目的 探讨烟雾病术后脑梗死的危险因素并建立列线图预测模型.方法 回顾性纳入502个大脑半球的临床资料并分为建模组(n=350)和验证组(n=152),对建模组进行单因素及多因素Logistic回归分析找出危险因素并建立列线图模型,分别采用Hosmer-Lemeshow拟合优度检验和ROC曲线评估列线图模型的校准度和区分度.结果 术后脑梗死的发生率为4.58％.多因素Logistic回归模型提示年龄≥50岁(OR=10.525)、近期短暂性脑缺血发作(Transient ischemic attack,TIA)(OR=3.271)、近期脑梗死直径≥1 cm(OR=4.206)是术后脑梗死的独立危险因素,后循环代偿(OR=0.260)是保护性因素.基于以上因素建立列线图,建模组和验证组的H-L检验提示模型校准度良好(χ2=31.962/32.674,P=0.964/0.956),列线图模型预测建模组和验证组的受试者工作特征曲线(Receiver operating characteristic curve,ROC)的曲线下面积(Area under curve,AUC)提示列线图模型区分度良好(AUC=0.888/0.845).结论 年龄 ≥50岁、近期T IA史、近期脑梗死直径≥1cm是烟雾病术后脑梗死的危险因素,后循环良好代偿是保护性因素.建立的列线图模型可有效预测烟雾病患者术后发生脑梗死的风险.

目的 提供一种烟雾病后循环分级方法,探究其与前循环、手术疗效及大脑灌注的相关性.方法 采用回顾性研究,大脑前循环用铃木分期代表,铃木分期1～6期分别赋值1～6分.后循环代偿分级为矢状位解剖上以中脑中心为原点,经胼胝体膝与胼胝体体部交界处、胼胝体体部与胼胝体压部交界处分别做射线,将大脑半球划分为三等份,按照烟雾病患者DSA图像VA从后往前所能达到的区域分别定义为0、1、2、3级,分别赋值0、1、2、3分.术后手术疗效采用松岛分级,大脑半球灌注水准采用全脑动脉自旋标记技术(ASL)评估.统计入组患者术前铃木分期、后循环代偿分级、术前大脑血流量(ASL-CBF)、术后松岛分级、术后ASL-CBF,算出灌注差(术后ASL-CBF—术前ASL-CBF).结果 后循环代偿分级与铃木分期呈正相关(r=0.502,P<0.01),与术后松岛分级无明显相关性(P=0.19),与ASL灌注差无明显相关性(P=0.651),但与术前ASL-CBF呈正相关(r=0.337,P<0.05).结论 该后循环代偿分级与铃木分期有相关性,且与术前灌注水平相关,可能有更好的临床实用性.

Objective:To compare the short-term efficacy and complications of superficial temporal artery to middle cerebral artery bypass combined encephalo-myo-synangiosis (STA-MCA+ EMS) and encephalo-duro-arterio-synangiosis (STA-MCA+ EDAS) in the treatment of Moyamoya disease.Methods:A retrospective analysis was conducted on the clinical data of adult patients with Moyamoya disease who underwent STA-MCA+ EMS ( n=75, EMS group) or STA-MCA+ EDAS ( n=176, EDAS group) in the Department of Neurosurgery, the First Affiliated Hospital of Zhengzhou University from January 2016 to June 2021. The modified Rankin scale score (mRS) was evaluated at discharge. At 3 and 6 months after surgery, follow-up by telephone or outpatient service was conducted to assess mRS and the presence or absence of recent complications, and re-examination of imaging examinations was performed to assess the bypass vessel patency rate and Matsushima grade. We compared the baseline data, clinical efficacy and complications of the two groups of patients. Results:Intraoperative indocyanine green angiography of 251 patients revealed the patency of bypass vessels. There was 1 death in the EMS group and 2 deaths in the EDAS group. The median follow-up time (quartiles) of 248 patients was 5 (4, 8) months. The first postoperative angiography showed that the bypass vessels of 1 patient in each group were not developed, and the bypass vessel patency rate was 99.2% (246/248). At the last follow-up, among the 248 patients, the mRS score of 0 was reported in 210 cases, 1 in 25 cases, 2 in 7 cases, 3 in 3 cases, 4 in 2 cases, and 5 in 1 case. Matsushima grade A was reported in 96 cases, grade B in 115 cases, and grade C in 37 cases. There were no statistically significant differences in age, gender, underlying disease, clinical type, Suzuki stage, mRS score at admission, or the surgical side between the two groups of patients (all P>0.05). There were no significant differences in the mRS at discharge, follow-up time, bypass patency rate, Matsushima grade, or the mRS at the last follow-up between the two groups of patients (all P>0.05). Compared with the EDAS group, the EMS group had higher incidences of perioperative cerebral infarction [10.8% (8/74) vs. 4.0% (7/174)], cerebral hemorrhage [8.1% (6/74) vs. 1.1% (2/174)], epilepsy [5.4% (4/74) vs. 0.6% (1/174)], and subdural effusion [14.9% (11/74) vs. 5.7% (10/174)] (all P<0.05). In terms of postoperative recent complications, the incidence of cerebral infarction in the EMS group was higher than that in the EDAS group [5.4% (4/74) vs. 0.6% (1/174), P=0.029]. Conclusions:Both types of bypass surgery have relatively high patency rates and favorable short-term therapeutic outcomes. The risk of cerebral infarction, cerebral hemorrhage, epilepsy, subdural effusion during perioperative period and postoperative recent cerebral infarction of STA-MCA+ EDAS seems lower.

烟雾病(MMD)是一种内科治疗无效的慢性进展型脑血管疾病,以颈内动脉末端和(或)大脑前动脉、大脑中动脉起始部进行性狭窄、闭塞而后继发烟雾状代偿血管为主要特征.目前MMD的病因和发病机制尚不明确.本文从免疫因子、免疫细胞、免疫基因、免疫相关疾病4个方面探讨MMD的免疫相关机制,期望对MMD的病因、发病机制的研究提供相关参考.