Kuroda Satoshi, Kawabori Masahito, Hirata Kenji, Shiga Tohru, Kashiwazaki Daina, Houkin Kiyohiro, Tamaki Nagara
Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan,
Acta Neurochir (Wien). 2014 Jan;156(1):77-83. doi: 10.1007/s00701-013-1961-0. Epub 2013 Dec 3.
Even after the recent randomized clinical trials JET and COSS, it is still unclear that impaired cerebrovascular reactivity (CVR) to acetazolamide and oxygen extraction fraction (OEF) can identify the candidates for superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis. This prospective study was aimed to evaluate the benefits of STA-MCA "double" anastomosis on long-term outcome in patients with reduced cerebral blood flow (CBF) and CVR (Type 3 ischemia) and elevated OEF attributable to occlusive carotid diseases.
This study included 49 patients with reduced CBF and CVR on SPECT in the ipsilateral MCA area. Using (15)O-gas PET, OEF was also measured in all patients. STA-MCA double anastomosis was recommended to the patients with Type 3 and elevated OEF. Those with Type 3 but normal OEF were medically treated.
Of 36 patients with Type 3 and elevated OEF, 25 consented to surgery. No perioperative morbidity or mortality were noted. The other 11 patients with Type 3 and elevated OEF were medically treated. Annual incidence of ipsilateral stroke was 0.7% and 6.5% in surgically and medically treated patients with Type 3 and elevated OEF, respectively (P = 0.0188). None of patients with Type 3 but normal OEF developed ipsilateral stroke during follow-up periods. STA-MCA "double" anastomosis significantly decreased OEF.
STA-MCA "double" anastomosis may still have the potential to reduce the risk of recurrent ipsilateral stroke in hemodynamically compromised patients. Further studies would be essential to advance diagnosis, surgical procedures, and perioperative managements to bring out maximal effects of bypass surgery.
即使在最近的随机临床试验JET和COSS之后，仍不清楚对乙酰唑胺的脑血管反应性（CVR）受损和氧摄取分数（OEF）能否识别颞浅动脉至大脑中动脉（STA-MCA）吻合术的候选者。这项前瞻性研究旨在评估STA-MCA“双重”吻合术对因颈动脉闭塞性疾病导致脑血流量（CBF）减少、CVR降低（3型缺血）和OEF升高的患者长期预后的益处。
本研究纳入了49例同侧大脑中动脉区域SPECT显示CBF和CVR降低的患者。所有患者均使用（15）O-气体PET测量OEF。对于3型且OEF升高的患者，建议进行STA-MCA双重吻合术。对于3型但OEF正常的患者，则进行药物治疗。
在36例3型且OEF升高的患者中，25例同意手术。未观察到围手术期发病率或死亡率。另外11例3型且OEF升高的患者接受了药物治疗。3型且OEF升高的手术治疗和药物治疗患者同侧卒中的年发病率分别为0.7%和6.5%（P = 0.0188）。在随访期间，3型但OEF正常的患者均未发生同侧卒中。STA-MCA“双重”吻合术显著降低了OEF。
STA-MCA“双重”吻合术仍有可能降低血流动力学受损患者同侧复发性卒中的风险。进一步的研究对于改进诊断、手术操作和围手术期管理以发挥旁路手术的最大效果至关重要。
