1、体外反搏对脑循环血流动力学的改变体外反搏对脑循环血流动力学的改变 Dr.Thomas LeungDirector of Acute Stroke UnitPrince of Wales HospitalThe Chinese University of Hong Kong Cerebral blood flow augmentation is important in stroke management 改善脑血流是中风治疗的主要目标改善脑血流是中风治疗的主要目标 Methods to improve cerebral blood flow 改善脑血改善脑血流的方法流的方法 How to Im
2、prove Cerebral Blood Flow?如何改善脑血流如何改善脑血流Thrombolysis 溶栓溶栓Angioplasty/stenting 支架成型术支架成型术v Open artery directly 打通血管打通血管v Systemic strategies 体循环体循环Diastolic counterpulsation 体外反搏体外反搏Pressor therapy 提升血压提升血压Partial aortic obstruction 球囊主动脉部分阻塞球囊主动脉部分阻塞 DBP MBP 舒张压舒张压 平均动脉压升高平均动脉压升高 Diastolic augmenta
3、tion SBP Afterload 收缩压收缩压 后负荷降低后负荷降低Basic Principles of External CounterpulsationAt the end of diastoleAt the beginning of diastoleSystolic unloadingCO 舒张初期舒张初期舒张末期舒张末期心输出量心输出量 Cerebral flow augmentation 1 脑血流增加脑血流增加 Improve collateral circulation 改善侧枝循环改善侧枝循环 Angiogenesis 2 血管新生血管新生VEGFVEGF Open pr
4、eformed collateral channels 3 开放侧开放侧枝循环血管枝循环血管 NO Endothelin-1 Endothelin-1 Rationale&Possible Mechanisms1.Am J Cardiol 1999;84(8):950-2,A7-8.2.Circulation 2001;104:II445.3.Curr Interv Cardiol Rep 2001;3(1):37-43.Methods to Evaluate Cerebral Blood Flow 评价脑血流的评价脑血流的方法方法Color Velocity Imaging Quantifi
5、cation(CVIQ)Color Velocity Imaging Quantification(CVIQ)彩色流速流量定量法彩色流速流量定量法 v New,noninvasive,reliable technique to reveal CBFv Extracranial blood flow volume(index of brain perfusion)v Sum of 2 CCAs+2 VAs Transcranial Doppler Ultrasonography(TCD)Transcranial Doppler Ultrasonography(TCD)v Measure cere
6、bral blood flow velocities in the cerebral arteryv Reflect relative change in cerebral blood flowv TCD monitoring reveals real time cerebral blood flow 2 31 4 2 5 3 4 1 1-beginning of systole;2-peak systole;3-diacrotic notch;4-end of diastole;5-augmented diastole(a)Normal(b)ECPReal Time Monitoring o
7、f Cerebral Blood Flow脑血流的动态监测 Baseline(3min)225mmHg(3 min)CBFVHRBPAfter(3min)CBFVHRBPCBFVHRBPE External Counterpulsation(ECP)for A Atherosclerotic S Stroke StudY Y-A pilot study (EASY EASY Pilot study)Objective Explore the therapeutic effect of ECP in patients with recent ischemic stroke 评估体外反搏对中风病人
8、的临床疗效评估体外反搏对中风病人的临床疗效 Explore the effect of ECP on brain perfusion 评估体外反搏对脑血供的影响评估体外反搏对脑血供的影响Part IStudy DesignA prospective,randomized,cross-over,assessment-blind study前瞻性前瞻性,随机随机,交叉设计交叉设计,盲法评估的研究盲法评估的研究Ischemic stroke patient with LADN=50ECPControlControlECPLast visitBaseline,visit 1Visit 2,wk 7Vi
9、sit 3,wk 14NIHSSCVIQNIHSS,mRSCVIQNIHSS,mRSCVIQ7 weeks7 weeksEarlyLate*ECP 35 one-hour daily sessionsIntention-to-treatIntention-to-treatP=0.061P=0.061Neurological Improvement(NIHSS)Neurological Improvement(NIHSS)Effect of ECP on NIHSS changes(GLM)Including Early and Late EffectsWk 7(wk Wk 7(wk 7-0 7
10、-0)Wk 14(wk Wk 14(wk 14-7 14-7)P=0.042P=0.042Changes in NIHSSResults Improvement-3.4-3.4-0.5-0.5-1.9-1.9-0.6-0.6-3.5-3.5-3-3-2.5-2.5-2-2-1.5-1.5-1-1-0.5-0.50 0Early Early LateLate神经功能缺损的改善神经功能缺损的改善Stroke.2008;39:1340-43 P=0.46P=0.46P=0.02P=0.02Favorable functional outcome:modified Rankin score 288%7
11、6%100%76%Functional Outcome Improvement(Functional Outcome Improvement(mRSmRS)Results 肢体功能恢复的评估肢体功能恢复的评估Stroke.2008;39:1340-43 P=NSEffect of ECP on CVIQ changes(GLM)Including Early and Late EffectsBrain Perfusion Improvement(CVIQ)Brain Perfusion Improvement(CVIQ)(mL/min)(mL/min)P=NSP=NSWk 7(wk Wk 7(
12、wk 7-0 7-0)Wk 14(wk Wk 14(wk 14-7 14-7)Changes in CVIQResults 脑血供的改善脑血供的改善Stroke.2008;39:1340-43 Methods Inclusion Criteria 入选标准入选标准Acute ischemic stroke patients admitted with 24 hrs of onset worsening of 1 point in the NIHSS for motor function within the first 5 days after onset中风中风2424小时内入院并在起病小时
13、内入院并在起病5 5天内肌力下降天内肌力下降 1 1分分Exclusion Criteria 排除标准排除标准 an initial limb power of 0/5 on admission,ICH and other contraindications 入院时肌力入院时肌力0 0级或脑出血及其他级或脑出血及其他ECPECP禁忌症禁忌症ECP for Stroke Patients with Progressive Motor DeficitsECP for Stroke Patients with Progressive Motor Deficits体外反搏在进展型中风病人中的运用体外反
14、搏在进展型中风病人中的运用Baseline DataBaseline Data 21 pts enrolled,mean NIHSS 8.821 pts enrolled,mean NIHSS 8.8 on admission on admission 21例病人纳入研究，基线NIHSS 8.8 分Clinical OutcomesClinical Outcomes at 90 daysat 90 days 临床疗效 11 pts 11 pts(52.4%)(52.4%)had a NIHSS 2 had a NIHSS 2 13 pts 13 pts(61.9%)(61.9%)had a h
15、ad a mRSmRS 2 2 Among 9 patients with an initial limb power of 0/5 before the start of ECP,Among 9 patients with an initial limb power of 0/5 before the start of ECP,4 4(44.4%)(44.4%)had a power of grade 4 or above had a power of grade 4 or above 50%病人NIHSS 或mRS 2 分，开始反搏前肌力0级的9例病人中4例肌力4级或以上Hemodynam
16、ic ChangesHemodynamic Changes 脑血流动力学改变A mean increase of A mean increase of 8.8%8.8%in mean BP in mean BP 平均血压升高8.8%8.8%A A 10.3%10.3%increase in mean CBFV in the relevant MCA,and increase in mean CBFV in the relevant MCA,and 6.3%6.3%increase in the increase in the irrelevant side irrelevant side 患侧
17、MCA脑血流速度增加10.3%，对侧MCA脑血流速度增加6.3%A trend of greater increase in mean CBFV in pts with good functional outcome A trend of greater increase in mean CBFV in pts with good functional outcome 功能恢复良好者反搏过程中MCA脑血流速度增加较多Results%increase from baseline mRS2(n=10)mRS2(n=5)Relevant side(mean SD)11.415.78.17.2Irre
18、levant side(mean SD)7.58.64.85.7IUB-opening of the aortic valve P-maximum systolic flow X closure of the aortic valve Y-closure of the pulmonary valve O opening of the mitral valve stimitutZ)()(Impedance Cardiography(ICG)BPXYOContinuous Arterial Pressure Continuous Cardiac OutputContinuous CBFV 血压,心
19、输出量和MCA脑血流速度动态监测Task Force MonitorConclusions ECP may improve neurological,functional recovery of ischemic stroke ECP可改善中风病人神经和肢体功能的恢复可改善中风病人神经和肢体功能的恢复 Cerebral perfusion enhancement was documented by TCD and CVIQ TCDTCD和和CVIQCVIQ检查发现反搏过程中脑血供有所改善检查发现反搏过程中脑血供有所改善 ECPs may serve as a promising treatment option for ischemic stroke patients and is worthy of further investigation ECP对中风病人的临床疗效有待于进一步的研究对中风病人的临床疗效有待于进一步的研究
