探头血管超声探测吻合后M4远心段（箭头所示）
图4 病史同病例1，行右侧颞浅动脉-大脑中动脉搭桥术前后影像学检查。图a~c分别为术前颈部血管超声（右侧颞浅动脉呈"高阻型"血流频谱）、数字减影血管造影（右侧颈外动脉造影）、CT灌注成像（右侧大脑中动脉供血区域灌注减低：脑血流量（CBF）=47.4 ml?（100 ml）-1?min-1，脑血容量（CBV）=2.88 ml?（100 ml）-1，达峰时间（TTP）=15.10 s，平均通过时间（MTT）=4.59 s）图d~f分别为术后5 d行颈部血管超声（右侧颞浅动脉呈"低阻型"血流频谱）、术后6个月数字减影血管造影（右侧颈外动脉造影可见右侧颞浅动脉向颅内供血）、术后5 d CT灌注成像（右侧大脑中动脉供血区域灌注改善：CBF=66.73 ml?（100 ml）-1?min-1，CBV=3.47 ml?（100 ml）-1，TTP=10.52 s，MTT=3.32 s）
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