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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） ›› 2023, Vol. 20 ›› Issue (10) : 1046 -1055. doi: 10.3877/cma.j.issn.1672-6448.2023.10.008

头颈部超声影像学

单侧颈内动脉闭塞患者行颞浅动脉-大脑中动脉搭桥术的脑血流动力学评估
魏淑婕, 惠品晶†(), 丁亚芳, 张白, 颜燕红, 周鹏, 黄亚波   
  1. 215006　苏州大学附属第一医院神经外科-颈脑血管超声科
    215006　苏州大学附属第一医院神经外科
  • 收稿日期:2022-11-04 出版日期:2023-10-01
  • 通信作者: 惠品晶
  • 基金资助:
    苏州市民生科技项目(SS202061); 苏州大学技术开发合作项目(H211064)

Evaluation of cerebral hemodynamics in patients with unilateral internal carotid artery occlusion undergoing superficial temporal artery-middle cerebral artery bypass

Shujie Wei, Pinjing Hui†(), Yafang Ding, Bai Zhang, Yanhong Yan, Peng Zhou, Yabo Huang   

  1. Department of Neurosurgery Carotid and Cerebrovascular Ultrasound, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
    Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
  • Received:2022-11-04 Published:2023-10-01
  • Corresponding author: Pinjing Hui
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魏淑婕, 惠品晶, 丁亚芳, 张白, 颜燕红, 周鹏, 黄亚波. 单侧颈内动脉闭塞患者行颞浅动脉-大脑中动脉搭桥术的脑血流动力学评估[J/OL]. 中华医学超声杂志（电子版）, 2023, 20(10): 1046-1055.

Shujie Wei, Pinjing Hui, Yafang Ding, Bai Zhang, Yanhong Yan, Peng Zhou, Yabo Huang. Evaluation of cerebral hemodynamics in patients with unilateral internal carotid artery occlusion undergoing superficial temporal artery-middle cerebral artery bypass[J/OL]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2023, 20(10): 1046-1055.

目的

应用经颅多普勒超声（TCD）及CT灌注成像（CTP）评估单侧颈内动脉闭塞患者行颞浅动脉-大脑中动脉搭桥（STA-MCA bypass）术前后的脑血流动力学变化。

方法

回顾性连续纳入2016年1月至2021年5月于苏州大学附属第一医院神经外科因慢性单侧颈内动脉闭塞行STA-MCA bypass术的患者85例。根据美国介入和治疗神经放射学学会/介入放射学学会（ASITN/SIR）标准将患者分为A组65例（ASITN/SIR 0~2级）和B组20例（ASITN/SIR 3级）。运用经颅多普勒（TCD）评估患者STA-MCA bypass术前后的双侧大脑中动脉（MCA）远段（检测深度30~40 cm）平均血流速度（Vm）、收缩期峰值血流速度（Vs）、舒张期末血流速度（Vd）、血管搏动指数（PI）。评估患者双侧基底节及颞叶CTP参数，计算脑血流量（CBF）、脑血容量（CBV）、平均通过时间（MTT）及达峰时间（TTP），并计算患侧/健侧CTP（rCTP）。采用美国国立卫生研究院卒中量表（NIHSS）评估患者神经系统评分。采用Spearman秩相关分析患侧MCA远段Vm与NHISS评分的相关性。

结果

TCD参数：术前及术后A、B两组的患侧MCA远段的Vm、Vs、Vd以及PI均低于健侧（P均<0.05）。术前A组患侧Vm、Vs、Vd以及PI均低于B组，2组患者术后的Vm、Vs、Vd以及PI均高于术前，差异均有统计学意义（P均<0.05）；术后2组间的Vm、Vs、Vd以及PI比较差异无统计学意义（P均>0.05）。rCTP参数：术前A组rCBF和rCBV均低于B组（P均<0.05），rMTT及rTTP均大于B组（P均<0.05）；2组术后的rCBF均高于术前，rMTT、rTTP均低于术前（P均<0.05），B组术后的rCBV低于术前（P均<0.05），A组术后颞叶rCBV较术前升高（P<0.05），基底节rCBV与术前相比差异无统计学意义（P>0.05）。NHISS评分：A组患者术前及术后NHISS评分均高于B组，差异均有统计学意义（P均<0.05）；2组患者术后NHISS评分均低于术前，差异均有统计学意义（P均<0.05）。A、B两组患者术前MCA Vm与NHISS评分呈负相关（r=-0.659、-0.626，P均<0.01），而术后MCA Vm与NHISS评分不存在线性相关关系。

结论

STA-MCA bypass术后，脑灌注得到明显改善。TCD及CTP有助于评估STA-MCA bypass围手术期的脑血流动力学改变，TCD是临床无创评估及随访脑血流动力学的有效工具。

关键词: 超声检查，多普勒，经颅, CT灌注成像, 颈内动脉闭塞, 颞浅动脉-大脑中动脉搭桥术, 血流动力学, 侧支循环
Objective

To evaluate cerebral hemodynamics before and after unilateral internal carotid artery occlusion in patients undergoing superficial temporal artery-middle cerebral artery bypass (STA-MCA bypass) by transcranial Doppler ultrasound (TCD) and CT perfusion imaging (CTP).

Methods

Eighty-five patients who underwent STA-MCA bypass grafting for unilateral internal carotid artery occlusion at the Neurosurgery Department of the First Affiliated Hospital of Soochow University from January 2016 to May 2021 were retrospectively enrolled. According to the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) criteria, the patients were divided into group A (65 cases; ASITN/SIR Grade 0-2) and group B (20 cases; ASITN/SIR Grade 3). The average blood flow velocity (Vm), peak systolic blood flow velocity (Vs), end-diastolic blood flow velocity (Vd), and vascular pulse index (PI) of the bilateral middle cerebral arteries (MCA) in the distal section (detection depth 30~40 cm) were evaluated by TCD before and after STA-MCA bypass. CTP parameters of the bilateral basal ganglia and temporal lobes were evaluated to calculate cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and peak time (TTP), as well as CTP of the affected side/healthy side (rCTP). The National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the neurological score. Spearman rank correlation was used to analyze the correlation between the Vm of the MCA distal segment and NHISS score.

Results

The Vm, Vs, Vd, and PI of the MCA distal segment on the affected side were lower than those on the healthy side in both groups A and B before and after surgery (P<0.05 for all). Preoperative Vm, Vs, Vd, and PI of the affected side in group A were lower than those in group B, and postoperative Vm, Vs, Vd, and PI of the two groups were significantly higher than those before surgery (P<0.05 for all). There were no significant differences in Vm, Vs, Vd, or PI between the two groups after surgery (P>0.05 for all). Before operation, rCBF and rCBV in group A were lower than those in group B, and rMTT and rTTP were higher than those in group B (P<0.05 for all). rCBF after operation was higher than that before operation, while rMTT and rTTP were lower than those before operation (P<0.05 for all).The postoperative rCBV of group B was lower than that before surgery (P<0.05), the postoperative rCBV of the temporal lobes in group A was higher than that before surgery (P<0.05), and the rCBV of the basal ganglia was not significantly different from that before surgery (P>0.05). Preoperative and postoperative NHISS scores in group A were significantly higher than those in group B, (P<0.05 for both). The NHISS scores of the two groups were significantly lower after surgery than before surgery (P<0.05 for both). There was a negative correlation between MCA Vm and NHISS score in both groups before surgery (r=-0.659, P<0.01; r=-0.626, P<0.01), while there was no linear correlation between MCA Vm and NHISS score after surgery.

Conclusion

After STA-MCA bypass surgery, cerebral perfusion is significantly improved. TCD and CTP are helpful to evaluate the perioperative cerebral hemodynamics of STA-MCA bypass, and TCD is an effective tool for non-invasive clinical evaluation and follow-up of cerebral hemodynamics.

Key words: Ultrasonography, Doppler, transcranial, CT perfusion imaging, Internal carotid artery occlusion, Superficial temporal artery-middle cerebral artery bypass, Hemodynamics, Collateral circulation
表1 2组单侧颈内动脉闭塞患者基线资料比较
资料 A组（n=65） B组（n=20） 统计值 P值
男性[例（%）] 48（74） 14（70） χ2=0.115 0.735
年龄（岁，） 59.63±9.16 55.10±10.10 t=1.888 0.063
高血压病[例（%）] 40（62） 12（60） χ2=0.015 0.902
血脂异常[例（%）] 26（40） 10（50） χ2=0.626 0.429
LDL-C（mmol/L，） 2.01±0.78 1.96±0.60 t=0.258 0.797
HDL-C（mmol/L，） 0.97±0.19 1.00±0.22 t=-0.715 0.477
TC（mmol/L，） 3.58±0.86 3.64±1.09 t=-0.283 0.778
TG（mmol/L，） 1.51±0.86 1.30±0.52 t=1.010 0.315
糖尿病[例（%）] 32（49） 8（40） χ2=0.523 0.470
空腹血糖（mmol/L，） 5.80±1.16 5.94±1.28 t=-0.464 0.644
hs-CRP[mg/L，M（P25，P75）] 7.12（1.74，12.84） 4.79（0.81，12.53） Z=-0.959 0.337
冠心病[例（%）] 13（65） 5（25） χ2=0.229 0.632
吸烟史[例（%）] 18（28） 5（25） χ2=0.056 0.813
左侧颈内动脉闭塞[例（%）] 24（37） 8（40） χ2=0.062 0.804
表2 2组单侧颈内动脉闭塞患者术前患侧MCA远段TCD参数比较（）
组别 例数 Vm（cm/s） Vs（cm/s）
患侧 健侧 t值 P值 患侧 健侧 t值 P值
A组 65 34.40±9.32 68.51±20.77 -12.23 <0.001 48.48±13.36 108.06±32.52 -13.90 <0.001
B组 20 44.15±12.11** 62.75±17.72 -3.86 0.001 63.10±16.81** 100.65±31.19 -4.57 <0.001
组别 例数 Vd（cm/s） PI
患侧 健侧 t值 P值 患侧 健侧 t值 P值
A组 65 27.22±7.40 48.14±14.34 -10.72 <0.001 0.62±0.10 0.87±0.15 -12.85 <0.001
B组 20 33.45±9.22** 43.35±12.33 -3.20 0.004 0.68±0.12* 0.89±0.20 -4.33 <0.001
表3 2组单侧颈内动脉闭塞患者术前与术后患侧MCA远段TCD参数比较（）
组别 例数 Vm（cm/s） Vs（cm/s）
术前 术后 t值 P值 术前 术后 t值 P值
A组 65 34.40±9.32 62.11±26.61 -8.79 <0.001 48.48±13.36 95.66±41.20 -9.46 <0.001
B组 20 44.15±12.11** 57.90±16.99 -3.45 0.003 63.10±16.81** 87.20±26.56 -3.47 0.003
组别 例数 Vd（cm/s） PI
术前 术后 t值 P值 术前 术后 t值 P值
A组 65 27.22±7.40 44.94±19.92 -7.54 <0.001 0.62±0.10 0.82±0.18 -8.64 <0.001
B组 20 33.45±9.22** 41.60±13.88 -2.52 0.021 0.68±0.12* 0.86±0.28 -2.20 0.040
表4 2组单侧颈内动脉闭塞患者rCTP参数比较（）
组别 例数 基底节rCTP参数
rCBF rCBV rMTT rTTP
术前 术后 术前 术后 术前 术后 术前 术后
A组 65 0.80±0.17 0.88±0.14** 0.92±0.19 0.91±0.19 1.43±0.36 1.22±0.23** 1.39±0.19 1.20±0.27**
B组 20 0.90±0.12 0.95±0.14* 1.15±0.15 0.94±0.17** 1.26±0.19 1.13±0.15* 1.24±0.23 1.10±0.09*
t值 -2.48 -1.19 -4.83 -0.673 2.03 1.62 3.02 1.62
P值 0.011 0.059 <0.001 0.526 0.046 0.110 0.004 0.110
组别 例数 颞叶rCTP参数
rCBF rCBV rMTT rTTP
术前 术后 术前 术后 术前 术后 术前 术后
A组 65 0.74±0.12 0.81±0.13** 0.83±0.15 0.88±0.16* 1.57±0.43 1.31±0.24** 1.40±0.18 1.22±0.13**
B组 20 0.81±0.11 0.87±0.11* 1.18±0.19 0.88±0.15** 1.36±0.27 1.25±0.14** 1.26±0.09 1.18±0.10**
t值 -2.20 -1.48 -8.03 0.11 2.04 1.05 3.35 1.16
P值 0.031 0.143 <0.001 0.914 0.044 0.299 0.001 0.248
图1 患者，女，56岁，因左上肢无力逐渐加重1个月余入院，NHISS评分为7分。图a为数字减影血管造影（DSA）示右侧颈内动脉闭塞（白色箭头所示）；图b为DSA示ASTIN/SIR 1级，仅有少量的代偿血流；图c为经颅多普勒超声（TCD）示术前患侧大脑中动脉（MCA）远段呈达峰时间延迟的“低速低搏动” 代偿血流频谱；图d为TCD示术后患侧MCA血流速及阻力指数升高，频谱形态相对正常；图e~h为CT灌注成像（CTP）示该患者术前患侧大脑半球感兴趣区相较于健侧脑血流量、脑血容量减低，平均通过时间、达峰时间延长；图i~l为CTP示该患者术后患侧大脑半球感兴趣区血流灌注情况较术前好转
图2 患者，男，53岁，因反复头晕3个月余入院，NHISS评分为3分。图a为数字减影血管造影（DSA）示右侧颈内动脉闭塞（白色箭头所示）；图b为DSA示ASTIN/SIR 3级，相对完全的代偿血流；图c为经颅多普勒超声（TCD）示术前患侧大脑中动脉（MCA）远段呈相对达峰时间延迟的低速代偿血流频谱；图d为TCD示术后患侧MCA血流速及阻力指数升高，频谱形态正常；图e~h为CT灌注成像（CTP）示该患者术前脑血流量减低，脑血容量升高，平均通过时间及达峰时间延长；图i~l为CTP示该患者术后患侧大脑半球感兴趣区血流灌注情况较术前好转
表5 2组单侧颈内动脉闭塞患者NHISS评分比较[M（P25，P75）]
组别 例数 术前NHISS评分 术后NHISS评分
A组 65 4（3，6） 3（2，4）**
B组 20 2.5（1，3） 1（0，2）**
Z值 3.41 2.73
P值 0.001 0.006
图3 单侧颈内动脉闭塞患者的患侧MCA远段Vm与NHISS评分的相关性分析。图a，b为术前A、B两组患侧MCA远段Vm与NHISS评分的相关性分析散点图；图c，d为术后2组患侧MCA远段Vm与NHISS评分的相关性分析散点图 注：MCA为大脑中动脉；Vm为平均血流速度；A组为ASITN/SIR 0~2级；B组为ASITN/SIR 3级
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