顱外-顱內(nèi)動脈旁路手術(shù)：歷史、現(xiàn)狀與展望課件

顱外-顱內(nèi)動脈旁路手術(shù)：歷史、現(xiàn)狀與展望

EXTRACRANIAL-INTRACRANIALBYPASSSURGERY

PAST,PRESENTANDFUTURE

顱外-顱內(nèi)動脈旁路手術(shù)：歷史、現(xiàn)狀與展望

EXTRACRAN

PioneersofBypassProcedures

●Jacobson(1960)(Vermont)

Reconstructedcarotidarteries

ofdogsandrabbits,achieving

a100%patencyrate

●Donaghy(Vermont)

Establishedmicrosurgicallab,

reconstructedvessels<1mmin

diameter

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HISTORYOFBYPASSPROCEDURES

旁路手術(shù)歷史

PioneersofBypassProceduresM.G.Yasargil&HisContributions

●Interestwasstimulatedwhen

hewasaskedtoperforman

embolectomyofacortical

artery,notyetmastered.

●Enthusiasmtocerebralrevas-

cularizationincreasedafter

thereportofanEC-ICbypass

M.G.Yasargil及其貢獻(xiàn)

●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(jìn)一步

引起其熱情

M.G.Yasargil&HisContributi●

1964InternationalCongressof

Neuroradiologists

Drs.SweetandRasmussen

advisedhimtocontactprof.

Donaghy

1965YasargilbeganhistraininginDonagh’slab.

1964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?！?964InternationalCongress

●Initialattemptstointerposea

femoralvasculargraftfrom

CCAtoMCA.Thegraftwould

progresstothrombosis.The

ideaof

performingSTA-MCA

bypasswasthenborn.

●Bytheendof1966morethan

30STA-MCAbypassindogs

hadbeenperformed

●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余例犬

STA-MCA旁路術(shù)

●InitialattemptstointerpoOct.30,1967YasargilperformedthefirstSTA-MCAbypass,inapatientwithMarfansyndromeandcompleteocclusionofMCA

Amajorstepwasmadeintothefieldofreconstructiveintracranialvascularmicroneurosurgery.

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(jìn)展！●Oct.30,1967Yasargilperform

CerebralIschemia

●Since1967STA-MCAbypasshadbeenwideaccepted,althoughtheindicationsremainedcontroversialbytheendof1960’.Dr.ZangrenheperformedthefirstcaseofSTA-MCAbypassinChina(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)。

INDICATIONSFORBYPASS

旁路手術(shù)應(yīng)用

CerebralIschemia

●Since196

●1977NorthAmericanEC-IC

BypassStudy(byDr.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-MCAwas

ineffectiveinpreventing

cerebralischemia

結(jié)論：STA-MCA不能防止腦缺血

●1977NorthAmericanEC-IC

●Failureofextracranial-intra-

cranialarterialbypassto

reducetheriskofischemic

stroke.Resultsofaninter-

nationalrandomizedtrial.

TheEC/ICBypassStudyGroup.

NEnglJMed313:1191-1200,

1985

●Markeddecreaseinthenumber

ofSTA-MCAbypassperformed

forcerebralischemia

●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(jī)試驗結(jié)果。EC/IC研究

組，新英格蘭醫(yī)學(xué)313:1191,

1985

●STA-MCA旁路手術(shù)量明顯

減少

●Failureofextracranial-int

●

CriticismtoEC/ICBypassStudy

▲Patientswerenotevaluated

preoperativelycerebrovascular

hemodynamicstatus

▲Bothpatientandtherapist

werenotblined

▲Onlyhalfofthepatients

receivingantiplateletagents

▲Alargepercentageofpatients

hadnosymptomsbeforeentry

▲Alargenumberofpatients

underwentsurgeryoutsidethe

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

●CriticismtoEC/ICBypassS

●Thestudyinvestigators

pointedoutthatrandomized

trialsinvolveonlyasmall

fractionofthepopulationat

riskandthatthisfactordoes

notpreventastudyfrombe-

ingvalid.

●研究組人員回應(yīng)

承認(rèn)該隨機(jī)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

●Thestudyinvestigators

●TheCarotidOcclusionSurgery

StudyRandomizedTrial(COSS)

U.SandCanada,49clinical

centers18PETcenters

(2002~2010)

●

頸動脈閉塞手術(shù)隨機(jī)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（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-ICbypassdid

notreducetheriskof

recurrentipsilateralischemic

strokeat2years.

JAMA,306:1983,2011

結(jié)論：EC/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

●TheCarotidOcclusionSurge

●

Forpatientswithsymptomatic

extracranialcarotidocclusion,

EC/ICbypassisnotroutinely

recommended

(ClassⅢEvidenceA)

●ForpatientswithstrokeorTIA

dueto50%to99%stenosisof

amajorintracranialartery,

EC/ICbypassisnotrecommended

(ClassⅢEvidenceB)

AHA/ASAGuidelinesforthe

Preventionofstroke2011

●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

●Forpatientswithsymptomat

●Extracranial-IntracranialBypass

forStroke—IsThistheEndof

theLineoraBumpintheRoad?

Neurosurgery71:557,2012

●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

●Extracranial-IntracranialB

●Althoughgeneralexpansionof

EC/ICbypassusewouldnot

besupported,aselectsubset

ofpatientswithmedically

refractoryhemodynamic

symptomsmaywellbenefit

fromsurgery.

●Limitedapplicationand

furtherstudywithaneyeto

futuredevelopments,rather

thancompleteabandonment,

iswarranted.

●雖然不支持廣泛開展，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(jìn)一步研究，而不是完全放棄。

●AlthoughgeneralexpansionAcutestroke

●Emergentcerebralrevascula-rizationisveryrational

Encouragingresultswerereported.

●Butothersconsideredtheacuteischemiaarelativecontraindication

Conclusion:OnlythosepatientswithcrescendoTIAormildtomoderatedeficits<6hrswithnoinfarctionshouldbeconsideredforEC/ICbypass

急性卒中

●急診腦血運(yùn)重建合理，有報

告結(jié)果令人鼓舞

●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(jìn)性TIA或輕至中度缺

陷（<6hrs）且無梗死者

Acutestroke

●Emergentcerebr

●Withtheadventofinterventional

neuroradiologyandthrombolytic

therapies,emergentEC/ICbypass

foracutestrokedecreased

●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。

●WiththeadventofintervenSAHandCerebralVasospasm

●STA-MCAbypasshasbeen

performed

●Thisindicationdidnotgain

wideacceptance.Endovascular

techniquescombinedwith“3H”

therapyassumedapivotalrole

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

SAHandCerebralVasospasm

●Forty-two-year-oldabuserwithSAHfromamycoticleftmiddlecerebralaneurysm.A,preoperativelateralcarotidinjectionshowsproximalcarotidspasm.B,lateralcommoncarotidangiogram2weeksafterbypassshowsmaturationofbypass.C,lateralcommoncarotidangiogram3weeksafterbypassshowsimprovementincarotidspasmanddiminishedcaliberofbypass.Forty-two-year-oldabuserwithAneurysms

●Carotidarteryocclusionremainedthemainstayforsomeaneurysms,butischemicdeficitsmaybeoccur.

動脈瘤

●頸動脈閉塞依然是某些顱內(nèi)動脈

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%

Aneurysms

●Carotidarteryoc

●

Yasargil(1967)2casesof

STA-MCAforgiantsupraclinoid

ICAaneurysm

●

Lougheed(1971)FirstEC/IC

bypass(CCA-saphenousvein-

intracranialICA)wasperformed

●

Sundt(1982)Pioneeredtheuse

ofveingrafts(SVGs)fromext-

racranialarteriestointracran-

ialarteriesfortreatmentof

unclippableaneurysms

●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

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)

●Yasargil(1967)2cases

●

Ausman（1978）

Firstdescribedtheuseofradial

arterygrafts(RAGs)

●

Morimoto(1988)

UseofRAGforaneurysms

●Ausman(1978)

首次介紹用橈動脈作移植物。

●Morimoto(1988)

將之用于動脈瘤手術(shù)

●Ausman（1978）

Firstdesc45M,ECA-MCAbypassfollowedbytrappingofthegiantsupraclinoidICAaneurysmwithpreserva-tionOfanteriorchoroidalartery(arrow)45M,ECA-MCAbypassfo65,F,CervicalICA-SVG-MCA2bypasswasperformedfollowedbytrappingofthegiantintracavernousaneurysm65,F,CervicalICA-SVG-MCA2顱外-顱內(nèi)動脈旁路手術(shù)：歷史、現(xiàn)狀與展望課件

●Spetzler(1990’)Developed

severalinnovations

▲thebonnetbypass

▲multiplearterialanastomosis

▲useofmetabolicbrain

protection

▲useofheparin

▲petrousICA-SVG-supraclinoid

ICAbypass

●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(hù)措施

▲肝素

▲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)

●Spetzler(1990’)Developed

Case1M,55,Leftcommoncarotidarteryaneurysm,nofillingoftheexternalcarotidartery.RSTA-LMCAbypasswasperformed.

Case1M,55,Leftcommoncarot

●Sekhar’sinnovations

▲placementofdistalanastomosis

ofSVGintotheM1orM2

bifurcation

▲useofICAorECAforthe

proximalanastomosis

▲useofintraoperativeDSAtostudy

thebypassgraft

▲ECA-petrousICAgrafts

▲extracranialVA-MCAor

intracranialVAgrafts

▲BA-veingraft-BA(under

hypothermiccirculatoryarrest)

●Sekhar的創(chuàng)新

▲將大隱靜脈遠(yuǎn)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-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）

●Sekhar’sinnovations

▲pl

SaphenousVeinGraftReconstructionofanUnclippableGiantBasilarArteryAneurysmPerformedwiththePatientunderDeepHypothermicCirculatoryArrest.SaphenousVeinGraftReconstr

●Otherinnovations

▲useofinternalmaxillaryartery

asdonorvessel

▲useoftunnelthroughthefloor

ofmiddlefossaratherthan

subcutaneousone

▲endoscopicharvestofsaphenous

vein

▲excimerlaser-assistednon-

occlusiveanastomosis(ELANA)

▲bloodfolwevaluationbytheuse

ofnon-invasiveoptimalvessel

analysis(NOVA)andintraopera-

tivequantitativeflowmeasure-

ment

▲intraoperativeevaluationusing

indocyaninegreen

●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

(ELANA)

▲術(shù)中無創(chuàng)血流定量分析（NOVA)

▲術(shù)中吲哚青綠評估

●Otherinnovations

▲useSchematicdiagramdepictstheendoscopicSVGharvest.A:Thefiberoptictrocarisusedtoinitiallylocateanddissectthesaphenousvein.B:Insufflationisperformedwithcarbondioxidetocreateroomforfurtherdissection.C:Thecauteryscissorsareusedtocoagulateandtransecttributaryveins.D:Theveincradleisusedtorunthelengthoftheveinbeforetheveingraftremoval.SchematicdiagramdepictstheExcimerLaser-AssistedNonocclusiveAnastomosis(ELANA)TechniqueExcimerLaser-AssistedNonocclCase1ECA-SVG-ICAbifercationbypassfortreatmentofagiantcavernousICAaneurysm.TheintracranialanastomosiswasperformedwiththeaidofELANACase2PetrousICA-SVG-MCAbypassfortreatmentofapreviouslycoiledpara-ophthalmicaneurysm.BothanastomsiswereperformedwiththeaidofELANACase1ECA-SVG-ICAbifercatiSkullBaseTumors

●Theuseofbypasstoenable

operationsondifficultskull

basetumorsisgenerally

acceptedbutisnotwithout

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

Case1Recurrentchondrosarcoma.Duringoperation,theintracavernousICAwasruptured.EmergencyradialarterybypassgraftwasperformedfromcervicalICAtoMCA2.SkullBaseTumors

●Theuseo顱外-顱內(nèi)動脈旁路手術(shù)：歷史、現(xiàn)狀與展望課件Case247,FIntracavernousandsupracavernousmeningiomaencasingandnarrowingtheleftICACase247,FIntracavernouECA-RAG-MCA2andcervicalICA-SVG-MCA2ECA-RAG-MCA2andcervicalICA-顱外-顱內(nèi)動脈旁路手術(shù)：歷史、現(xiàn)狀與展望課件

●Theuseofbypassforskull

basetumorshasgreatly

declinedbecauseofuseof

radiosurgeryfortumor

remnants.However,this

techniqueremainsavaluable

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

●Theuseofbypassforskull

●Whenamajorvesselisinvaded

orencasedbytumors,thereare

twocontroversies:

Whetheronetrytoskeletonize

thetumororwhetherthevessel

shouldberesected?

Whetherthepatientshouldbe

revascularizeduniversallyor

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)還是選擇性施行血運(yùn)重

建？

●Whenamajorvesselisinva

●Whetherthevesselshouldbe

leftinsitudependsuponthe

attitudeofsurgeonandthe

natureoftumor

Benigntumorsotherthan

meningiomamayusuallybe

dissectedawayfromvessel.

Chordomaandchondrosarco-

ma,mostcanbedissected

awayfromvessel,butinsome

patientsgraftingwillbeneeded.

●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。

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)。

●Whetherthevesselshouldb

●Whetherornotabypassshould

beperformedinallpatients

whoseICAorVAhasbeen

sacrificed?－controversial

Selectiveapproachonthe

basisofpreoperativeocclusion

test

Universalapproachonthe

basisofargumentthatevenif

adequatecollateralcirculation

present,patientsmaystill

sustainastrokeaftervascular

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

●Whetherornotabypasssho

MoyamoyaDisease

●Yasargil(1972)Firstcaseof

STA-MCAfora4-yearoldchild

withmoyamoyadisease

●Spetzler(1980)IndirectSTA-

MCAforbilateralocclusionof

supraclinoidICA(directSTA-

MCAwasplanned,butno

suitablerecipientcortical

vesselwasfoundatsurgery）

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）MoyamoyaDisease

●Yasargil●

Theefficacyofdirectand

indirectbypasswas

demonstratedinpatients

withischemicmoyamoya

disease

●Theeffectivenessofre-

vascularizationinpre-

ventinghemorrhage

remainsacontroversy

●

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%

●Theefficacyofdirectand

●Forpatientswithocclusive

carotidorMCAdisease,limited

applicationandfurtherstudy

withaneyetofutuneis

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(jìn)

一步研究

FUTUREOFBYPASS

旁路手術(shù)展望

●Forpatientswithocclus●Newimagingmodalitiesfor

evaluationofacutestroke

▲acuteinfarctionorpenumbra?

▲withinthepenumbrazone,

theareaswillbecomeinfarcted

orsurvivewithoutperfusion?

●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，如不恢復(fù)灌注，

哪些可發(fā)展成梗死，哪些

可存活?！馧ewimagingmodalitiesfor

CoregisteredimagesofPW/DWMRIandmultitracerPETinapatientwithanacuteright-sidehemiparesis.TheROIswereplacedaccordingtotheMRIcriteriaandthentransferredtothePETimages(ROIcolors:redindicatesDWIlesion;blue,mismatch;yellow,oligemia;green,referenceregion).

VolumetriccomparisonofTTP(MRI)andOEF(PET)imagesin2patientsmeasuredinthechronicphaseofstroke.Inbothpatients,aTTPdelayof>4secondsindicatesaconsiderablemismatchvolume(redcontouronTTPimages).Themismatchvolumeswere473cm3forpatientaand199.7cm3forpatientb.However,onlypatientbhadacorrespondingvolumeofpenumbra(260cm3).CoregisteredimagesofPW/DW

ThreeROIswereplacedmanuallyattherCBFmap(topleft):ROI1coveredtheischemiccoreasdetectedfromtheDWI(bottomleft),ROI2coveredthepenumbrathatprogressedtoinfarctionatthefinalT2-weightedimage(T2WI,bottomright),andROI3coveredthepenumbrathatrecovered.MapsofMTT(topmiddle)showedprolongedMTTinthetotalrightmiddlecerebralarteryterritory,whereasrCBV(topright)wasmarkedlyreducedintheinternalcapsulebutonlymildlyreducedintherestofthemiddlecerebralarteryterritory.TheADCmap(bottommiddle)demonstratesseverelyreducedADCinthecoreoftheinfarction.Acute(4-hour)andchronic(28-day)MRIofa56-year-oldmanwhopresentedwithlefthemiparesis,facialparesis,andgazepalsy.ThreeROIswereplacedmanualWomanwithaphasiaandright-sidedweaknessimagedinitiallyat6hoursfromstrokeonset.A–G,ImagesareDW(A),ADC(B),FA(C),rCBF(D),MTT(E),rCBV(F),and6-dayfollow-upT2-weighted.ThreeregionsofinterestareshownontherCBFmapinD.Region1,“infarctcore”coverstheareathathashyperintensityontheDWimage,abnormalityonrCBFandMTTimages,andhyperintensityonfollow-upT2-weightedimage.Region2,“penumbrathatinfarcts”coverstheareathathasnoabnormalityonDWimage,butthatisabnormalonrCBFandMTTimagesandhashyperintensityonfollow-upT2-weightedimage.Region3,“hypoperfusedtissuethatremainsviable,”coverstheareathathasabnormalityonrCBFandMTTimagesbutthatisnormalonDWimageandisnormalonfollow-upT2-weightedimage.Womanwithaphasiaandright-s●Withfurtherdevelopmentsin

imagingmodalitiesandbetter

definitionsofischemicbutviable

tissure(OEF)thresholds,there

willbemorethoughtson

emergentsurgicalprocedures

foracutestroke.

●隨影像技術(shù)的發(fā)展，能更好地界

定缺血但存活的組織（OEF）

的閾值，會有更多關(guān)于急性卒中

急診手術(shù)的構(gòu)想●Withfurtherdevelopmentsin●Bypassprocedureremainsan

adjuvantforaneurysmand

skullbasetumortreatment

Advancedimagingperfusion

techniquesmayimprovethe

accuracyofballoonocclusive

test.

Newbypasstechniquesmay

beuseful.

●旁路手術(shù)依然是某些動脈瘤和

顱底腫瘤的輔助治療手段。

灌注成像技術(shù)的發(fā)展會提

高球囊閉塞試驗的準(zhǔn)確性

新的旁路手術(shù)方法

●Bypassprocedureremainsan●Theroleofbypassformoyamoya

diseaseawaitstheresultsof

largerandomizedtrials.

Moredetailedstudiesonthe

preventionofhemorrhagicevents

areexpected

●需大規(guī)模隨機(jī)研究來證實旁路

術(shù)對moyamoya病的效果

對預(yù)防出血的效果需進(jìn)一

步研究

●TheroleofbypassformoyamTHANKSTHANKS顱外-顱內(nèi)動脈旁路手術(shù)：歷史、現(xiàn)狀與展望

EXTRACRANIAL-INTRACRANIALBYPASSSURGERY

PAST,PRESENTANDFUTURE

顱外-顱內(nèi)動脈旁路手術(shù)：歷史、現(xiàn)狀與展望

EXTRACRAN

PioneersofBypassProcedures

●Jacobson(1960)(Vermont)

Reconstructedcarotidarteries

ofdogsandrabbits,achieving

a100%patencyrate

●Donaghy(Vermont)

Establishedmicrosurgicallab,

reconstructedvessels<1mmin

diameter

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HISTORYOFBYPASSPROCEDURES

旁路手術(shù)歷史

PioneersofBypassProceduresM.G.Yasargil&HisContributions

●Interestwasstimulatedwhen

hewasaskedtoperforman

embolectomyofacortical

artery,notyetmastered.

●Enthusiasmtocerebralrevas-

cularizationincreasedafter

thereportofanEC-ICbypass

M.G.Yasargil及其貢獻(xiàn)

●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(jìn)一步

引起其熱情

M.G.Yasargil&HisContributi●

1964InternationalCongressof

Neuroradiologists

Drs.SweetandRasmussen

advisedhimtocontactprof.

Donaghy

1965YasargilbeganhistraininginDonagh’slab.

1964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?！?964InternationalCongress

●Initialattemptstointerposea

femoralvasculargraftfrom

CCAtoMCA.Thegraftwould

progresstothrombosis.The

ideaof

performingSTA-MCA

bypasswasthenborn.

●Bytheendof1966morethan

30STA-MCAbypassindogs

hadbeenperformed

●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余例犬

STA-MCA旁路術(shù)

●InitialattemptstointerpoOct.30,1967YasargilperformedthefirstSTA-MCAbypass,inapatientwithMarfansyndromeandcompleteocclusionofMCA

Amajorstepwasmadeintothefieldofreconstructiveintracranialvascularmicroneurosurgery.

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(jìn)展！●Oct.30,1967Yasargilperform

CerebralIschemia

●Since1967STA-MCAbypasshadbeenwideaccepted,althoughtheindicationsremainedcontroversialbytheendof1960’.Dr.ZangrenheperformedthefirstcaseofSTA-MCAbypassinChina(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)。

INDICATIONSFORBYPASS

旁路手術(shù)應(yīng)用

CerebralIschemia

●Since196

●1977NorthAmericanEC-IC

BypassStudy(byDr.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-MCAwas

ineffectiveinpreventing

cerebralischemia

結(jié)論：STA-MCA不能防止腦缺血

●1977NorthAmericanEC-IC

●Failureofextracranial-intra-

cranialarterialbypassto

reducetheriskofischemic

stroke.Resultsofaninter-

nationalrandomizedtrial.

TheEC/ICBypassStudyGroup.

NEnglJMed313:1191-1200,

1985

●Markeddecreaseinthenumber

ofSTA-MCAbypassperformed

forcerebralischemia

●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(jī)試驗結(jié)果。EC/IC研究

組，新英格蘭醫(yī)學(xué)313:1191,

1985

●STA-MCA旁路手術(shù)量明顯

減少

●Failureofextracranial-int

●

CriticismtoEC/ICBypassStudy

▲Patientswerenotevaluated

preoperativelycerebrovascular

hemodynamicstatus

▲Bothpatientandtherapist

werenotblined

▲Onlyhalfofthepatients

receivingantiplateletagents

▲Alargepercentageofpatients

hadnosymptomsbeforeentry

▲Alargenumberofpatients

underwentsurgeryoutsidethe

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

●CriticismtoEC/ICBypassS

●Thestudyinvestigators

pointedoutthatrandomized

trialsinvolveonlyasmall

fractionofthepopulationat

riskandthatthisfactordoes

notpreventastudyfrombe-

ingvalid.

●研究組人員回應(yīng)

承認(rèn)該隨機(jī)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

●Thestudyinvestigators

●TheCarotidOcclusionSurgery

StudyRandomizedTrial(COSS)

U.SandCanada,49clinical

centers18PETcenters

(2002~2010)

●

頸動脈閉塞手術(shù)隨機(jī)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（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-ICbypassdid

notreducetheriskof

recurrentipsilateralischemic

strokeat2years.

JAMA,306:1983,2011

結(jié)論：EC/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

●TheCarotidOcclusionSurge

●

Forpatientswithsymptomatic

extracranialcarotidocclusion,

EC/ICbypassisnotroutinely

recommended

(ClassⅢEvidenceA)

●ForpatientswithstrokeorTIA

dueto50%to99%stenosisof

amajorintracranialartery,

EC/ICbypassisnotrecommended

(ClassⅢEvidenceB)

AHA/ASAGuidelinesforthe

Preventionofstroke2011

●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

●Forpatientswithsymptomat

●Extracranial-IntracranialBypass

forStroke—IsThistheEndof

theLineoraBumpintheRoad?

Neurosurgery71:557,2012

●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

●Extracranial-IntracranialB

●Althoughgeneralexpansionof

EC/ICbypassusewouldnot

besupported,aselectsubset

ofpatientswithmedically

refracto