摘要：

研究背景 烟雾病的血管搭桥术主要以大脑中动脉（MCA）作为受体动脉，围手术期和随访期间存在大脑前动脉（ACA）供血区缺血风险。本研究对比分析颞浅动脉（STA）-ACA和STA-MCA双搭桥术与STA-MCA双搭桥术治疗烟雾病的疗效。方法 纳入2017年1月至2020年12月中国医科大学附属第一医院治疗的32例大脑前动脉供血区缺血的烟雾病患者共计41例次手术，分别行STA-ACA和STA-MCA双搭桥术联合颞肌脑贴敷术（ACA组，10例计10例次手术）和STA-MCA双搭桥术联合颞肌脑贴敷术（MCA组，25例计31例次手术），对比分析颞浅动脉血流指标[包括切割流量（CF）、血流量和切割流量指数（CFI）]、桥血管通畅性、脑灌注[包括平均通过时间（MTT）、达峰时间（TTP）、脑血流量（CBF）和脑血容量（CBV）相对值]、神经功能预后[改良Rankin量表（mRS）]，以及围手术期和随访期间脑缺血和颅内出血并发症发生率和病死率。结果 32例患者顺利完成41例次手术，ACA组术中颞浅动脉CF值低于MCA组[24.00（15.38，53.00） ml/min对47（36，70） ml/min；Z=-2.547，P=0.011]，术后1周CFI值高于MCA组[3.57（1.66，4.66）对1.30（0.75，1.70）；Z=-2.357，P=0.018]，而两组术后1周颞浅动脉血流量差异无统计学意义[82.00（62.50，103.00） ml/min对75.00（27.90，104.50） ml/min；Z=-0.221，P=0.825]。ACA组桥血管通畅率为12/12，MCA组为81.58%（31/38），组间差异无统计学意义（χ²=1.268，P=0.260）。围手术期ACA组有1例次（1/10）出现双侧额叶多发点状缺血，MCA组有4例次（12.90%）出现术侧额叶缺血、1例次（3.23%）术侧颞枕叶大面积缺血伴颞叶出血，两组并发症发生率差异无统计学意义（Fisher确切概率法：P=1.000）。术后1年ACA组未发生脑缺血、颅内出血和死亡，MCA组1例次（3.23%）出现术侧额叶缺血，两组并发症发生率差异无统计学意义（Fisher确切概率法：P=1.000）；ACA组好转6例次（6/10）、无变化3例次（3/10）、恶化1例次（1/10），MCA组好转10例次（32.26%）、无变化17例次（54.84%）、恶化4例次（12.90%），组间差异亦无统计学意义（Z=-1.355，P=0.223）。结论 STA-ACA和STA-MCA双搭桥术联合颞肌脑贴敷术治疗大脑前动脉供血区缺血的烟雾病，桥血管通畅性良好，可获得满意的长期疗效；与STA-MCA双搭桥术联合颞肌脑贴敷术相比，该术式颞浅动脉CFI值更高，而术后长期疗效相当。

关键词: 脑底异常血管网病, 脑血管重建术, 颞动脉, 大脑前动脉, 大脑中动脉, 脑血管造影术

Abstract:

Background Bypass surgery for moyamoya disease (MMD) mainly used the middle cerebral artery (MCA) as the recipient artery. There is a high risk of ischemia in the blood supply area of the anterior cerebral artery (ACA) during the perioperative period and follow-up period. This study compared and analyzed the efficacy of superficial temporal artery (STA)-ACA and STA-MCA double barrel bypass and STA-MCA double barrel bypass in the treatment of MMD. Methods In total 41 hemispheres of 32 ACA territory ischemic MMD patients were treated from January 2017 to December 2020 in The First Hospital of China Medical University. Separately performed STA-ACA and STA-MCA double barrel bypass and encephalo-myo-synangiosis (EMS; ACA group, 10 hemispheres of 10 patients) and STA-MCA double barrel bypass and EMS (MCA group, 31 hemispheres of 25 patients). Compared and analyzed STA blood flow[including cut flow (CF), blood flow and cut flow index (CFI)], bypass vascular patency, cerebral perfusion[including the relative value of mean transit time (MTT), time to peak (TTP), cerebral blood flow (CBF) and cerebral blood volume (CBV)], neurological prognosis[modified Rankin Scale (mRS)], and the cerebral ischemia and intracranial hemorrhage morbidity and mortality in perioperative period and follow-up period. Results Thirty-two patients successfully completed 41 hemisphere operations. Intraoperative STA CF value of ACA group was significantly lower than MCA group[24.00 (15.38, 53.00) ml/min vs. 47 (36, 70) ml/min; Z=-2.547, P=0.011]. CFI of STA one week after operation of ACA group was significantly greater than MCA group[3.57 (1.66, 4.66) vs. 1.30 (0.75, 1.70); Z=-2.357, P=0.018]. No statistical significance between 2 groups in STA blood flow one week after operation[82.00 (62.50, 103.00) ml/min vs. 75.00 (27.90, 104.50) ml/min; Z=-0.221, P=0.825]. The ACA group anastomotic patency rate was 12/12 and the MCA group was 81.58% (31/38), the difference was not statistically significant (χ²=1.268, P=0.260). Bilateral frontal ischemia was observed in one hemisphere operation (1/10) in ACA group at perioperative period. Frontal ischemia was observed in 4 hemisphere operations (12.90%) and hemorrhagic temporal occipital infarction was observed in one hemisphere operation (3.23%) in MCA group at perioperative period. There was no statistically significant difference in the morbidity between 2 groups (Fisher exact probability:P=1.000). No cerebral ischemia, intracranial hemorrhage and death occurred in ACA group, and surgical side frontal ischemia was observed in one hemisphere operation one year after operation in MCA group. There was no statistically significant difference in the morbidity between 2 groups (Fisher exact probability:P=1.000). ACA group improved in 6 hemisphere operations (6/10), no changed in 3 hemisphere operations (3/10), deteriorated in one hemisphere operation (1/10). MCA group improved in 10 hemisphere operations (32.26%), no changed in 17 hemisphere operations (54.84%), deteriorated in 4 hemisphere operations (12.90%). There was no statistically significant difference between 2 groups (Z=-1.355, P=0.223). Conclusions The STA-ACA and STA-MCA double barrel bypass in the treatment of ACA territory ischemic MMD patients can obtain good anastomotic patency rate and satisfactory long-term efficacy. Compared with the STA-MCA double barrel bypass, this surgery can obtain higher STA CFI, while long-term outcomes of patients were the same.

Key words: Moyamoya disease, Cerebral revascularization, Temporal arteries, Anterior cerebral artery, Middle cerebral artery, Cerebral angiography