颅外-颅内动脉旁路手术：历史、现状与展望课件

颅外-颅内动脉旁路手术：历史、现状与展望

EXTRACRANIAL-INTRACRANIALBYPASSSURGERY

PAST,PRESENTANDFUTURE

颅外-颅内动脉旁路手术：历史、现状与展望

EXTRACRAN

PioneersofBypassProcedures

●Jacobson(1960)(Vermont)

Reconstructedcarotidarteries

ofdogsandrabbits,achieving

a100%patencyrate

●Donaghy(Vermont)

Establishedmicrosurgicallab,

reconstructedvessels<1mmin

diameter

旁路手术的先驱

●Jacobson(1960)(佛蒙得）

重建犬和兔颈动脉，100%

通畅

●Donaghy(佛蒙得）

建立显微神经外科实验室，

重建直径<1mm的血管HISTORYOFBYPASSPROCEDURES

旁路手术历史

PioneersofBypassProceduresM.G.Yasargil&HisContributions

●Interestwasstimulatedwhen

hewasaskedtoperforman

embolectomyofacortical

artery,notyetmastered.

●Enthusiasmtocerebralrevas-

cularizationincreasedafter

thereportofanEC-ICbypass

M.G.Yasargil及其贡献

●其兴趣因一例皮层动脉取栓

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

引起其热情

M.G.Yasargil&HisContributi●

1964InternationalCongressof

Neuroradiologists

Drs.SweetandRasmussen

advisedhimtocontactprof.

Donaghy

1965YasargilbeganhistraininginDonagh’slab.

1964年，国际神经放射大会，Sweet

和Rasmussen建议其与Donaghy联

系。1965年，开始在Donaghy实验室

训练。●1964InternationalCongress

●Initialattemptstointerposea

femoralvasculargraftfrom

CCAtoMCA.Thegraftwould

progresstothrombosis.The

ideaof

performingSTA-MCA

bypasswasthenborn.

●Bytheendof1966morethan

30STA-MCAbypassindogs

hadbeenperformed

●初始时，作CCA-股部血管

移植物-MCA术，但移植血

管内血栓形成。

产生STA-MCA旁路术设想

●至1966年底完成30余例犬

STA-MCA旁路术

●InitialattemptstointerpoOct.30,1967YasargilperformedthefirstSTA-MCAbypass,inapatientwithMarfansyndromeandcompleteocclusionofMCA

Amajorstepwasmadeintothefieldofreconstructiveintracranialvascularmicroneurosurgery.

1967年，Yasargil为一例Marfan综合征伴大脑中动脉闭塞者成功施行首例STA-MCA旁路术

颅内血管重建的重要进展！●Oct.30,1967Yasargilperform

CerebralIschemia

●Since1967STA-MCAbypasshadbeenwideaccepted,althoughtheindicationsremainedcontroversialbytheendof1960’.Dr.ZangrenheperformedthefirstcaseofSTA-MCAbypassinChina(1976).

脑缺血

●1967年后，STA-MCA被广泛应

用，尽管到六十年代末，其适应

证仍有争议。臧人和教授于1976年在国内首先开展STA-MCA旁路术。

INDICATIONSFORBYPASS

旁路手术应用

CerebralIschemia

●Since196

●1977NorthAmericanEC-IC

BypassStudy(byDr.Henry

Barnett)

●1977年开始的北美EC-IC旁路研究

内科治疗组714例0.6%

STA-MCA+内科663例2.5%

30天死亡和致残、卒中率

Conclusion:STA-MCAwas

ineffectiveinpreventing

cerebralischemia

结论：STA-MCA不能防止脑缺血

●1977NorthAmericanEC-IC

●Failureofextracranial-intra-

cranialarterialbypassto

reducetheriskofischemic

stroke.Resultsofaninter-

nationalrandomizedtrial.

TheEC/ICBypassStudyGroup.

NEnglJMed313:1191-1200,

1985

●Markeddecreaseinthenumber

ofSTA-MCAbypassperformed

forcerebralischemia

●颅内-外动脉旁路术不能降

低缺血性卒中的风险。国际

随机试验结果。EC/IC研究

组，新英格兰医学313:1191,

1985

●STA-MCA旁路手术量明显

减少

●Failureofextracranial-int

●

CriticismtoEC/ICBypassStudy

▲Patientswerenotevaluated

preoperativelycerebrovascular

hemodynamicstatus

▲Bothpatientandtherapist

werenotblined

▲Onlyhalfofthepatients

receivingantiplateletagents

▲Alargepercentageofpatients

hadnosymptomsbeforeentry

▲Alargenumberofpatients

underwentsurgeryoutsidethe

study

●对EC/IC旁路研究的批评

▲未评估病人术前的脑血流动力

状态

▲非双盲研究

▲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

▲许多手术病人未纳入研究

●CriticismtoEC/ICBypassS

●Thestudyinvestigators

pointedoutthatrandomized

trialsinvolveonlyasmall

fractionofthepopulationat

riskandthatthisfactordoes

notpreventastudyfrombe-

ingvalid.

●研究组人员回应

承认该随机试验仅包括小部

分卒中风险人群，但并不影

响试验的可靠性

●Thestudyinvestigators

●TheCarotidOcclusionSurgery

StudyRandomizedTrial(COSS)

U.SandCanada,49clinical

centers18PETcenters

(2002~2010)

●

颈动脉闭塞手术随机研究（COSS）

美国、加拿大49个临床中心

18个PET中心(2002~2010)

30天同侧卒中2年终点事件

手术组（STA-MCA+内科治疗）97例14（14.4%）20（21.0%）

内科组（抗栓+危险因素控制）98例2（2.0%）20（22.7%）

Conclusion:EC-ICbypassdid

notreducetheriskof

recurrentipsilateralischemic

strokeat2years.

JAMA,306:1983,2011

结论：EC/IC旁路术不能降低同

侧缺血性卒中的风险

JAMA,306:1983,2011

●TheCarotidOcclusionSurge

●

Forpatientswithsymptomatic

extracranialcarotidocclusion,

EC/ICbypassisnotroutinely

recommended

(ClassⅢEvidenceA)

●ForpatientswithstrokeorTIA

dueto50%to99%stenosisof

amajorintracranialartery,

EC/ICbypassisnotrecommended

(ClassⅢEvidenceB)

AHA/ASAGuidelinesforthe

Preventionofstroke2011

●症状性颅外颈动脉闭塞，通常不推荐

旁路术（Ⅲ级推荐，A级证据）

●颅内主要动脉狭窄50%以上，不推荐

旁路术（Ⅲ级推荐，B级证据）

美国心脏学会/卒中学会2011版卒中

预防指南

●Forpatientswithsymptomat

●Extracranial-IntracranialBypass

forStroke—IsThistheEndof

theLineoraBumpintheRoad?

Neurosurgery71:557,2012

●颅内外旁路手术预防卒中—

路

到尽头，还是（又一）撞击？

神经外科71:557,2012

●Extracranial-IntracranialB

●Althoughgeneralexpansionof

EC/ICbypassusewouldnot

besupported,aselectsubset

ofpatientswithmedically

refractoryhemodynamic

symptomsmaywellbenefit

fromsurgery.

●Limitedapplicationand

furtherstudywithaneyeto

futuredevelopments,rather

thancompleteabandonment,

iswarranted.

●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

病人，手术可能有益。

●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。

●AlthoughgeneralexpansionAcutestroke

●Emergentcerebralrevascula-rizationisveryrational

Encouragingresultswerereported.

●Butothersconsideredtheacuteischemiaarelativecontraindication

Conclusion:OnlythosepatientswithcrescendoTIAormildtomoderatedeficits<6hrswithnoinfarctionshouldbeconsideredforEC/ICbypass

急性卒中

●急诊脑血运重建合理，有报

告结果令人鼓舞

●其他学者认为，急性缺血是

急诊重建的相对禁忌。

Crowell,Jafar(1986)报告67例，27例改善，26例无变化，11例死亡

结论：EC/IC旁路术仅可用

于渐进性TIA或轻至中度缺

陷（<6hrs）且无梗死者

Acutestroke

●Emergentcerebr

●Withtheadventofinterventional

neuroradiologyandthrombolytic

therapies,emergentEC/ICbypass

foracutestrokedecreased

●介入神经放射和溶栓治疗的出

现，使急性卒中的急诊旁路术

减少。

●WiththeadventofintervenSAHandCerebralVasospasm

●STA-MCAbypasshasbeen

performed

●Thisindicationdidnotgain

wideacceptance.Endovascular

techniquescombinedwith“3H”

therapyassumedapivotalrole

SAH与脑血管痉挛

●曾采用STA-MCA旁路术

Batjer,Samson(1986)报告11例，术后6例改善，2例稳定

●未被广泛接受。主要采用血

管内技术和“三高”疗法

SAHandCerebralVasospasm

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

●Carotidarteryocclusionremainedthemainstayforsomeaneurysms,butischemicdeficitsmaybeoccur.

动脉瘤

●颈动脉闭塞依然是某些颅内动脉

瘤的重要治疗手段，但可能发生

缺血损害。

颈动脉闭塞后脑缺血损害

闭塞后脑缺血损害

破裂动脉瘤33%颈内动脉41%~59%未破裂动脉瘤12%颈总动脉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

大颈内动脉瘤术中采用STA-MCA

旁路术

●Lougheed(1971)完成首例颈总

动脉-大隐静脉-颅内颈内动脉旁路

术

●

Sundt（1982）颅外动脉-大隐

静脉-颅内动脉旁路术用于不可夹

闭动脉瘤的先驱

●Yasargil(1967)2cases

●

Ausman（1978）

Firstdescribedtheuseofradial

arterygrafts(RAGs)

●

Morimoto(1988)

UseofRAGforaneurysms

●Ausman(1978)

首次介绍用桡动脉作移植物。

●Morimoto(1988)

将之用于动脉瘤手术

●Ausman（1978）

Firstdesc45M,ECA-MCAbypassfollowedbytrappingofthegiantsupraclinoidICAaneurysmwithpreserva-tionOfanteriorchoroidalartery(arrow)45M,ECA-MCAbypassfo65,F,CervicalICA-SVG-MCA2bypasswasperformedfollowedbytrappingofthegiantintracavernousaneurysm65,F,CervicalICA-SVG-MCA2颅外-颅内动脉旁路手术：历史、现状与展望课件

●Spetzler(1990’)Developed

severalinnovations

▲thebonnetbypass

▲multiplearterialanastomosis

▲useofmetabolicbrain

protection

▲useofheparin

▲petrousICA-SVG-supraclinoid

ICAbypass

●Spetzler(90年代）若干创新

▲bonnet旁路术（从头的一侧至

另一侧）

▲多支动脉吻合

▲脑代谢保护措施

▲肝素

▲岩骨段颈内动脉-大隐静脉-床突

上段颈内动脉旁路术

●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的创新

▲将大隐静脉远端吻合于M1或

M2分叉

▲近端吻合于ICA或ECA

▲术中DSA即时检查移植血管

▲颈外动脉-移植血管-岩骨段颈内

动脉

▲颅外椎动脉-移植血管-大脑中动

脉或颅内椎动脉

▲基底动脉-移植血管-基底动脉

（低温停循环下）

●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

●其它创新

▲用颌内动脉作供血动脉

▲移植血管穿越中颅窝底隧道而

非皮下

▲内镜下截取大隐静脉

▲

消融激光辅助非阻断吻合

(ELANA)

▲术中无创血流定量分析（NOVA)

▲术中吲哚青绿评估

●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

颅底肿瘤

●为切除某些复杂的颅底肿瘤，旁

路手术被接受，但并非无反对

Case1Recurrentchondrosarcoma.Duringoperation,theintracavernousICAwasruptured.EmergencyradialarterybypassgraftwasperformedfromcervicalICAtoMCA2.SkullBaseTumors

●Theuseo颅外-颅内动脉旁路手术：历史、现状与展望课件Case247,FIntracavernousandsupracavernousmeningiomaencasingandnarrowingtheleftICACase247,FIntracavernouECA-RAG-MCA2andcervicalICA-SVG-MCA2ECA-RAG-MCA2andcervicalICA-颅外-颅内动脉旁路手术：历史、现状与展望课件

●Theuseofbypassforskull

basetumorshasgreatly

declinedbecauseofuseof

radiosurgeryfortumor

remnants.However,this

techniqueremainsavaluable

tool

●因放射外科的应用，旁路手术用

于颅底肿瘤大为减少，但依然是

一有用方法

●Theuseofbypassforskull

●Whenamajorvesselisinvaded

orencasedbytumors,thereare

twocontroversies:

Whetheronetrytoskeletonize

thetumororwhetherthevessel

shouldberesected?

Whetherthepatientshouldbe

revascularizeduniversallyor

selectively?

●对重要血管被肿瘤侵犯或包

绕，两点争论：

将肿瘤与血管分开，还

是连同血管一并切除？

将重要血管切除后，常

规还是选择性施行血运重

建？

●Whenamajorvesselisinva

●Whetherthevesselshouldbe

leftinsitudependsuponthe

attitudeofsurgeonandthe

natureoftumor

Benigntumorsotherthan

meningiomamayusuallybe

dissectedawayfromvessel.

Chordomaandchondrosarco-

ma,mostcanbedissected

awayfromvessel,butinsome

patientsgraftingwillbeneeded.

●是否保留血管，取决于医生和肿瘤

性质

除脑膜瘤外的良性肿瘤，多可

与血管分开。

脊索瘤和软骨肉瘤也多可与血

管分开，但有时需切除血管并作旁

路手术。

●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

术—

争议

选择施行根据术前闭塞试验

结果

常规施行因即使侧支循环良

好，血管闭塞后仍可发生卒中

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）

烟雾病

●

Yasargil(1972)首次为一例4岁

moyamoya病儿施行STA-MCA术

●Spetzler(1980)为一例双侧床突

上段ICA闭塞者行间接旁路术（原计

划作直接手术，但术中未找到合适

皮层动脉）MoyamoyaDisease

●Yasargil●

Theefficacyofdirectand

indirectbypasswas

demonstratedinpatients

withischemicmoyamoya

disease

●Theeffectivenessofre-

vascularizationinpre-

ventinghemorrhage

remainsacontroversy

●

直接和间接旁路术对缺血性

moyamoya病人有效

●但对防止出血的效果仍有争议

复发出血率Fujii(1997)手术组（152）19.1%

非手术组（138）

28.3%

●Theefficacyofdirectand

●Forpatientswithocclusive

carotidorMCAdisease,limited

applicationandfurtherstudy

withaneyetofutuneis

warranted

●对闭塞性颈动脉或大脑中动脉病

人，严格选择适应证，并需作进

一步研究

FUTUREOFBYPASS

旁路手术展望

●Forpatientswithocclus●Newimagingmodalitiesfor

evaluationofacutestroke

▲acuteinfarctionorpenumbra?

▲withinthepenumbrazone,

theareaswillbecomeinfarcted

orsurvivewithoutperfusion?

●现代影像技术（DMR,PMR,

PCT/CTA,PET)可鉴别急性

卒中病人的：

▲急性梗死还是半暗区

▲半暗区中，如不恢复灌注，

哪些可发展成梗死，哪些

可存活。●Newimagingmodalitiesfor

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.

●随影像技术的发展，能更好地界

定缺血但存活的组织（OEF）

的阈值，会有更多关于急性卒中

急诊手术的构想●Withfurtherdevelopmentsin●Bypassprocedureremainsan

adjuvantforaneurysmand

skullbasetumortreatment

Advancedimagingperfusion

techniquesmayimprovethe

accuracyofballoonocclusive

test.

Newbypasstechniquesmay

beuseful.

●旁路手术依然是某些动脉瘤和

颅底肿瘤的辅助治疗手段。

灌注成像技术的发展会提

高球囊闭塞试验的准确性

新的旁路手术方法

●Bypassprocedureremainsan●Theroleofbypassformoyamoya

diseaseawaitstheresultsof

largerandomizedtrials.

Moredetailedstudiesonthe

preventionofhemorrhagicevents

areexpected

●需大规模随机研究来证实旁路

术对moyamoya病的效果

对预防出血的效果需进一

步研究

●TheroleofbypassformoyamTHANKSTHANKS颅外-颅内动脉旁路手术：历史、现状与展望

EXTRACRANIAL-INTRACRANIALBYPASSSURGERY

PAST,PRESENTANDFUTURE

颅外-颅内动脉旁路手术：历史、现状与展望

EXTRACRAN

PioneersofBypassProcedures

●Jacobson(1960)(Vermont)

Reconstructedcarotidarteries

ofdogsandrabbits,achieving

a100%patencyrate

●Donaghy(Vermont)

Establishedmicrosurgicallab,

reconstructedvessels<1mmin

diameter

旁路手术的先驱

●Jacobson(1960)(佛蒙得）

重建犬和兔颈动脉，100%

通畅

●Donaghy(佛蒙得）

建立显微神经外科实验室，

重建直径<1mm的血管HISTORYOFBYPASSPROCEDURES

旁路手术历史

PioneersofBypassProceduresM.G.Yasargil&HisContributions

●Interestwasstimulatedwhen

hewasaskedtoperforman

embolectomyofacortical

artery,notyetmastered.

●Enthusiasmtocerebralrevas-

cularizationincreasedafter

thereportofanEC-ICbypass

M.G.Yasargil及其贡献

●其兴趣因一例皮层动脉取栓

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

引起其热情

M.G.Yasargil&HisContributi●

1964InternationalCongressof

Neuroradiologists

Drs.SweetandRasmussen

advisedhimtocontactprof.

Donaghy

1965YasargilbeganhistraininginDonagh’slab.

1964年，国际神经放射大会，Sweet

和Rasmussen建议其与Donaghy联

系。1965年，开始在Donaghy实验室

训练。●1964InternationalCongress

●Initialattemptstointerposea

femoralvasculargraftfrom

CCAtoMCA.Thegraftwould

progresstothrombosis.The

ideaof

performingSTA-MCA

bypasswasthenborn.

●Bytheendof1966morethan

30STA-MCAbypassindogs

hadbeenperformed

●初始时，作CCA-股部血管

移植物-MCA术，但移植血

管内血栓形成。

产生STA-MCA旁路术设想

●至1966年底完成30余例犬

STA-MCA旁路术

●InitialattemptstointerpoOct.30,1967YasargilperformedthefirstSTA-MCAbypass,inapatientwithMarfansyndromeandcompleteocclusionofMCA

Amajorstepwasmadeintothefieldofreconstructiveintracranialvascularmicroneurosurgery.

1967年，Yasargil为一例Marfan综合征伴大脑中动脉闭塞者成功施行首例STA-MCA旁路术

颅内血管重建的重要进展！●Oct.30,1967Yasargilperform

CerebralIschemia

●Since1967STA-MCAbypasshadbeenwideaccepted,althoughtheindicationsremainedcontroversialbytheendof1960’.Dr.ZangrenheperformedthefirstcaseofSTA-MCAbypassinChina(1976).

脑缺血

●1967年后，STA-MCA被广泛应

用，尽管到六十年代末，其适应

证仍有争议。臧人和教授于1976年在国内首先开展STA-MCA旁路术。

INDICATIONSFORBYPASS

旁路手术应用

CerebralIschemia

●Since196

●1977NorthAmericanEC-IC

BypassStudy(byDr.Henry

Barnett)

●1977年开始的北美EC-IC旁路研究

内科治疗组714例0.6%

STA-MCA+内科663例2.5%

30天死亡和致残、卒中率

Conclusion:STA-MCAwas

ineffectiveinpreventing

cerebralischemia

结论：STA-MCA不能防止脑缺血

●1977NorthAmericanEC-IC

●Failureofextracranial-intra-

cranialarterialbypassto

reducetheriskofischemic

stroke.Resultsofaninter-

nationalrandomizedtrial.

TheEC/ICBypassStudyGroup.

NEnglJMed313:1191-1200,

1985

●Markeddecreaseinthenumber

ofSTA-MCAbypassperformed

forcerebralischemia

●颅内-外动脉旁路术不能降

低缺血性卒中的风险。国际

随机试验结果。EC/IC研究

组，新英格兰医学313:1191,

1985

●STA-MCA旁路手术量明显

减少

●Failureofextracranial-int

●

CriticismtoEC/ICBypassStudy

▲Patientswerenotevaluated

preoperativelycerebrovascular

hemodynamicstatus

▲Bothpatientandtherapist

werenotblined

▲Onlyhalfofthepatients

receivingantiplateletagents

▲Alargepercentageofpatients

hadnosymptomsbeforeentry

▲Alargenumberofpatients

underwentsurgeryoutsidethe

study

●对EC/IC旁路研究的批评

▲未评估病人术前的脑血流动力

状态

▲非双盲研究

▲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

▲许多手术病人未纳入研究

●CriticismtoEC/ICBypassS

●Thestudyinvestigators

pointedoutthatrandomized

trialsinvolveonlyasmall

fractionofthepopulationat

riskandthatthisfactordoes

notpreventastudyfrombe-

ingvalid.

●研究组人员回应

承认该随机试验仅包括小部

分卒中风险人群，但并不影

响试验的可靠性

●Thestudyinvestigators

●TheCarotidOcclusionSurgery

StudyRandomizedTrial(COSS)

U.SandCanada,49clinical

centers18PETcenters

(2002~2010)

●

颈动脉闭塞手术随机研究（COSS）

美国、加拿大49个临床中心

18个PET中心(2002~2010)

30天同侧卒中2年终点事件

手术组（STA-MCA+内科治疗）97例14（14.4%）20（21.0%）

内科组（抗栓+危险因素控制）98例2（2.0%）20（22.7%）

Conclusion:EC-ICbypassdid

notreducetheriskof

recurrentipsilateralischemic

strokeat2years.

JAMA,306:1983,2011

结论：EC/IC旁路术不能降低同

侧缺血性卒中的风险

JAMA,306:1983,2011

●TheCarotidOcclusionSurge

●

Forpatientswithsymptomatic

extracranialcarotidocclusion,

EC/ICbypassisnotroutinely

recommended

(ClassⅢEvidenceA)

●ForpatientswithstrokeorTIA

dueto50%to99%stenosisof

amajorintracranialartery,

EC/ICbypassisnotrecommended

(ClassⅢEvidenceB)

AHA/ASAGuidelinesforthe

Preventionofstroke2011

●症状性颅外颈动脉闭塞，通常不推荐

旁路术（Ⅲ级推荐，A级证据）

●颅内主要动脉狭窄50%以上，不推荐

旁路术（Ⅲ级推荐，B级证据）

美国心脏学会/卒中学会2011版卒中

预防指南

●Forpatientswithsymptomat

●Extracranial-IntracranialBypass

forStroke—IsThistheEndof

theLineoraBumpintheRoad?

Neurosurgery71:557,2012

●颅内外旁路手术预防卒中—

路

到尽头，还是（又一）撞击？

神经外科71:557,2012

●Extracranial-IntracranialB

●Althoughgeneralexpansionof

EC/ICbypassusewouldnot

besupported,aselectsubset

ofpatientswithmedically

refracto