摘要： 目的 总结烟雾病患者大脑中动脉供血区血流方向，对比分析顺血流搭桥术与逆血流搭桥术对围手术期并发症和桥血管长期通畅性的影响。方法 纳入2010年6-12月在复旦大学附属华山医院行颞浅动脉-大脑中动脉搭桥术联合脑-硬膜-颞肌贴敷术和硬膜翻转术的50例烟雾病患者，术前均根据DSA判断大脑中动脉供血区血流方向，并根据桥血管血流方向分为顺血流组（与受体动脉血流方向一致，32例）和逆血流组（与受体动脉血流方向相反，18例）。吲哚菁绿荧光血管造影术（ICGA）观察术中血流对冲现象，记录围手术期短暂性神经功能障碍和术后30天缺血性卒中发生率；中期随访（平均为7.31个月）分别以DSA和Matsushima分级系统评价吻合口通畅性及桥血管供血范围；远期疗效（平均39.72个月）则以TCD显示的桥血管收缩期峰值流速（PSV）、舒张期末流速（EDV）和阻力指数（RI）等血流动力学特征为主要评价指标。结果 ICGA证实两组患者吻合口均保持通畅，但顺血流组血流对冲（χ²=4.668，P=0.031）和术后短暂性神经功能障碍（χ²=6.630，P=0.010）发生率均低于逆血流组，而术后30天缺血性卒中发生率组间差异无统计学意义（χ²=0.177，P=0.674）；中期随访时，吻合口仍保持通畅，两组桥血管供血范围差异亦无统计学意义（χ²=0.613，P=0.434）；长期随访时，顺血流组桥血管PSV（t=3.599，P=0.001）和EDV（t=2.993，P=0.004）高于逆血流组、RI低于逆血流组（t=3.328，P=0.002）。结论 顺血流搭桥术可以有效降低围手术期分水岭推移和术后短暂性神经功能障碍的风险，且远期疗效观察其桥血管血流速度更快、阻力指数更低。

关键词: 脑底异常血管网病, 脑血管重建术, 大脑中动脉, 血流动力学, 手术中并发症, 手术后并发症

Abstract: Objective To analysis the middle cerebral artery (MCA) blood flow direction and compare the efficacy and safety of orthodromic and antidromic bypass. Methods Fifty cases with moyamoya disease (MMD) surgical treated in Huashan Hospital of Fudan University from June to December 2010 were enrolled in the study. MCA blood flow direction was analysed according to DSA and classified into two types (antegrade flow and reversed flow). The surgical procedure was superficial temporal artery (STA)-MCA bypass, combined with encephalo-duro-myo-synangiosis (EDMS) and dural subvolution. For the bypass procedure, when blood flow in donor and recipient artery was in same direction, the case would be classified into orthodromic bypass group (orthodromic group, 32 cases), otherwise as antidromic bypass group (antidromic group, 18 cases). Blood flow interference phenomenon on cortex surface detected by intraoperative indocyanine green angiography (ICGA), postoperative transient neurological dysfunction (TND) and ischemic stroke in postoperative 30 d. DSA data and Matsushima grading system were used to evaluate anastomotic patency and bypass blood perfusion area in mid-term follow-up (mean 7.31 months). Hemodynamic parameters such as peak systolic velocity (PSV), end diastolic velocity (EDV) and resistant index (RI) demonstrated by transcranial Doppler (TCD) in long-term follow-up (mean 39.72 months) were all documented and used to compare the safety and efficacy between 2 groups. Results Patency of all stomas were confirmed by ICGA. The orthodromic group demonstrated a lower rate of blood flow interference (χ²=4.668, P=0.031) and TND (χ²=6.630, P=0.010) compared with antidromic group. The incidence of ischemic stroke had no difference between 2 groups (χ²=0.177, P=0.674). In mid-term follow-up, DSA confirmed the patency of all stomas, and no difference in bypass blood perfusion area between 2 groups (χ²=0.613, P=0.434). During long-term follow-up, syndromic group showed higher PSV (t=3.599, P=0.001) and EDV (t=2.993, P=0.004), and lower RI (t=3.328, P=0.002) compared with antidromic group. Conclusions Orthodromic bypass may reduce the risk of watershed shift and TND in perioperative period, increase blood flow velocity and decrease RI in the bypass vessel in long-term follow-up.

Key words: Moyamoya disease, Cerebral revascularization, Middle cerebral artery, Hemodynamics, Intraoperative complications, Postoperative complications