Halsey J H
Neurologic Institute, New York, NY 10032-2603.
Stroke. 1992 Nov;23(11):1583-7. doi: 10.1161/01.str.23.11.1583.
Controversy continues about the pathogenesis of perioperative stroke in carotid endarterectomy and the use of shunting. The purpose of this study was to determine, using transcranial Doppler ultrasonography, the severity of ischemia during clamping of the carotid artery as a basis for analysis of complications in patients operated on with and without shunting.
In a retrospective study, 11 centers contributed 1,495 carotid endarterectomies monitored with transcranial Doppler. The cases were divided into groups with severe, mild, and no ischemia, and each group was subdivided according to shunt use. The perioperative rate of severe stroke attributable to intraoperative ischemia, in addition to total perioperative stroke, was determined for each subgroup.
Severe ischemia occurred in 7.2% of our cases but cleared spontaneously in about half of these. In those with persisting ischemia the rate of severe stroke was very high, while shunting protected against stroke in such cases. If ischemia did not occur, the stroke rate was higher with shunting, although not so high as in unshunted cases with severe ischemia. Slightly more than one third of the severe strokes were due to postoperative cerebral hemorrhage or carotid thrombosis, unrelated to clamp-induced ischemia or shunting.
Carotid endarterectomy complications might be reduced by selectively shunting only for severe persisting ischemia. Monitoring of cerebral ischemia would be essential to selective shunting.
关于颈动脉内膜切除术围手术期卒中的发病机制及分流术的应用仍存在争议。本研究的目的是使用经颅多普勒超声检查确定颈动脉夹闭期间缺血的严重程度，以此作为分析接受分流术和未接受分流术患者并发症的基础。
在一项回顾性研究中，11个中心提供了1495例接受经颅多普勒监测的颈动脉内膜切除术病例。这些病例被分为严重缺血、轻度缺血和无缺血组，每组再根据是否使用分流术进一步细分。确定每个亚组中因术中缺血导致的围手术期严重卒中发生率以及总的围手术期卒中发生率。
我们的病例中有7.2%发生了严重缺血，但其中约一半可自发缓解。在持续缺血的患者中，严重卒中的发生率非常高，而分流术可预防此类情况下的卒中。如果未发生缺血，分流术患者的卒中发生率较高，尽管不像未分流且有严重缺血的患者那么高。略超过三分之一的严重卒中是由术后脑出血或颈动脉血栓形成引起的，与夹闭诱导的缺血或分流术无关。
仅对严重持续缺血进行选择性分流术可能会降低颈动脉内膜切除术的并发症。对脑缺血进行监测对于选择性分流术至关重要。
