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中华脑血管病杂志(电子版)

中华脑血管病杂志(电子版) ›› 2021, Vol. 15 ›› Issue (01) : 34 -40. doi: 10.11817/j.issn.1673-9248.2021.01.006

所属专题： 文献；

论著

荧光造影在烟雾病颅内外血管搭桥术中的应用
黄亚波1, 周鹏1, 韩庆东1, 陆晓诚1, 惠品晶1, 颜艳红1, 张世明1, 王中1,†()   
  1. 1. 215006　苏州大学附属第一医院神经外科
  • 收稿日期:2020-08-13 出版日期:2021-02-01
  • 通信作者: 王中

Intraoperative fluorescent angiography application in intracranial-to-extracranial bypass surgery treatment for moyamoya disease

Yabo Huang1, Peng Zhou1, Qingdong Han1, Xiaocheng Lu1, Pingjin Hui1, Yanhong Yan1, Shiming Zhang1, Zhong Wang1,†()   

  1. 1. Department of Neurosurgery, the First Affiliated Hospital of Soochow University, Suzhou 215006, China
  • Received:2020-08-13 Published:2021-02-01
  • Corresponding author: Zhong Wang
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黄亚波, 周鹏, 韩庆东, 陆晓诚, 惠品晶, 颜艳红, 张世明, 王中. 荧光造影在烟雾病颅内外血管搭桥术中的应用[J]. 中华脑血管病杂志(电子版), 2021, 15(01): 34-40.

Yabo Huang, Peng Zhou, Qingdong Han, Xiaocheng Lu, Pingjin Hui, Yanhong Yan, Shiming Zhang, Zhong Wang. Intraoperative fluorescent angiography application in intracranial-to-extracranial bypass surgery treatment for moyamoya disease[J]. Chinese Journal of Cerebrovascular Diseases(Electronic Edition), 2021, 15(01): 34-40.

目的

应用荧光造影技术于烟雾病（MMD）颅内外血管搭桥术中研究皮质脑血流动力学特点及致病机制。

方法

回顾性分析2019年6~12月苏州大学附属第一医院收治的28例缺血性MMD（MMD组）和16例动脉粥样硬化性脑血管疾病（ACVD组）所致烟雾综合征患者，均采用颞浅动脉-大脑中动脉（STA-MCA）搭桥术联合脑-硬膜-肌肉-动脉-颅骨周围组织血管融合术进行治疗。同时选取同期收治的5例未破裂动脉瘤患者作为对照组（均采用夹闭术进行治疗）。应用吲哚菁绿（ICG）荧光造影结合Flow 800软件分析搭桥术中吻合血管的畅通性、血流方向和“分水岭推移”现象；同时术中应用荧光素钠（NaFL）荧光造影评估NaFL外渗。比较各组患者外渗发生率及外渗程度。

结果

术中证实44例患者STA-MCA搭桥术的吻合口均通畅，42例为双向血流，2例为单向血流；2例MMD患者搭桥术中观测到大脑皮质“分水岭推移”现象。在对照组患者中未观察到外渗，27例（96.4%）MMD组患者和11例（68.8%）ACVD组患者搭桥术中出现NaFL外渗。MMD组患者NaFL外渗程度比ACVD组患者高，且差异有统计学意义（χ2=8.92，P=0.03）。

结论

ICG联合Flow 800软件进行血流动力学分析有助于了解MMD患者颅内外血管搭桥术中复杂的皮质血流动力学变化，术中NaFL荧光造影证实MMD患者存在血脑屏障破坏。

关键词: 荧光造影, 烟雾病, 血管搭桥术
Objective

To investigate cortical hemodynamic characteristics and pathogenic mechanism using intraoperative fluorescent angiography after superficial temporal artery-middle cerebral artery (STA-MCA) bypass surgery in moyamoya disease (MMD).

Methods

The clinical data of 28 patients with MMD and 16 patients with atherosclerotic cerebrovascular disease (ACVD) were analyzed retrospectively. These patients were admitted in Department of Neurosurgery，the First Affiliated hospital of Soochow University between June 2019 and December 2019. The STA-MCA anastomosis with encephalo-duro-myo-arterio-pericranio-synangiosis (EDMAPS) was used for cerebral revascularization. We used intraoperative indocyanine green (ICG) angiography with Flow 800 software to analyze check bypass patency, flow direction and the phenomenon of "watershed shift" in STA-MCA bypass surgery. The patients were divided into MMD group, ACVD group and control group (5 patients that underwent clipping for unruptured aneurysms). Sodium fluorescein (NaFL) extravasation was evaluated during videoangiography when checking for bypass patency. A grading system (0, +, ++, +++) was used to define the extent of extravasation. Frequency and intensity of leakage was compared among different groups.

Results

During the operation, it was confirmed that the anastomosis of all the 44 cases of STA-MCA bypass surgery was patency, with 42 cases of two-way blood flow and 2 cases of one-way blood flow. The phenomenon of "watershed shift" was observed in the cerebral cortex of 2 patients with moyamoya disease during bypass surgery. NaFL extravasation was observed in none of the patients undergoing clipping for unruptured aneurysms. NaFL extravasation appeared in 27/28 (96.4%) patients with MMD and in 11/16 (68.7%) patients with ACVD during bypass procedures. The MMD group was characterized by a much greater intensity of NaFL extravasation (grade +++ in 60.7%) than the ACVD group (grade +++ in 25.0%, P＜0.05).

Conclusions

Intraoperative ICG fluorescence angiography combined with hemodynamic parameter analysis obtained by Flow 800 software is an effective method to evaluate the complex hemodynamic characteristics after STA-MCA bypass surgery in moyamoya disease. Intraoperative NaFL fluorescence angiography confirmed the presence of blood-brain barrier disruption in moyamoya disease. It provides a new perspective to explore the pathogenic mechanism of moyamoya disease.

Key words: Fluorescent angiography, Moyamoya disease, Bypass Surgery
图1 术中吲哚菁绿（ICG）荧光造影结合Flow 800软件分析皮质脑血流动力学变化。图a为搭桥前显微镜下显示大脑皮质动脉分布；图b为搭桥前术中ICG荧光造影发现血流在此处双向摆动（黑色箭头），说明此处存在血流对冲点；图c为搭桥前Flow 800软件分析显示血流双向波动的血流对冲点（黑色箭头）；图d显示颞浅动脉-大脑中动脉（STA-MCA）端侧血管吻合术；图e为术中ICG荧光造影显示吻合血管血流通畅，出现新的血流双向摆动的血流对冲点（白色箭头）；图f为Flow 800软件分析显示吻合血管血流通畅，呈红色“T”型双向血流（黑色箭头），出现新的血流双向波动的血流对冲点（白色箭头），即“分水岭移位”现象
图2 术中采用荧光素钠（NaFL）荧光造影半定量分级系统量化NaFL外渗程度。图a显示无NaFL外渗，为0级；图b显示少于5个小的外渗点（白色箭头），为+级；图c显示大于等于5个小点或1个大点（白色箭头），为++级；图d显示2个或更多的大点，为+++级；图e显示在高倍镜下观察大片NaFL外渗点的特点：外渗区皮质血管壁看起来颜色更暗，皮质表面和深部的薄壁组织的染色更深；图f显示血流发生层流，在高倍镜下呈现为颜色更深的黄绿色线样血流（白色箭头），动态观察可以清晰地看清血流呈双向流动
表1 各组患者术中NaFL外渗发生率及外渗程度比较[例（%）]
组别 例数 外渗发生率 外渗程度分级
0 + ++ +++
对照组 5 0（0） 5（100） 0 0 0
ACVD组 16 11（68.8） 5（31.25） 3（18.75） 4（25.0） 4（25.0）
MMD组 28 27（96.4） 1（3.6） 3（10.7） 7（25.0） 17（60.7）
χ2值 6.23 8.92
P值 0.01 0.03
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