脑血流有效灌注压的无创检测及其对急性脑梗死的临床意义

摘要/Abstract

摘要：

目的探索脑血流有效灌注压（effective cerebral perfusion pressure，CPPe）的无创检测方法的有效性以及急性脑梗死患者CPPe与颈内动脉血管狭窄程度的相关性。方法本研究为前瞻性研究，收集2010年1月～2012年1月在广州医科大学附属第二医院神经内科住院的41例发病1周内的急性脑梗死患者，所有患者均经数字减影血管造影（digital subtraction angiography， DSA）和经颅多普勒超声（transcranial Doppler ultrasonography，TCD）评估颈内动脉狭窄程度及大脑中动脉无创血压、有创血压及血流速度，根据上述检测结果计算CPPe，比较TCD、DSA评价CPPe的有效性。同时根据北美症状性颈动脉狭窄内膜切除研究（North American Symptomatic Carotid Endarterectomy Trial，NASCET）标准分为轻度狭窄组、中度狭窄组和重度狭窄组，比较各组间的血管狭窄危险因素、 CPPe和美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale，NIHSS）评分，以及CPPe 和NIHSS评分与颈内动脉血管狭窄程度的相关性。结果所有急性脑梗死患者的有创和无创CPPe比较，结果发现有创CPPe的中位数为56.6 mmHg，无创CPPe的中位数为57.8 mmHg，两者之间的差异无显著性（P＞0.05）。轻度狭窄组、中度狭窄组和重度狭窄组3组急性脑梗死患者的有创CPPe的中位数分别为60.6 mmHg、42.5 mmHg和1.6 mmHg；无创CPPe 的中位数分别为62.2 mmHg、42.7 mmHg和0.27 mmHg；NIHSS评分的中位数分别为4、3和8；比较CPPe、 NIHSS评分在各组间的差异有显著性，H值分别为26.906、26.906及11.233（P＜0.01）。相关分析显示急性脑梗死患者CPPe与DSA显示的血管狭窄程度密切相关，相关系数分别为－0.782和－0.814，差异有显著性（P＜0.01）；而NIHSS评分与DSA显示的血管狭窄程度无相关性，相关系数为0.222，差异无显著性（P＞0.05）。结论通过TCD无创检测并计算CPPe的新方法可以获得较为准确的CPPe，而且CPPe与急性脑梗死患者的颈内动脉狭窄程度密切相关，这使得CPPe可能可以为脑血管病患者无创脑血流检测、指导个体化血压调控提供可靠证据。

文章导读： 脑血流有效灌注压可以为脑血管病患者无创脑血流检测、指导个体化血压调控提供可靠证据。

关键词: 急性脑梗死; 脑血流有效灌注压; 数字减影血管造影; 超声检查; 多普勒; 经颅

Abstract:

Objective To explore the effectiveness of noninvasive detection method of the effective cerebral perfusion pressure (CPPe) and the relationship between the CPPe and the internal carotid artery (ICA) stenosis in patients with acute cerebral infarction. Methods For the prospective study, this study collected 41 cases patients with acute cerebral infarction within 1 week in the Second Affiliated Hospital of Guangzhou University from January 2010 to January 2012. We used digital subtraction angiography (DSA) and transcranial Doppler ultrasonography (TCD) to prospectively detect the internal carotid artery stenosis degree, noninvasive blood pressure, invasive blood pressure and cerebral artery blood flow velocity of 41 patients. After calculating CPPe according to tested results, we compared the specificity and accuracy of invasive and noninvasive CPPe in all of the patients with acute cerebral infarction. At the same time according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) standard, all of the patients with acute cerebral infarction were divided into mild stenosis group, moderate stenosis group and severe stenosis group. And we also compared vascular risk factors, CPPe and National Institutes of Health Stroke Scale (NIHSS) score among three groups, and analyzed the correlation between CPPe, NIHSS score and intracranial artery stenosis degree. Results Compare all of the patients with acute cerebral infarction of invasive and noninvasive CPPe, the results showed that the invasive CPPe had a median of 56.6 mmHg, the noninvasive CPPe had a median of 57.8 mmHg, and there was no significant difference between the two evaluation methods by TCD and DSA. The invasive CPPe of three groups of patients with acute cerebral infarction had a median of 60.6 mmHg, 42.5 mmHg and 1.6 mmHg; the noninvasive CPPe of three groups of patients with acute cerebral infarction had a median of 62.2 mmHg, 42.7 mmHg and 0.27 mmHg; while the NIHSS score of three groups of patients with acute cerebral infarction had a median of 4, 3 and 8. The differences of CPPe and NIHSS score among three groups were statistically significant, and the H value was 26.906, 26.906 and 11.233 (P <0.01). Correlation analysis showed that the CPPe with ICA stenosis degree of NASCET stenosis rate was closely related in patients with acute cerebral infarction with significant difference (P <0.01), and the correlation coefficient was -0.782 and -0.814, respectively. While the NIHSS scores had no statistical relationship compared with ICA stenosis degree of NASCET stenosis rate, and the correlation coefficient was 0.222. Conclusion The noninvasive method gained CPPe by TCD was similar to the invasive method to detect CPPe. CPPe was closely related to the degree of ICA stenosis of patients with cerebral infarction. The CPPe maybe could provide reliable evidence for noninvasive detection of the cerebral blood flow and guide the individual blood pressure regulation and control of cerebrovascular disease patients

Key words: Acute cerebral infarction; Effective cerebral perfusion pressure; Digital subtraction angiography; Ultrasonography detection, Doppler, Transcranial

梁兵1,2，袁芳1,3，梁云云4，傅贤1，解龙昌1，殷建瑞1，高庆春1. 脑血流有效灌注压的无创检测及其对急性脑梗死的临床意义[J]. 中国卒中杂志, 2014, 9(08): 638-644.

LIANG Bing*,YUAN Fang, LIANG Yun-Yun, FU Xian, XIE Long-Chang, YIN Jian-Rui, GAO Qing-Chun.. The Effective Cerebral Blood Flow Perfusion Pressure Noninvasive Monitoring and Its
Relationship with the Clinical Significance of Acute Cerebral Infarction[J]. Chinese Journal of Stroke, 2014, 9(08): 638-644.

参考文献

1 王拥军. 适应与代偿[J]. 中国卒中杂志, 2007, 2:652-654.

2 Aaslid R, Markwalder TM, Nones H. Noninvasive

transcranial Doppler ultrasound recording of f low

velocity in basal cerebral arteries[J]. J Neurosurg,

1982, 57:769-774.

3 Weyland A, Buhre W, Grund S, et al. Cerebrovascular tone rather than intracranial pressure determines

t h e e f f e c t i v e d own s t r e am p r e s s u r e of t h e

cerebral circulation in the absence of intracranial

hypertension[J]. J Neurosurg Anesthesiol, 2000,

12:210-216.

4 Hsu HY, Chen YT, Hu HH. Limitations in estimating

critical closing pressure by noninvasive blood

pressure measurements[J]. Stroke, 2004, 35:e91-e92.

5 Gao QC, Fu X, Chen XY, et a1. A method of evaluating

the lower limit of cerebral autoregulation and its

correlation with blood pressure by transcranial Doppler

in rats[J]. Ultrasound Med Biol, 2012, 38:1244-1250.

6 中国高血压联盟. 中国高血压防治指南[J]. 中华内科

杂志, 2000, 39:140-144.

7 方圻, 王钟林, 宁田海, 等. 血脂异常防治建议[J]. 中华

心血管病杂志, 1997, 25:169.

8 周玉珍, 鲍俊, 王鹏. 吸烟、饮酒和吸烟饮酒协同作

用对脑血流动力学的影响[J]. 现代预防医学, 2012,

12:107-109.

9 中华神经科学会中华神经外科学会. 各类脑血管疾病

诊断要点[J]. 中华神经科杂志, 1996, 29:379-380.

10 Giller CA, Bowman G, Dyer H, et al. Cerebral arterial

diameters during changes in blood pressure and

carbon dioxide during craniotomy[J]. Neurosurgery,

1993, 32:737-741.

11 Panerai RB. Transcranial Doppler for evaluation of

cerebral autoregulation[J]. Clin Auton Res, 2009,

19:197-211.

12 Hilz MJ, Stemper B, Heckmann JG, et al. Mechanisms of

cerebral autoregulation, assessment and interpretation by

means of transcranial Doppler sonography[J]. Fortschr

Neurol Psychiatr, 2000, 68:398-412.

13 朱良付, 黄如训, 高庆春, 等. 人脑循环临界关闭压、有

效脑灌注压无创测定方法的研究[J]. 中华超声影像学

杂志, 2005, 5:366-369.

14 Dewey RC, Pieper HP, Hunt WE. Experimental

cerebral hemodynamics, vasomotor tone, critical

closing pressure, and vascular bed resistance[J]. J

Neurosurg, 1974, 41:597-606.

15 López-Magaña JA, Richards HK, Radolovich DK, et a1.

Critical closing pressure:comparison of three methods[J].

J Cereb Blood Flow Metab, 2009, 29:987-993.

16 Aaslid R, Lash SR, Bardy GH, et a1. Dynamic

pressure-f low velocity relationships in the human

cerebral circulation[J]. Stroke, 2003, 34:1645-1649.

17 黄小钦, 贾建平, 宋旸, 等. 急性缺血性卒中患者超急

性期NIHSS评分与CT血管成像脑血管狭窄或闭塞关

系研究[J]. 脑与神经疾病杂志, 2010, 18:408-412.

[1]	李如娟, 杨川, 马晓辉, 侯焕峰, 付会杰, 马晓丹, 方军涛, 靳金灵, 杨金波. DSA评估无症状大脑中动脉闭塞患者侧支循环状态研究 [J]. 中国卒中杂志, 2022, 17(12): 1355-1359.
[2]	任伟超, 马宁, 张亚梅, 王铁军. 经远端桡动脉入路行数字减影血管造影的临床效果研究[J]. 中国卒中杂志, 2022, 17(11): 1216-1220.
[3]	仲伟斌, 王鹏飞, 于进超, 张金彪, 李振光. 支架治疗颈动脉夹层导致急性脑梗死2例报告及文献复习[J]. 中国卒中杂志, 2022, 17(06): 653-657.
[4]	林丽珍, 范杰诚, 朱新蕊, 贾凡, 郭培武, 王昱凯, 张淑云. 小脑与卒中后运动学习关系的研究进展[J]. 中国卒中杂志, 2021, 16(12): 1296-1301.
[5]	嵇朋, 屈雪萍, 江利敏, 郭向东, 孙根, 刘松灿, 孟凡超, 李小刚. 阻塞型睡眠呼吸暂停低通气综合征对急性缺血性卒中患者脑血管反应性的影响[J]. 中国卒中杂志, 2021, 16(10): 1034-1038.
[6]	岳庆雄, 刘佳, 周瑜, 余雪慧, 沙雨佳, 王涛, 李世军. 基于经食管超声心动图的卵圆孔未闭形态与隐源性卒中的关系研究[J]. 中国卒中杂志, 2021, 16(09): 915-920.
[7]	侯瑞华, 吕麦扣, 温慧军. D-二聚体与纤维蛋白原比值与青年急性脑梗死患者颈动脉粥样硬化斑块的相关性分析[J]. 中国卒中杂志, 2021, 16(08): 805-809.
[8]	高素颖, 秦一凡, 张会玲, 于凯, 王拥军, 冀瑞俊. 年龄与急性脑梗死患者1年预后的关系研究[J]. 中国卒中杂志, 2021, 16(08): 810-815.
[9]	李安, 夏艳秋, 傅建玲, 袁梦, 郭馨予, 崔丽君. 经颅直流电刺激在卒中后吞咽障碍康复治疗中的应用研究进展[J]. 中国卒中杂志, 2021, 16(08): 855-860.
[10]	王建晖, 马静丽, 王云龙, 刘阳, 司艳琴. 阳极经颅直流电刺激联合多奈哌齐治疗卒中后认知障碍的疗效观察[J]. 中国卒中杂志, 2021, 16(06): 596-601.
[11]	朱慧敏，张新颜，程欣欣，饶江，张羽，刘莉. 低频重复经颅磁刺激联合镜像神经元训练系统对卒中后慢性完全性失语的效果研究[J]. 中国卒中杂志, 2021, 16(01): 45-50.
[12]	安立澌，曲凯，邢英琦. 因卒中起病经血管超声诊断为永存舌下动脉1例[J]. 中国卒中杂志, 2020, 15(12): 1337-1341.
[13]	陈黔妹，刘芳，盛灿，吴大鹏，刘佳琪. 高同型半胱氨酸对合并非瓣膜性心房颤动的急性脑梗死患者近期预后的影响[J]. 中国卒中杂志, 2020, 15(11): 1192-1197.
[14]	陈洁，刘嘉，董培，董可辉，莫大鹏，王伊龙，赵性泉，龚浠平. 特发性高颅压患者脑血流自动调节研究[J]. 中国卒中杂志, 2020, 15(11): 1218-1222.
[15]	尹明宇，胡昔权. 重复经颅磁刺激治疗卒中后认知障碍的研究进展[J]. 中国卒中杂志, 2020, 15(07): 713-719.