摘要目的 探讨双侧颈内动脉(ICA)重度狭窄性病变行一侧颈动脉内膜切除术(CEA)后的脑血流动力学改变情况.方法 回顾性分析2012年2月至2018年6月苏州大学附属第一医院神经外科连续收治的41例ICA狭窄患者.所有患者均经基于血管超声的多模态影像学检查证实存在双侧ICA重度狭窄性病变,采用一侧CEA治疗.应用CT血管成像(CTA)评估手术前、后的前交通动脉(ACoA)和后交通动脉(PCoA)的开放情况.根据术后ACoA是否开放,分为ACoA开放组(简称开放组,15例)和ACoA未开放组(简称未开放组,26例).通过经颅多普勒(TCD)和CT灌注成像(CTP)评估两组手术前、后的脑血流动力学变化(包括脑血流量、脑血容量、平均通过时间、达峰时间),并分析其临床转归.结果 (1)CTA显示的脑侧支循环变化情况:CEA后ACoA开放率明显增加[术前为4.9％(2/41),术后为36.6％(15/41)];手术侧PCoA均关闭[术前开放率为51.2％(21/41),术后为0％],非手术侧PCoA未改变[术前、后开放率均为46.3％(19/41)].(2) TCD参数变化:手术前、后比较,开放组和未开放组手术侧、开放组非手术侧大脑中动脉(MCA)的平均血流速度(Vm)、搏动指数(PI)均升高(均P＜0.05),但未开放组非手术侧MCA Vm、PI术前、术后的差异均无统计学意义(均P ＞0.05);术后组间比较,两组手术侧MCA Vm、PI以及两组非手术侧MCA PI的差异均无统计学意义(均P＞0.05),但开放组非手术侧MCA Vm较未开放组明显升高(P＜0.001).(3)CTP参数变化情况:手术前、后比较,两组手术侧、开放组非手术侧CTP各参数均明显改善(均P＜0.05),而未开放组非手术侧CTP各参数的差异均无统计学意义(均P＞0.05);术后组间比较,两组手术侧CTP各参数的差异无统计学意义(均P＞0.05),但开放组非手术侧CTP各参数较未开放组均改善(均P ＜0.05).(4)临床转归:两组手术侧ICA所供应脑组织区域的神经功能缺损均得以改善,而对于非手术侧ICA所供应脑组织区域的神经功能缺损,开放组改善比例高于未开放组(7/15对比5/26,P=0.024).结论 双侧ICA重度狭窄性病变行一侧CEA后,ACoA开放能同时改善非手术侧的脑灌注.

abstractsObjective To investigate the changes of cerebral hemodynamics after unilateral carotid endarterectomy (CEA) for severe stenotic lesions of bilateral internal carotid artery (ICA).Methods The clinical data of 41 consecutive patients with ICA stenosis admitted to Department of Neurosurgery,the First Affiliated Hospital of Soochow University from February 2012 to June 2018 were retrospectively studied.All patients were diagnosed by multi-modal images based on cerebrovascular ultrasound results with severe stenotic lesions of bilateral ICA and underwent unilateral CEA.The patency of anterior communicating arteries (ACoA) and posterior communicating arteries (PCoA) were evaluated by CT angiography (CTA) before and after CEA.According to postoperative CTA revealing whether ACoA was patent or not,41 cases were divided into ACoA patent group (15 cases) and ACoA non-patent group (26 cases).We used transcranial Doppler (TCD) and CT perfusion imaging (CTP) to evaluate these changes of cerebral hemodynamics after operation in two groups,and analyzed their clinical outcomes.Results (1) Changes of cerebral collateral circulation based on CTA images:After CEA,the opening rate of ACoA increased significantly [pre-operation:4.9％ (2/41),postoperation:36.6％ (15/41)],and all the PCoA on the operated side were closed [pre-operation:51.2％ (21/41),postoperation:0％].In contrast,the opening rate of PCoA remained unchanged on the non-operated side [pre-operation:46.3％ (19/41),postoperation:46.3％ (19/41)].(2) Changes of TCD parameters:Compared with the mean velocity (Vm) and pulsatility index (PI) before surgery,those of the middle cerebral artery (MCA) on the operated side of two groups and on the non-operated side of ACoA patent group were significantly increased (all P ＜ 0.05),whereas those parameters on the non-operated side of ACoA non-patent group after surgery had no significant differences compared with those before operation (all P ＞ 0.05).There was no significant difference in Vm or PI of MCA on the operated side or PI of MCA on non-operated side between two groups after operation (all P ＞ 0.05),whereas the Vm of MCA on non-operated side in the ACoA patent group was significantly higher than that in ACoA non-patent group (P ＜ 0.001).(3) Changes of CTP parameters:Compared with before surgery,the CTP parameters on the operated side of two groups and on non-operated side of ACoA patent group significantly improved after operation (all P ＜ 0.05),while the CTP parameters on the non-operated side of ACoA non-patent group had no significant differences after operation (all P ＞ 0.05).There were no significant differences in CTP parameters on the operated side between two groups after operation (all P ＞ 0.05),whereas the CTP parameters on the non-operated side in ACoA patent group were significantly improved compared with those in ACoA non-patent group (all P ＜ 0.05).(4) Clinical outcomes:The neurological function deficits of brain areas supplied by ICA on the operated side improved in both groups.As to the neurological function deficits of brain areas supplied by ICA on the non-operated side,the improvement rate in ACoA patent group was higher than that in ACoA non-patent group (7/15 vs.5/26,P =0.024).Conclusion After unilateral CEA for severe stenotic lesions of bilateral ICA,the opening of ACoA could simultaneously improve the cerebral perfusion on the non-operated side.