小儿烟雾病血管病中脑血管血压自动调节监测与术后短暂性脑缺血发作
Cerebrovascular blood pressure autoregulation monitoring and postoperative transient ischemic attack in pediatric moyamoya vasculopathy.
作者信息
Lee Jennifer K, Williams Monica, Reyes Michael, Ahn Edward S
机构信息
Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA.
Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
出版信息
Paediatr Anaesth. 2018 Feb;28(2):94-102. doi: 10.1111/pan.13293. Epub 2017 Dec 5.
BACKGROUND
Children with moyamoya vasculopathy are at high risk of perioperative cerebral ischemia or hyperperfusion. Maintaining blood pressure within the range of functional cerebrovascular blood pressure autoregulation might reduce the risk of perioperative neurologic injury.
AIMS
We tested whether blood pressure autoregulation is associated with postoperative transient ischemic attack in a study of patients with pediatric moyamoya vasculopathy.
METHODS
We conducted an observational study of 15 pediatric patients undergoing surgical revascularization with pial synangiosis. Nine patients had bilateral moyamoya and 6 had unilateral moyamoya. We measured autoregulatory vasoreactivity intraoperatively and during the first postoperative night with the hemoglobin volume index, a value derived from near-infrared spectroscopy. We also identified the optimal mean arterial blood pressure at which autoregulation was most robust in each patient.
RESULTS
Of the 15 children monitored, 3 with bilateral moyamoya and one with unilateral moyamoya experienced a transient ischemic attack. Poorer autoregulation during surgery was associated with postoperative transient ischemic attack among those with bilateral vasculopathy (P = .048, difference in hemoglobin volume index medians: 0.023, 95% confidence interval: 0.003-0.071). This relationship was not observed with postoperative autoregulation. The optimal mean arterial blood pressure was identifiable during surgery in all monitored patients, varied among patients, and often differed between the intraoperative and postoperative periods.
CONCLUSION
Dysfunctional intraoperative autoregulation may increase the risk of TIA in patients with pediatric moyamoya vasculopathy. The blood pressure range that supports autoregulation appears to vary among patients. Using autoregulation monitoring to guide individualized blood pressure goals should be studied as a potential method to reduce perioperative neurologic morbidity in pediatric patients with moyamoya.
背景
烟雾病性血管病变患儿围手术期发生脑缺血或高灌注的风险较高。将血压维持在功能性脑血管血压自动调节范围内可能会降低围手术期神经损伤的风险。
目的
在一项关于小儿烟雾病性血管病变患者的研究中，我们测试了血压自动调节与术后短暂性脑缺血发作是否相关。
方法
我们对15例接受软脑膜血管吻合术进行血管重建手术的儿科患者进行了一项观察性研究。9例患者为双侧烟雾病，6例为单侧烟雾病。我们在术中及术后第一个晚上使用血红蛋白体积指数（一种源自近红外光谱的值）测量自动调节血管反应性。我们还确定了每位患者自动调节最稳定时的最佳平均动脉血压。
结果
在监测的15名儿童中，3例双侧烟雾病患者和1例单侧烟雾病患者发生了短暂性脑缺血发作。在双侧血管病变患者中，手术期间较差的自动调节与术后短暂性脑缺血发作相关（P = 0.048，血红蛋白体积指数中位数差异：0.023，95%置信区间：0.003 - 0.071）。术后自动调节未观察到这种关系。在所有监测患者的手术期间均可确定最佳平均动脉血压，不同患者之间存在差异，并且术中和术后期间通常也有所不同。
结论
小儿烟雾病性血管病变患者术中自动调节功能障碍可能会增加短暂性脑缺血发作的风险。支持自动调节的血压范围似乎因患者而异。应研究使用自动调节监测来指导个体化血压目标，作为降低小儿烟雾病患者围手术期神经发病率的一种潜在方法。
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