顱外顱內(nèi)旁路手術(shù)

1、顱外-顱內(nèi)動脈旁路手術(shù)：歷史、現(xiàn)狀與展望EXTRACRANIAL-INTRACRANIAL BYPASS SURGERYPAST, PRESENT AND FUTURE,解放軍總醫(yī)院神經(jīng)外科 全軍神經(jīng)外科研究所 Dept of Neurosurg, General Hospital of PLAInstitute of Neurosurg, Chinese PLA,Pioneers of Bypass Procedure

2、s● Jacobson(1960)(Vermont) Reconstructed carotid arteries of dogs and rabbits, achieving a 100% patency rate● Donaghy (Vermont) Established microsurgical lab, reconstructed vessels <1mm in dia

3、meter,旁路手術(shù)的先驅(qū) ● Jacobson(1960)(佛蒙得） 重建犬和兔頸動脈，100% 通暢 ● Donaghy (佛蒙得） 建立顯微神經(jīng)外科實驗室， 重建直徑<1mm的血管,HISTORY OF BYPASS PROCEDURES,旁路手術(shù)歷史,M.G. Yasargil & His Contributions● Interest was stimulated when

4、 he was asked to perform an embolectomy of a cortical artery, not yet mastered. ● Enthusiasm to cerebral revas- cularization increased after the report of an EC-IC bypass,M.G.Yasargil及其貢獻

5、 ● 其興趣因一例皮層動脈取栓 術(shù)（尚未掌握該技術(shù)）激發(fā) ● Woringer(1963) EC/IC 旁路手術(shù)論文的發(fā)表進一步 引起其熱情,● 1964 International Congress of Neuroradiologists Drs. Sweet and Rasmussen advised him to contact prof. Don

6、aghy 1965 Yasargil began his training in Donagh’s lab. 196

7、4年，國際神經(jīng)放射大會，Sweet 和Rasmussen 建議其與 Donaghy聯(lián) 系。1965年，開始在Donaghy實驗室 訓(xùn)練。,● Initial attempts to interpose a femoral vascular graft from CCA to MCA. The graft would progress to thrombosis. The

8、 idea of performing STA-MCA bypass was then born.● By the end of 1966 more than 30 STA-MCA bypass in dogs had been performed,● 初始時，作CCA-股部血管 移植物-MCA術(shù)，但移植血 管內(nèi)血栓形成。 產(chǎn)生STA-MCA旁路術(shù)設(shè)想 ● 至1966年底完成30余

9、例犬 STA-MCA旁路術(shù),Oct. 30, 1967 Yasargil performed the first STA-MCA bypass, in a patient with Marfan syndrome and complete occlusion of MCA A major step was made into the field of reconstructive intracranial vascula

10、r microneurosurgery. 1967年，Yasargil為一例Marfan綜合征伴大腦中動脈閉塞者成功施行首例STA-MCA旁路術(shù)顱內(nèi)血管重建的重要進展！,●,Cerebral Ischemia● Since 1967 STA-MCA bypass had been wide accepted, although the indications remained controversial by the end

11、 of 1960’.Dr.Zang renhe performed the first case of STA-MCA bypass in China(1976).,腦缺血 ● 1967年后，STA-MCA被廣泛應(yīng) 用，盡管到六十年代末，其適應(yīng) 證仍有爭議。臧人和教授于1976年在國內(nèi)首先開展STA-MCA旁路術(shù)。,INDICATIONS FOR BYPASS,,旁路手術(shù)應(yīng)用,● 1977 North American

12、 EC-IC Bypass Study (by Dr. Henry Barnett),● 1977年開始的北美EC-IC旁路研究,內(nèi)科治療組 714例 0.6%STA-MCA+內(nèi)科 663例 2.5%,30天死亡和致殘、卒中率,Conclusion: STA-MCA was ineffective in preventing

13、 cerebral ischemia,結(jié)論：STA-MCA不能防止腦缺血,● Failure of extracranial-intra- cranial arterial bypass to reduce the risk of ischemic stroke. Results of an inter- national randomized trial. The EC/IC Bypas

14、s Study Group. N Engl J Med 313:1191-1200, 1985● Marked decrease in the number of STA-MCA bypass performed for cerebral ischemia,● 顱內(nèi)-外動脈旁路術(shù)不能降 低缺血性卒中的風(fēng)險。國際 隨機試驗結(jié)果。EC/IC研究 組，新英格蘭醫(yī)學(xué)313:1191, 1985

15、 ● STA-MCA旁路手術(shù)量明顯 減少,● Criticism to EC/IC Bypass Study ▲ Patients were not evaluated preoperatively cerebrovascular hemodynamic status ▲ Both patient and therapist were not bl

16、ined ▲ Only half of the patients receiving antiplatelet agents ▲ A large percentage of patients had no symptoms before entry ▲ A large number of patients underwent surgery outside t

17、he study,● 對EC/IC旁路研究的批評 ▲ 未評估病人術(shù)前的腦血流動力 狀態(tài) ▲ 非雙盲研究 ▲僅半數(shù)病人接受抗血小板治療 ▲ 相當(dāng)部分病人入組前無癥狀 ▲許多手術(shù)病人未納入研究,● The study investigators pointed out that randomized trials involve only a small

18、 fraction of the population at risk and that this factor does not prevent a study from be- ing valid.,● 研究組人員回應(yīng) 承認(rèn)該隨機試驗僅包括小部 分卒中風(fēng)險人群，但并不影 響試驗的可靠性,● The Carotid Occlusion Surgery Study Randomize

19、d Trial(COSS) U.S and Canada, 49 clinical centers 18 PET centers (2002~2010 ),● 頸動脈閉塞手術(shù)隨機研究（COSS） 美國、加拿大 49 個臨床中心 18個PET中心 (2002~2010),30天同側(cè)卒中 2年終點事件 手術(shù)組（STA-MCA+內(nèi)科治療） 97例 14

20、（14.4%） 20（21.0%）內(nèi)科組（抗栓+危險因素控制） 98例 2（2.0%） 20（22.7%）,Conclusion: EC-IC bypass did not reduce the risk of recurrent ipsilateral ischemic stroke at 2 years. JAMA,306:1983,2011,結(jié)論：E

21、C/IC旁路術(shù)不能降低同 側(cè)缺血性卒中的風(fēng)險 JAMA,306:1983,2011,● For patients with symptomatic extracranial carotid occlusion, EC/IC bypass is not routinely recommended ( Class Ⅲ Evidence A) ● For pati

22、ents with stroke or TIA due to 50% to 99%stenosis of a major intracranial artery, EC/IC bypass is not recommended (Class Ⅲ Evidence B) AHA/ASA Guidelines for the Prevention of stroke 2011,●

23、癥狀性顱外頸動脈閉塞，通常不推薦 旁路術(shù)（Ⅲ級推薦，A級證據(jù)）,● 顱內(nèi)主要動脈狹窄50%以上，不推薦 旁路術(shù) （Ⅲ級推薦，B級證據(jù)） 美國心臟學(xué)會/卒中學(xué)會 2011版卒中 預(yù)防指南,● Extracranial-Intracranial Bypass for Stroke — Is This the End of the Line or a Bump in the Road?

24、 Neurosurgery 71:557,2012,● 顱內(nèi)外旁路手術(shù)預(yù)防卒中— 路 到盡頭，還是（又一）撞擊？ 神經(jīng)外科 71:557,2012,● Although general expansion of EC/IC bypass use would not be supported, a select subset of patients with medically

25、refractory hemodynamic symptoms may well benefit from surgery. ● Limited application and further study with an eye to future developments, rather than complete abandonment, is warranted.,● 雖然不

26、支持廣泛開展，但對某些 藥物治療無效的血動力學(xué)損害的 病人，手術(shù)可能有益。● 有限的應(yīng)用加上著眼于未來的 進一步研究，而不是完全放棄。,Acute stroke● Emergent cerebral revascula-rization is very rationalEncouraging results were reported. ● But others considered the acute is

27、chemia a relative contraindicationConclusion: Only those patients with crescendo TIA or mild to moderate deficits <6 hrs with no infarction should be considered for EC/IC bypass,急性卒中● 急診腦血運重建合理，有報 告結(jié)果令人鼓舞 ●

28、其他學(xué)者認(rèn)為，急性缺血是 急診重建的相對禁忌。,Crowell, Jafar(1986) 報告67例，27例改善，26例無變化，11例死亡,結(jié)論：EC/IC旁路術(shù)僅可用于漸進性TIA或輕至中度缺陷（ <6 hrs ）且無梗死者,● With the advent of interventional neuroradiology and thrombolytic therapies, emergent E

29、C/IC bypass for acute stroke decreased,● 介入神經(jīng)放射和溶栓治療的出 現(xiàn)，使急性卒中的急診旁路術(shù) 減少 。,SAH and Cerebral Vasospasm ● STA-MCA bypass has been performed ● This indication did not gain wide acceptance. Endovascu

30、lar techniques combined with“3H” therapy assumed a pivotal role,SAH與腦血管痙攣● 曾采用STA-MCA旁路術(shù),Batjer, Samson(1986) 報告11例，術(shù)后6例改善，2例穩(wěn)定,● 未被廣泛接受。主要采用血 管內(nèi)技術(shù)和“三高” 療法,Forty-two-year-old abuser with SAH from a mycotic left

31、 middle cerebral aneurysm. A,preoperative lateral carotid injection shows proximal carotid spasm.B,lateral common carotid angiogram 2 weeks after bypass shows maturation of bypass.C,lateral common carotid angiogram 3 wee

32、ks after bypass shows improvement in carotid spasm and diminished caliber of bypass.,Aneurysms ● Carotid artery occlusion remained the mainstay for some aneurysms ,but ischemic deficits maybe occur.,動脈瘤● 頸動脈閉塞依然是某些顱內(nèi)動脈

33、 瘤的重要治療手段，但可能發(fā)生 缺血損害。,頸動脈閉塞后 腦缺血損害,閉塞后腦缺血損害,破裂動脈瘤 33% 頸內(nèi)動脈 41%~59%未破裂動脈瘤 12% 頸總動脈 24%~32%,● Yas

34、argil (1967) 2 cases of STA-MCA for giant supraclinoid ICA aneurysm ● Lougheed (1971) First EC/IC bypass (CCA- saphenous vein- intracranial ICA) was performed ● Sundt(1982) Pioneered the use

35、 of vein grafts (SVGs) from ext- racranial arteries to intracran- ial arteries for treatment of unclippable aneurysms,● Yasargil(1967) 2例床突上段巨 大頸內(nèi)動脈瘤術(shù)中采用STA-MCA 旁路術(shù) ● Lougheed(1971) 完成首例頸總

36、 動脈-大隱靜脈-顱內(nèi)頸內(nèi)動脈旁路 術(shù) ● Sundt（1982） 顱外動脈-大隱 靜脈-顱內(nèi)動脈旁路術(shù)用于不可夾 閉動脈瘤的先驅(qū),● Ausman （1978） First described the use of radial artery grafts (RAGs) ● Morimoto (1988) Use of RAG for aneurysms,● Ausman (1978)

37、 首次介紹用橈動脈作移植物?！?Morimoto (1988) 將之用于動脈瘤手術(shù),45 M, ECA-MCA bypass followed by trapping of the giant supraclinoid ICA aneurysm with preserva-tion Of anterior choroidal artery (arrow),65, F, Ce

38、rvical ICA-SVG - MCA2 bypass was performed followed by trapping of the giant intracavernous aneurysm,● Spetzler(1990’) Developed several innovations ▲ the bonnet bypass ▲ multiple arterial anas

39、tomosis ▲ use of metabolic brain protection ▲ use of heparin ▲ petrous ICA-SVG-supraclinoid ICA bypass,● Spetzler(90年代） 若干創(chuàng)新 ▲ bonnet 旁路術(shù)（從頭的一側(cè)至 另一側(cè)） ▲ 多支動脈吻合 ▲ 腦代謝保護措施 ▲ 肝素

40、 ▲ 巖骨段頸內(nèi)動脈-大隱靜脈-床突 上段頸內(nèi)動脈旁路術(shù),Case 1 M,55,Left common carotid artery aneurysm, no filling of the external carotid artery.RSTA-LMCA bypass was performed.,● Sekhar’s innovations ▲ placement of distal anastomosis

41、 of SVG into the M1 or M2 bifurcation ▲ use of ICA or ECA for the proximal anastomosis ▲ use of intraoperative DSA to study the bypass graft ▲ ECA-petrous ICA grafts ▲ extr

42、acranial VA-MCA or intracranial VA grafts ▲ BA-vein graft-BA (under hypothermic circulatory arrest),● Sekhar 的創(chuàng)新 ▲ 將大隱靜脈遠端吻合于 M1或 M2 分叉 ▲ 近端吻合于ICA或ECA ▲ 術(shù)中DSA即時檢查移植血管 ▲ 頸外動脈-

43、移植血管-巖骨段頸內(nèi) 動脈 ▲ 顱外椎動脈-移植血管-大腦中動 脈或顱內(nèi)椎動脈 ▲ 基底動脈 - 移植血管 - 基底動脈 （低溫停循環(huán)下）,Saphenous Vein Graft Reconstruction of an Unclippable Giant Basilar Artery Aneurysm Performed with the Patient under Deep Hypoth

44、ermic Circulatory Arrest.,● Other innovations ▲ use of internal maxillary artery as donor vessel ▲ use of tunnel through the floor of middle fossa rather than subcutaneous one ▲

45、 endoscopic harvest of saphenous vein ▲ excimer laser-assisted non- occlusive anastomosis (ELANA) ▲ blood folw evaluation by the use of non-invasive optimal vessel analysis (NOVA) an

46、d intraopera- tive quantitative flow measure- ment ▲ intraoperative evaluation using indocyanine green,● 其它創(chuàng)新 ▲ 用頜內(nèi)動脈作供血動脈 ▲ 移植血管穿越中顱窩底隧道而 非皮下 ▲ 內(nèi)鏡下截取大隱靜脈 ▲ 消融激光輔助非阻斷吻合

47、 (ELANA) ▲術(shù)中無創(chuàng)血流定量分析 （NOVA) ▲ 術(shù)中吲哚青綠評估,Schematic diagram depicts the endoscopic SVG harvest. A: The fiberoptic trocar is used to initially locate and dissect the saphenous vein. B: Insufflation is perfor

48、med with carbon dioxide to create room for further dissection. C: The cautery scissors are used to coagulate and transect tributary veins. D: The vein cradle is used to run the length of the vein before the vein graft re

49、moval.,Excimer Laser-Assisted Nonocclusive Anastomosis (ELANA) Technique,Case 1 ECA-SVG-ICA bifercation bypass for treatment of a giant cavernous ICA aneurysm. The intracranial anastomosis was performed with

50、 the aid of ELANA,Case 2 Petrous ICA-SVG-MCA bypass for treatment of a previously coiled para-ophthalmic aneurysm. Both anastomsis were performed with the aid of ELANA,Skull Base Tumors ● The use o

51、f bypass to enable operations on difficult skull base tumors is generally accepted but is not without detractors,顱底腫瘤● 為切除某些復(fù)雜的顱底腫瘤，旁 路手術(shù)被接受，但并非無反對,,Case 1 Recurrent chondrosarcoma. During operat

52、ion, the intracavernous ICA was ruptured. Emergency radial artery bypass graft was performed from cervical ICA to MCA2.,Case 2 47, F Intracavernous and supracavernous meningioma encasing and narrowing the left

53、ICA,ECA-RAG-MCA2 and cervical ICA-SVG-MCA2,● The use of bypass for skull base tumors has greatly declined because of use of radiosurgery for tumor remnants. However, this technique remains a v

54、aluable tool,● 因放射外科的應(yīng)用，旁路手術(shù)用 于顱底腫瘤大為減少，但依然是 一有用方法,● When a major vessel is invaded or encased by tumors, there are two controversies: Whether one try to skeletonize the tumor or whether th

55、e vessel should be resected ? Whether the patient should be revascularized universally or selectively ?,● 對重要血管被腫瘤侵犯或包 繞，兩點爭論： 將腫瘤與血管分開，還 是連同血管一并切除？ 將重要血管切除后，常 規(guī)還是選擇性施行

56、血運重 建？,● Whether the vessel should be left in situ depends upon the attitude of surgeon and the nature of tumor Benign tumors other than meningioma may usually be dissected a

57、way from vessel. Chordoma and chondrosarco- ma, most can be dissected away from vessel, but in some patients grafting will be needed.,● 是否保留血管，取決于醫(yī)生和腫瘤 性質(zhì) 除腦膜瘤外的良性腫瘤，多可 與血管分開。

58、 脊索瘤和軟骨肉瘤也多可與血 管分開，但有時需切除血管并作旁 路手術(shù)。,● Whether or not a bypass should be performed in all patients whose ICA or VA has been sacrificed?－controversial Selective approach on

59、 the basis of preoperative occlusion test Universal approach on the basis of argument that even if adequate collateral circulation present, patients may still sustain a stroke after

60、 vascular occlusion,● 重要血管切除后，是否均需作旁路 術(shù) — 爭議 選擇施行 根據(jù)術(shù)前閉塞試驗 結(jié)果 常規(guī)施行 因即使側(cè)支循環(huán)良 好，血管閉塞后仍可發(fā)生卒中 Origitano (1994) 22% TIA 或梗死 Larson(1995) 10%TIA, 5% 梗死 , 5%死亡,Moyamoya Disease

61、● Yasargil (1972) First case of STA-MCA for a 4-year old child with moyamoya disease● Spetzler (1980) Indirect STA- MCA for bilateral occlusion of supraclinoid ICA (direct STA- MCA was planned, but

62、 no suitable recipient cortical vessel was found at surgery）,煙霧病● Yasargil (1972) 首次為一例4歲 moyamoya 病兒施行STA-MCA術(shù)● Spetzler (1980)為一例雙側(cè)床突 上段ICA閉塞者行間接旁路術(shù)（原計 劃作直接手術(shù)，但術(shù)中未找到合適 皮層動脈）,● The efficacy of di

63、rect and indirect bypass was demonstrated in patients with ischemic moyamoya disease ● The effectiveness of re- vascularization in pre- venting hemorrhage remains a con

64、troversy,● 直接和間接旁路術(shù)對缺血性 moyamoya 病人有效● 但對防止出血的效果仍有爭議,復(fù)發(fā)出血率Fujii (1997) 手術(shù)組（152） 19.1% 非手術(shù)組（138） 28.3%,● For patients with occlusive carotid or MCA disease, limited appli

65、cation and further study with an eye to futune is warranted,● 對閉塞性頸動脈或大腦中動脈病 人，嚴(yán)格選擇適應(yīng)證，并需作進 一步研究,FUTURE OF BYPASS,旁路手術(shù)展望,● New imaging modalities for evaluation of acute stroke ▲ acute in

66、farction or penumbra? ▲ within the penumbra zone, the areas will become infarcted or survive without perfusion?,● 現(xiàn)代影像技術(shù)（DMR, PMR, PCT/CTA, PET) 可鑒別急性 卒中病人的： ▲ 急性梗死還是半暗區(qū) ▲ 半暗區(qū)中，如不恢

67、復(fù)灌注， 哪些可發(fā)展成梗死，哪些 可存活。,Coregistered images of PW/DW MRI and multitracer PET in a patient with an acute right-side hemiparesis. The ROIs were placed according to the MRI criteria and then transferred to the

68、 PET images (ROI colors: red indicates DWI lesion; blue, mismatch; yellow, oligemia; green, reference region).,Volumetric comparison of TTP (MRI) and OEF (PET) images in 2 patients measured in the chronic phase of stroke

69、. In both patients, a TTP delay of >4 seconds indicates a considerable mismatch volume (red contour on TTP images). The mismatch volumes were 473 cm3 for patient a and 199.7 cm3 for patient b. However, only patient b