剪除动脉瘤破裂后延迟性脑缺血患者的术中神经电生理监测

N. A. Bobriakov, S. I. Petrov, E. V. Sereda, A. G. Moskalev, A. A. Ponomarev, I. Y. Kazankov, E. Y. Sedova, E. N. Maksimova
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In order to study the factors leading to the development of DCI, 2 groups were identified with transient SCP according to IONM: with the development of DCI – 7 patients out of the above 16 patients, including 3 men (42.9 %) and 4 women (57.1 %), aged 49.6 ± 8.5 years; and control group – 19 patients, including 9 men (47.4 %) and 10 women (52.6 %), aged 46.2 ± 10.9 years, in whom ND did not increase on the first postoperative day and by the time of discharge. The groups did not differ significantly in age, sex, aneurysm location, rupture period, and baseline ND.Results. In patients with DCI, in 9 cases (56.2 %), during the operation, SCP from the side of somatosensory evoked potentials (SSEP) and transcranial motor evoked potentials (TcMEP) was not registered, in 7 cases (43.8 %) transient SCP was registered, of which 3 patients (42.8 %) had TcMEP and SSEP, in 2 patients (28.6 %) – only TcMEP and in 2 patients (28.6 %) – only SSEP. In the control group, transient SCR of TcMEPs and SSEPs were registered in 4 patients (21.6 %), only TcMEPs – in 9 patients (47.4 %), only SSEPs – in 6 patients (31.6 %). When comparing two groups of patients with transient SCR (DCI‑group and control group), a statistically significant predominance was revealed in the first group of patients with severity 3 according to the Hunt–Hess scale (42.9 % vs 5.2 %), while in the second group patients of severity 1 and 2 prevailed (94.8 % vs 57.2 %) (p <0.05). When analyzing the data of ultrasonic duplex scanning of extra- and intracranial arteries in both groups, a statistically significant increase in peak systolic blood flow velocity in the middle cerebral artery was revealed (in the group with DCI before surgery – 100 (80–139) cm/s, after surgery – 175 (139–278) cm/s (p = 0.001), in the control group before surgery – 100 (100–118) cm/s, after surgery – 150 (116–194) cm/s (p = 0.0001)), as well as the Lindegaard index (in the group with DCI before surgery – 2.5 ± 0.7, after surgery – 3.5 ± 1.1 (p = 0.01), in the control group before surgery – 2.1 ± 0.3, after surgery 2.9 ± 1.1 (p = 0.0002)), but the differences between the groups were not statistically significant (p = 0.092).Conclusion. At this stage, it cannot be unequivocally stated that transient SCP according to IONM may be one of the risk factors for the development of DCI after clipping of ruptured cerebral aneurysms. 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引用次数: 0

摘要

目的通过术中神经电生理监测(IONM)研究延迟性脑缺血(DCI)患者术后剪除破裂脑动脉瘤过程中各项参数(SCP)的明显变化。研究纳入了 16 名患者,其中男性 7 名(43.8%),女性 9 名(56.2%),年龄为(51.1±9.3)岁,他们在 2016-2021 年期间接受了脑动脉瘤破裂剪切手术,术后第一天神经功能缺损(ND)仍保持在术前水平,但在住院结束时有所增加。为了研究导致DCI发展的因素,根据IONM确定了两组一过性SCP患者:DCI发展组--上述16名患者中的7名患者,包括3名男性(42.9%)和4名女性(57.1%),年龄为(49.6±8.5)岁;对照组--19名患者,包括9名男性(47.4%)和10名女性(52.6%),年龄为(46.2±10.9)岁,这些患者的ND在术后第一天和出院时都没有增加。两组患者在年龄、性别、动脉瘤位置、破裂时间和基线 ND 方面无明显差异。在 DCI 患者中,有 9 例(56.2%)在手术过程中未记录到来自体感诱发电位(SSEP)和经颅运动诱发电位(TcMEP)一侧的 SCP,有 7 例(43.8%)记录到瞬时 SCP,其中 3 例(42.8%)患者有 TcMEP 和 SSEP,2 例(28.6%)患者只有 TcMEP,2 例(28.6%)患者只有 SSEP。在对照组中,4 名患者(21.6%)出现 TcMEP 和 SSEP 的短暂 SCR,9 名患者(47.4%)仅出现 TcMEP,6 名患者(31.6%)仅出现 SSEP。在对两组一过性 SCR 患者(DCI 组和对照组)进行比较时发现,根据 Hunt-Hess 量表,第一组患者中严重程度为 3 的患者占多数(42.9% 对 5.2%),而第二组患者中严重程度为 1 和 2 的患者占多数(94.8% 对 57.2%)(P <0.05)。在分析两组患者颅内外动脉超声双工扫描数据时,发现大脑中动脉收缩期血流速度峰值有显著的统计学增长(DCI 组患者术前-100 (80-139) cm/s,术后-175 (139-278) cm/s (p = 0. 001),对照组患者术前-100 (80-139) cm/s,术后-175 (139-278) cm/s (p = 0. 001)。001),对照组术前 - 100(100-118)cm/s,术后 - 150(116-194)cm/s(P = 0.0001)),以及 Lindegaard 指数(DCI 组术前 - 2.5 ± 0.7,术后 - 3.5 ± 1.1(p = 0.01),对照组术前 - 2.1 ± 0.3,术后 2.9 ± 1.1(p = 0.0002)),但组间差异无统计学意义(p = 0.092)。现阶段还不能明确指出,根据 IONM 测量的一过性 SCP 可能是夹闭脑动脉瘤破裂后发生 DCI 的风险因素之一。然而,根据 IONM,入院时严重程度按 Hunt-Hess 量表估计为 3 分的一过性 SCR 患者,从统计学角度看,发生 DCI 的可能性明显更高。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Intraoperative neurophysiological monitoring in patients with delayed cerebral ischemia after clipping of ruptured arterial aneurysms
Aim. Research of significant changes in parameters (SCP) by intraoperative neurophysiological monitoring (IONM) during clipping of ruptured cerebral aneurysms in patients with delayed cerebral ischemia (DCI) in the postoperative period.Materials and methods. The study included 16 patients, 7 (43.8 %) men and 9 (56.2 %) women, aged 51.1 ± 9.3 years, who underwent clipping of ruptured cerebral aneurysms for the period 2016–2021, in which the neurological deficit (ND) remained at the preoperative level on the first postoperative day, but increased by the end of hospitalization. In order to study the factors leading to the development of DCI, 2 groups were identified with transient SCP according to IONM: with the development of DCI – 7 patients out of the above 16 patients, including 3 men (42.9 %) and 4 women (57.1 %), aged 49.6 ± 8.5 years; and control group – 19 patients, including 9 men (47.4 %) and 10 women (52.6 %), aged 46.2 ± 10.9 years, in whom ND did not increase on the first postoperative day and by the time of discharge. The groups did not differ significantly in age, sex, aneurysm location, rupture period, and baseline ND.Results. In patients with DCI, in 9 cases (56.2 %), during the operation, SCP from the side of somatosensory evoked potentials (SSEP) and transcranial motor evoked potentials (TcMEP) was not registered, in 7 cases (43.8 %) transient SCP was registered, of which 3 patients (42.8 %) had TcMEP and SSEP, in 2 patients (28.6 %) – only TcMEP and in 2 patients (28.6 %) – only SSEP. In the control group, transient SCR of TcMEPs and SSEPs were registered in 4 patients (21.6 %), only TcMEPs – in 9 patients (47.4 %), only SSEPs – in 6 patients (31.6 %). When comparing two groups of patients with transient SCR (DCI‑group and control group), a statistically significant predominance was revealed in the first group of patients with severity 3 according to the Hunt–Hess scale (42.9 % vs 5.2 %), while in the second group patients of severity 1 and 2 prevailed (94.8 % vs 57.2 %) (p <0.05). When analyzing the data of ultrasonic duplex scanning of extra- and intracranial arteries in both groups, a statistically significant increase in peak systolic blood flow velocity in the middle cerebral artery was revealed (in the group with DCI before surgery – 100 (80–139) cm/s, after surgery – 175 (139–278) cm/s (p = 0.001), in the control group before surgery – 100 (100–118) cm/s, after surgery – 150 (116–194) cm/s (p = 0.0001)), as well as the Lindegaard index (in the group with DCI before surgery – 2.5 ± 0.7, after surgery – 3.5 ± 1.1 (p = 0.01), in the control group before surgery – 2.1 ± 0.3, after surgery 2.9 ± 1.1 (p = 0.0002)), but the differences between the groups were not statistically significant (p = 0.092).Conclusion. At this stage, it cannot be unequivocally stated that transient SCP according to IONM may be one of the risk factors for the development of DCI after clipping of ruptured cerebral aneurysms. However, patients with transient SCR according to IONM, whose severity at admission is estimated at 3 points on the Hunt–Hess scale, are statistically significantly more likely to develop DCI.
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