Muroi Carl, Khan Nadia, Bellut David, Fujioka Masayuki, Yonekawa Yasuhiro
Department of Neurosurgery, University Hospital Zurich, Switzerland.
Br J Neurosurg. 2011 Jun;25(3):357-62. doi: 10.3109/02688697.2010.551673. Epub 2011 Apr 18.
Despite the failure of the international extracranial-intracranial (EC-IC) bypass study in showing the benefit of bypass procedure for prevention of stroke recurrence, it has been regarded to be beneficial in a subgroup of well-selected patients with haemodynamic impairment. This report includes the EC-IC bypass experience of a single centre over a period of 14 years. All consecutive 72 patients with atherosclerotic occlusive cerebrovascular lesions associated with haemodynamic compromise treated by EC-IC bypass surgery were retrospectively reviewed. Pre-operatively, 61% of patients presented with minor stroke and the remaining 39% with recurrent transient ischemic attacks (TIAs) despite maximal medical therapy. Angiography revealed a unilateral internal carotid artery (ICA) stenosis/occlusion in 79%, bilateral ICA stenosis/occlusion in 15%, MCA stenosis/occlusion in 3% and other multiple vessel stenosis/occlusion in 3% of the cases. H(2)(15)O positron emission tomography (PET) or 99mTc-HMPAO SPECT with acetazolamide challenge was performed for haemodynamic evaluation of the cerebral blood flow (CBF). All the patients had impaired haemodynamics pre-operatively in terms of reduced regional cerebrovascular reserve capacity and rCBF. Standard STA-MCA bypass procedure was performed in all patients. A total of 68 patients with 82 bypasses were reviewed with a mean follow-up period of 34 months. Stroke recurrence took place in 10 patients (15%) resulting in an annual stroke risk of 5%. Improved cerebral haemodynamics was documented in 81% of revascularised hemispheres. Patients with unchanged or worse haemodynamic parameters had significantly more post-operative TIAs or strokes when compared to those with improved perfusion reserves (30% vs.5% of patients, p<0.05). In conclusion, EC-IC bypass procedure in selected patients with occlusive cerebrovascular lesions associated with haemodynamic impairment has revealed to be effective for prevention of further cerebral ischemia, when compared with a stroke risk rate of 15% reported to date in patients only under antiplatelet agents or anticoagulant therapy.
尽管国际颅外-颅内（EC-IC）搭桥研究未能证明搭桥手术对预防中风复发有益，但在精心挑选的有血流动力学损害的亚组患者中，该手术被认为是有益的。本报告涵盖了一个中心14年间的EC-IC搭桥经验。对所有连续接受EC-IC搭桥手术治疗的72例伴有血流动力学损害的动脉粥样硬化闭塞性脑血管病变患者进行了回顾性研究。术前，61%的患者出现轻度中风，其余39%尽管接受了最大程度的药物治疗仍有复发性短暂性脑缺血发作（TIA）。血管造影显示，79%的病例存在单侧颈内动脉（ICA）狭窄/闭塞，15%为双侧ICA狭窄/闭塞，3%为大脑中动脉（MCA）狭窄/闭塞，3%为其他多支血管狭窄/闭塞。采用H₂¹⁵O正电子发射断层扫描（PET）或99mTc-HMPAO单光子发射计算机断层扫描（SPECT）并进行乙酰唑胺激发试验，以评估脑血流量（CBF）的血流动力学情况。所有患者术前均存在血流动力学损害，表现为局部脑血管储备能力和局部脑血流量（rCBF）降低。所有患者均接受了标准的颞浅动脉-大脑中动脉（STA-MCA）搭桥手术。对总共68例患者的82次搭桥手术进行了回顾，平均随访期为34个月。10例患者（15%）发生中风复发，年中风风险为5%。81%的血运重建半球记录到脑血流动力学改善。与灌注储备改善的患者相比，血流动力学参数未改变或恶化的患者术后TIA或中风明显更多（分别为30%和5%的患者，p<0.05）。总之，与迄今为止仅接受抗血小板药物或抗凝治疗的患者15%的中风风险率相比，在选定的伴有血流动力学损害的闭塞性脑血管病变患者中，EC-IC搭桥手术已显示出对预防进一步脑缺血有效。
