单心室分期手术重建过程中的神经损伤与脑血流量
Neurological Injury and Cerebral Blood Flow in Single Ventricles Throughout Staged Surgical Reconstruction.
作者信息
Fogel Mark A, Li Christine, Elci Okan U, Pawlowski Tom, Schwab Peter J, Wilson Felice, Nicolson Susan C, Montenegro Lisa M, Diaz Laura, Spray Thomas L, Gaynor J William, Fuller Stephanie, Mascio Christopher, Keller Marc S, Harris Matthew A, Whitehead Kevin K, Bethel Jim, Vossough Arastoo, Licht Daniel J
机构信息
From Division of Cardiology, Department of Pediatrics (M.A.F., C.L., T.P., F.W., M.A.H., K.K.W.), Department of Radiology (M.A.F., M.S.K., M.A.H., K.K.W., A.V.), Department of Anesthesiology and Critical Care Medicine (S.C.N., L.M.M., L.D.), Division of Cardiothoracic Surgery, Department of Surgery (T.L.S., J.W.G., S.F., C.M.), and Department of Neurology (P.J.S., D.J.L.), The Children's Hospital of Philadelphia/Perelman School of Medicine, University of Pennsylvania, Philadelphia; and Westat, Rockville, MD (O.U.E., J.B.).
出版信息
Circulation. 2017 Feb 14;135(7):671-682. doi: 10.1161/CIRCULATIONAHA.116.021724. Epub 2016 Dec 28.
BACKGROUND
Patients with a single ventricle experience a high rate of brain injury and adverse neurodevelopmental outcome; however, the incidence of brain abnormalities throughout surgical reconstruction and their relationship with cerebral blood flow, oxygen delivery, and carbon dioxide reactivity remain unknown.
METHODS
Patients with a single ventricle were studied with magnetic resonance imaging scans immediately prior to bidirectional Glenn (pre-BDG), before Fontan (BDG), and then 3 to 9 months after Fontan reconstruction.
RESULTS
One hundred sixty-eight consecutive subjects recruited into the project underwent 235 scans: 63 pre-BDG (mean age, 4.8±1.7 months), 118 BDG (2.9±1.4 years), and 54 after Fontan (2.4±1.0 years). Nonacute ischemic white matter changes on T2-weighted imaging, focal tissue loss, and ventriculomegaly were all more commonly detected in BDG and Fontan compared with pre-BDG patients (<0.05). BDG patients had significantly higher cerebral blood flow than did Fontan patients. The odds of discovering brain injury with adjustment for surgical stage as well as ≥2 coexisting lesions within a patient decreased (63%-75% and 44%, respectively) with increasing amount of cerebral blood flow (<0.05). In general, there was no association of oxygen delivery (except for ventriculomegaly in the BDG group) or carbon dioxide reactivity with neurological injury.
CONCLUSIONS
Significant brain abnormalities are commonly present in patients with a single ventricle, and detection of these lesions increases as children progress through staged surgical reconstruction, with multiple coexisting lesions more common earlier than later. In addition, this study demonstrated that BDG patients had greater cerebral blood flow than did Fontan patients and that an inverse association exists of various indexes of cerebral blood flow with these brain lesions. However, CO reactivity and oxygen delivery (with 1 exception) were not associated with brain lesion development.
CLINICAL TRIAL REGISTRATION
URL: http://www.clinicaltrials.gov. Unique identifier: NCT02135081.
背景
单心室患者脑损伤发生率高且神经发育不良结局常见；然而，在整个手术重建过程中脑异常的发生率及其与脑血流量、氧输送和二氧化碳反应性的关系尚不清楚。
方法
对单心室患者在双向格林分流术（BDG）前、Fontan手术前（BDG）以及Fontan重建术后3至9个月进行磁共振成像扫描研究。
结果
该项目连续招募的168名受试者共接受了235次扫描：63次在BDG前（平均年龄4.8±1.7个月），118次在BDG时（2.9±1.4岁），54次在Fontan术后（2.4±1.0岁）。与BDG前的患者相比，在BDG和Fontan阶段，T2加权成像上的非急性缺血性白质改变、局灶性组织丢失和脑室扩大更为常见（<0.05）。BDG患者的脑血流量显著高于Fontan患者。随着脑血流量增加，校正手术阶段以及患者存在≥2种并存病变后发现脑损伤的几率降低（分别为63%-75%和44%）（<0.05）。总体而言，氧输送（BDG组脑室扩大除外）或二氧化碳反应性与神经损伤无关联。
结论
单心室患者通常存在明显的脑异常，随着儿童进行分期手术重建，这些病变的检出率增加，多种并存病变在早期比晚期更常见。此外，本研究表明BDG患者的脑血流量高于Fontan患者，且脑血流量的各种指标与这些脑病变呈负相关。然而，二氧化碳反应性和氧输送（有1个例外）与脑病变发展无关。
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