1、颅外颅外- -颅内动脉旁路手术：历史、现状与展望颅内动脉旁路手术：历史、现状与展望 EXTRACRANIAL-INTRACRANIAL BYPASS SURGERY PAST, PRESENT AND FUTURE 解放军总医院神经外科解放军总医院神经外科 全军神经外科研究所全军神经外科研究所 Dept of Neurosurg, General Hospital of PLA Institute of Neurosurg, Chinese PLA Pioneers of Bypass Procedures Jacobson(1960)(Vermont) Reconstructed carot
2、id arteries of dogs and rabbits, achieving a 100% patency rate Donaghy (Vermont) Established microsurgical lab, reconstructed vessels 1mm in diameter 旁路手术的先驱旁路手术的先驱 Jacobson(1960)(佛蒙得）佛蒙得） 重建犬和兔颈动脉，重建犬和兔颈动脉，100% 通畅通畅 Donaghy (佛蒙得）佛蒙得） 建立显微神经外科实验室，建立显微神经外科实验室， 重建直径重建直径1mm的血管的血管 HISTORY OF BYPASS PROC
3、EDURES 旁路手术历史旁路手术历史 M.G. Yasargil & His Contributions Interest was stimulated when 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及其贡献及其贡献 其兴趣因一例皮层动脉取栓其兴趣因一例皮层动脉取栓 术（尚
4、未掌握该技术）激发术（尚未掌握该技术）激发 Woringer(1963) EC/IC 旁路手术论文的发表进一步旁路手术论文的发表进一步 引起其热情引起其热情 1964 International Congress of Neuroradiologists Drs. Sweet and Rasmussen advised him to contact prof. Donaghy 1965 Yasargil began his training in Donaghs lab. 1964年，国际神经放射大会，年，国际神经放射大会，Sweet 和和Rasmussen 建议其与建议其与 Donaghy联
5、联 系。系。1965年，开始在年，开始在Donaghy实验室实验室 训练。训练。 Initial attempts to interpose a femoral vascular graft from CCA to MCA. The graft would progress to thrombosis. The 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 初始时，作初始时，作CCA-股部血管股部
6、血管 移植物移植物-MCA术，但移植血术，但移植血 管内血栓形成。管内血栓形成。 产生产生STA-MCA旁路术设想旁路术设想 至至1966年底完成年底完成30余例犬余例犬 STA-MCA旁路术旁路术 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 vascular
7、microneurosurgery. 1967年，年，Yasargil为一例为一例Marfan综综 合征伴大脑中动脉闭塞者成功施行首例合征伴大脑中动脉闭塞者成功施行首例 STA-MCA旁路术旁路术 颅内血管重建的重要进展！颅内血管重建的重要进展！ Cerebral Ischemia Since 1967 STA-MCA bypass had been wide accepted, although the indications remained controversial by the end of 1960. Dr.Zang renhe performed the first case o
8、f STA-MCA bypass in China(1976). 脑缺血脑缺血 1967年后，年后，STA-MCA被广泛应被广泛应 用，尽管到六十年代末，其适应用，尽管到六十年代末，其适应 证仍有争议。证仍有争议。 臧人和教授于臧人和教授于1976年在国内首先年在国内首先 开展开展STA-MCA旁路术。旁路术。 INDICATIONS FOR BYPASS 旁路手术应用旁路手术应用 1977 North American EC-IC Bypass Study (by Dr. Henry Barnett) 1977年开始的年开始的北美北美EC-IC旁旁 路研究路研究 内科治疗组内科治疗组 714
9、例例 0.6% STA-MCA+内科内科 663例例 2.5% 30天死亡和天死亡和 致残、卒中率致残、卒中率 Conclusion: STA-MCA was ineffective in preventing cerebral ischemia 结论：结论：STA-MCA不能防止脑不能防止脑 缺血缺血 Failure of extracranial-intra- cranial arterial bypass to reduce the risk of ischemic stroke. Results of an inter- national randomized trial. The E
10、C/IC Bypass Study Group. N Engl J Med 313:1191-1200, 1985 Marked decrease in the number of STA-MCA bypass performed for cerebral ischemia 颅内颅内-外动脉旁路术不能降外动脉旁路术不能降 低缺血性卒中的风险。国际低缺血性卒中的风险。国际 随机试验结果。随机试验结果。EC/IC研究研究 组，组，新英格兰医学新英格兰医学313:1191, 1985 STA-MCA旁路手术量明显旁路手术量明显 减少减少 Criticism to EC/IC Bypass Study
11、 Patients were not evaluated preoperatively cerebrovascular hemodynamic status Both patient and therapist were not blined 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 the study
12、 对对EC/IC旁路研究的批评旁路研究的批评 未评估病人术前的脑血流动力未评估病人术前的脑血流动力 状态状态 非双盲研究非双盲研究 仅半数病人接受抗血小板治疗仅半数病人接受抗血小板治疗 相当部分病人入组前无症状相当部分病人入组前无症状 许多手术病人未纳入研究许多手术病人未纳入研究 The study investigators pointed out that randomized trials involve only a small fraction of the population at risk and that this factor does not prevent a stud
13、y from be- ing valid. 研究组人员回应研究组人员回应 承认该随机试验仅包括小部承认该随机试验仅包括小部 分卒中风险人群，但并不影分卒中风险人群，但并不影 响试验的可靠性响试验的可靠性 The Carotid Occlusion Surgery Study Randomized Trial(COSS) U.S and Canada, 49 clinical centers 18 PET centers (20022010 ) 颈动脉闭塞手术随机研究（颈动脉闭塞手术随机研究（COSS） 美国、加拿大美国、加拿大 49 个临床中心个临床中心 18个个PET中心中心 (200220
14、10) 30天同侧卒中天同侧卒中 2年终点事件年终点事件 手术组（手术组（STA-MCA+内科治疗）内科治疗） 97例例 14（14.4%） 20（21.0%） 内科组（抗栓内科组（抗栓+危险因素控制）危险因素控制） 98例例 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 结论：结论：EC/IC旁路术不能降低同旁路术不能降低同 侧缺血性卒中的风险侧缺血性卒中的风险
15、JAMA,306:1983,2011 For patients with symptomatic extracranial carotid occlusion, EC/IC bypass is not routinely recommended ( Class Evidence A) For patients with stroke or TIA due to 50% to 99%stenosis of a major intracranial artery, EC/IC bypass is not recommended (Class Evidence B) AHA/ASA Guidelin
16、es for the Prevention of stroke 2011 症状性颅外颈动脉闭塞，通常不推荐症状性颅外颈动脉闭塞，通常不推荐 旁路术（旁路术（级推荐，级推荐，A级证据）级证据） 颅内主要动脉狭窄颅内主要动脉狭窄50%以上，不推荐以上，不推荐 旁路术旁路术 （级推荐，级推荐，B级证据）级证据） 美国心脏学会美国心脏学会/卒中学会卒中学会 2011版卒中版卒中 预防指南预防指南 Extracranial-Intracranial Bypass for Stroke Is This the End of the Line or a Bump in the Road? Neurosurg
17、ery 71:557,2012 颅内外旁路手术预防卒中颅内外旁路手术预防卒中 路路 到尽头，还是（又一）撞击？到尽头，还是（又一）撞击？ 神经外科神经外科 71:557,2012 Although general expansion of EC/IC bypass use would not be supported, a select subset of patients with medically refractory hemodynamic symptoms may well benefit from surgery. Limited application and further s
18、tudy with an eye to future developments, rather than complete abandonment, is warranted. 虽然不支持广泛开展，但对某些虽然不支持广泛开展，但对某些 药物治疗无效的血动力学损害的药物治疗无效的血动力学损害的 病人，手术可能有益。病人，手术可能有益。 有限的应用加上着眼于未来的有限的应用加上着眼于未来的 进一步研究，而不是完全放弃。进一步研究，而不是完全放弃。 Acute stroke Emergent cerebral revascula- rization is very rational Encourag
19、ing results were reported. But others considered the acute ischemia a relative contraindication Conclusion: Only those patients with crescendo TIA or mild to moderate deficits 6 hrs with no infarction should be considered for EC/IC bypass 急性卒中急性卒中 急诊脑血运重建合理，有报急诊脑血运重建合理，有报 告结果令人鼓舞告结果令人鼓舞 其他学者认为，急性缺血是
20、其他学者认为，急性缺血是 急诊重建的相对禁忌。急诊重建的相对禁忌。 Crowell, Jafar(1986) 报告报告67例，例，27例改善，例改善，26例无变化，例无变化，11例死亡例死亡 结论：结论：EC/IC旁路术仅可用旁路术仅可用 于渐进性于渐进性TIA或轻至中度缺或轻至中度缺 陷（陷（ 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 patie
21、nt b. However, only patient b had a corresponding volume of penumbra (260 cm3). Three ROIs were placed manually at the rCBF map (top left): ROI 1 covered the ischemic core as detected from the DWI (bottom left), ROI 2 covered the penumbra that progressed to infarction at the final T2-weighted image
22、(T2WI, bottom right), and ROI 3 covered the penumbra that recovered. Maps of MTT (top middle) showed prolonged MTT in the total right middle cerebral artery territory, whereas rCBV (top right) was markedly reduced in the internal capsule but only mildly reduced in the rest of the middle cerebral art
23、ery territory. The ADC map (bottom middle) demonstrates severely reduced ADC in the core of the infarction. Acute (4-hour) and chronic (28-day) MRI of a 56-year-old man who presented with left hemiparesis, facial paresis, and gaze palsy. Woman with aphasia and right- sided weakness imaged initially
24、at 6 hours from stroke onset. AG, Images are DW (A), ADC (B), FA (C), rCBF (D), MTT (E), rCBV (F), and 6-day follow-up T2-weighted. Three regions of interest are shown on the rCBF map in D. Region 1, “infarct core” covers the area that has hyperintensity on the DW image, abnormality on rCBF and MTT
25、images, and hyperintensity on follow-up T2-weighted image. Region 2, “penumbra that infarcts” covers the area that has no abnormality on DW image, but that is abnormal on rCBF and MTT images and has hyperintensity on follow-up T2-weighted image. Region 3, “hypoperfused tissue that remains viable,” c
26、overs the area that has abnormality on rCBF and MTT images but that is normal on DW image and is normal on follow-up T2-weighted image. With further developments in imaging modalities and better definitions of ischemic but viable tissure (OEF ) thresholds, there will be more thoughts on emergent sur
27、gical procedures for acute stroke. 随影像技术的发展，能更好地界随影像技术的发展，能更好地界 定缺血但存活的组织（定缺血但存活的组织（ OEF ） 的阈值，会有更多关于急性卒中的阈值，会有更多关于急性卒中 急诊手术的构想急诊手术的构想 Bypass procedure remains an adjuvant for aneurysm and skull base tumor treatment Advanced imaging perfusion techniques may improve the accuracy of balloon occlusive
28、test. New bypass techniques may be useful. 旁路手术依然是某些动脉瘤和旁路手术依然是某些动脉瘤和 颅底肿瘤的辅助治疗手段。颅底肿瘤的辅助治疗手段。 灌注成像技术的发展会提灌注成像技术的发展会提 高球囊闭塞试验的准确性高球囊闭塞试验的准确性 新的旁路手术方法新的旁路手术方法 The role of bypass for moyamoya disease awaits the results of large randomized trials. More detailed studies on the prevention of hemorrhagic events are expected 需大规模随机研究来证实旁路需大规模随机研究来证实旁路 术对术对moyamoya病的效果病的效果 对预防出血的效果需进一对预防出血的效果需进一 步研究步研究 THANKS
