頸內(nèi)動(dòng)脈重度狹窄或閉塞患者側(cè)支循環(huán)與搏動(dòng)指數(shù)及持續(xù)注意功能的相關(guān)性研究

危薇，羅華，徐志彬

·論著·

頸內(nèi)動(dòng)脈重度狹窄或閉塞患者側(cè)支循環(huán)與搏動(dòng)指數(shù)及持續(xù)注意功能的相關(guān)性研究

危薇，羅華，徐志彬

目的探討頸內(nèi)動(dòng)脈重度狹窄或閉塞患者側(cè)支循環(huán)與搏動(dòng)指數(shù)(PI)及持續(xù)注意功能的相關(guān)性。方法對(duì)135例頸內(nèi)動(dòng)脈重度狹窄或閉塞患者進(jìn)行DSA檢查并根據(jù)側(cè)支循環(huán)開(kāi)放情況分組。另選擇30名健康老年人作為對(duì)照組。采用TCD檢查檢測(cè)雙側(cè)大腦中動(dòng)脈收縮期和舒張期血流速度(Vs和Vd)、平均血流速度(Vm)和PI。采用持續(xù)性操作測(cè)驗(yàn)的遺漏數(shù)、認(rèn)錯(cuò)數(shù)、平均反應(yīng)時(shí)評(píng)估持續(xù)注意功能。對(duì)結(jié)果進(jìn)行比較分析。結(jié)果(1)135例頸內(nèi)動(dòng)脈重度狹窄或閉塞患者根據(jù)側(cè)支循環(huán)開(kāi)放情況分為前交通動(dòng)脈(AcoA)開(kāi)放組(31例)、后交通動(dòng)脈(PcoA)開(kāi)放組(20例)、AcoA+PcoA開(kāi)放組(19例)、初級(jí)側(cè)支循環(huán)開(kāi)放組(即AcoA、PcoA、AcoA+PcoA開(kāi)放)(70例)、次級(jí)側(cè)支循環(huán)開(kāi)放組(主要包括眼動(dòng)脈、軟腦膜吻合支和新生供血血管)(15例)、初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組(13例)和無(wú)側(cè)支循環(huán)開(kāi)放組(37例)。(2)與對(duì)照組比較，其余各組患者的Vs、Vd、Vm和PI均顯著降低(均P<0.05)。與無(wú)側(cè)支循環(huán)開(kāi)放組比較，AcoA開(kāi)放組、初級(jí)側(cè)支循環(huán)開(kāi)放組的Vd及AcoA+PcoA開(kāi)放組的Vd、Vm均明顯升高，AcoA開(kāi)放組、AcoA+PcoA開(kāi)放組、初級(jí)側(cè)支循環(huán)開(kāi)放組及初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組的PI均明顯降低(均P<0.05)。與PcoA開(kāi)放組比較，AcoA開(kāi)放組、AcoA+PcoA開(kāi)放組的PI均明顯降低(均P<0.05)。與次級(jí)側(cè)支循環(huán)開(kāi)放組比較，初級(jí)側(cè)支循環(huán)開(kāi)放組的Vs、Vd、Vm和初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組的Vd、Vm均明顯升高，初級(jí)側(cè)支循環(huán)開(kāi)放組和和初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組的PI均明顯降低 (均P<0.05)。(3)與對(duì)照組比較，其余各組患者的遺漏數(shù)、認(rèn)錯(cuò)數(shù)和平均反應(yīng)時(shí)均顯著增加(均P<0.05)。與無(wú)側(cè)支循環(huán)開(kāi)放組比較，AcoA開(kāi)放組、AcoA+PcoA開(kāi)放組及初級(jí)側(cè)支循環(huán)開(kāi)放組的遺漏數(shù)、認(rèn)錯(cuò)數(shù)和平均反應(yīng)時(shí)均明顯減少；初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組的遺漏數(shù)和認(rèn)錯(cuò)數(shù)均明顯減少(均P<0.05)。與PcoA開(kāi)放組比較，AcoA開(kāi)放組的遺漏數(shù)和認(rèn)錯(cuò)數(shù)均明顯減少；AcoA+PcoA開(kāi)放組的遺漏數(shù)、認(rèn)錯(cuò)數(shù)和平均反應(yīng)時(shí)均明顯減少(均P<0.05)。與AcoA+PcoA開(kāi)放組比較，AcoA開(kāi)放組的遺漏數(shù)、認(rèn)錯(cuò)數(shù)和平均反應(yīng)時(shí)均明顯增加(均P<0.05)。與次級(jí)側(cè)支循環(huán)開(kāi)放組比較，初級(jí)側(cè)支循環(huán)開(kāi)放組的遺漏數(shù)、認(rèn)錯(cuò)數(shù)和平均反應(yīng)時(shí)均明顯減少；初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組的遺漏數(shù)和認(rèn)錯(cuò)數(shù)均明顯減少(均P<0.05)。(4)AcoA開(kāi)放組、初級(jí)側(cè)支循環(huán)開(kāi)放組和次級(jí)側(cè)支循環(huán)開(kāi)放組的PI與平均反應(yīng)時(shí)呈正相關(guān)(r=0.441,r=0.364,r=0.552；均P<0.05)。PcoA開(kāi)放組和無(wú)側(cè)支循環(huán)開(kāi)放組的PI與遺漏數(shù)呈正相關(guān)(r=0.668,r=0.397；均P<0.05)；與認(rèn)錯(cuò)數(shù)呈正相關(guān)(r=0.509,r=0.480；均P<0.05)。結(jié)論頸內(nèi)動(dòng)脈重度狹窄或閉塞患者患側(cè)高PI可反映其持續(xù)注意功能受損。

頸動(dòng)脈狹窄；側(cè)支循環(huán)；搏動(dòng)指數(shù)；持續(xù)性操作測(cè)驗(yàn)

頸內(nèi)動(dòng)脈重度狹窄或閉塞患者由于顱內(nèi)動(dòng)脈側(cè)支循環(huán)建立不同，可導(dǎo)致臨床表現(xiàn)和預(yù)后差異。注意是所有認(rèn)知功能的調(diào)節(jié)機(jī)制，雖然有研究[1]證明頸內(nèi)動(dòng)脈狹窄患者存在認(rèn)知功能障礙，但關(guān)于不同側(cè)支循環(huán)形成導(dǎo)致注意功能改變差異的研究極少。由于頸內(nèi)動(dòng)脈狹窄患者廣泛存在腦血流灌注異常，本研究將患側(cè)大腦中動(dòng)脈(MCA)的搏動(dòng)指數(shù)(PI)與患者持續(xù)注意功能測(cè)定結(jié)合，從腦血流動(dòng)力學(xué)和注意功能方面分析其認(rèn)知改變特征。

1 對(duì)象與方法

1.1 對(duì)象 系2014年6月～2016年10月我院收治的頸內(nèi)動(dòng)脈重度狹窄或閉塞患者135例，均符合北美癥狀性頸動(dòng)脈內(nèi)膜剝脫術(shù)試驗(yàn)診斷單側(cè)頸內(nèi)動(dòng)脈重度狹窄(70%～99%)或閉塞(100%)的標(biāo)準(zhǔn)[2]，并經(jīng)DSA檢查證實(shí)。其中，男67例，女68例；年齡61～83歲，平均(68.71±5.55)歲；受教育年限5～14年，平均(7.41±2.21)年。排除意識(shí)障礙、失語(yǔ)、肢體障礙、顱腦外傷、顱內(nèi)有梗死灶或占位性病變、精神疾病、嚴(yán)重心、肝、腎疾病、有頸內(nèi)動(dòng)脈以外的血管狹窄、TCD顳窗透聲不良的患者。另選擇體檢結(jié)果正常的健康老年人30名作為對(duì)照組。其中，男15名，女15名；年齡60～80歲，平均(70.00±6.41)歲；受教育年限3～15年，平均(7.57±3.33)年。兩組性別、年齡、受教育年限的差異無(wú)統(tǒng)計(jì)學(xué)意義，具有可比性。

1.2 方法

1.2.1 DSA檢查 采用東芝公司RTP14301J-G1E型X線DSA機(jī)行DSA檢查，經(jīng)專(zhuān)業(yè)介入醫(yī)師經(jīng)股動(dòng)脈插管，做選擇性血管造影，顯示雙側(cè)頸總動(dòng)脈、頸內(nèi)動(dòng)脈、頸外動(dòng)脈、椎-基底動(dòng)脈全腦血管造影。根據(jù)DSA檢查所見(jiàn)側(cè)支循環(huán)開(kāi)放情況將患者分組。

1.2.2 TCD檢查 受試者仰臥位，檢查人員使用德力凱公司的EMS-9A型經(jīng)顱多普勒超聲診斷儀，用1.6 MHz脈沖探頭分別經(jīng)受試者雙側(cè)顳窗取得最佳MCA血流信號(hào)，病例組記錄患側(cè)，對(duì)照組記錄雙側(cè)MCA 收縮期和舒張期血流速度(Vs和Vd)、平均血流速度(Vm)和PI。

1.2.3 持續(xù)注意功能的檢測(cè) 采用持續(xù)性操作測(cè)驗(yàn)(CPT)進(jìn)行持續(xù)注意功能的檢測(cè)，與既往測(cè)試方法[3]相同，由計(jì)算機(jī)輔助完成。在電腦屏幕中央，隨機(jī)出現(xiàn)字母，以“X”以外的任何字母為視覺(jué)性靶刺激，受試者需對(duì)靶刺激盡快作出按空格鍵反應(yīng)。測(cè)試包含6個(gè)版塊，每個(gè)版塊包括3個(gè)子塊，每個(gè)子塊有20個(gè)字母顯示，總共測(cè)試360次。子塊之間的間隔時(shí)間為1 s、2 s、4 s隨機(jī)呈現(xiàn)。程序自動(dòng)記錄的指標(biāo)：(1)遺漏數(shù)：對(duì)靶刺激未作出反應(yīng)的次數(shù)；(2)認(rèn)錯(cuò)數(shù)：對(duì)非靶刺激作出反應(yīng)的次數(shù)；(3)平均反應(yīng)時(shí)：從視覺(jué)刺激呈現(xiàn)到按下空格鍵的平均時(shí)間。

2 結(jié) 果

2.1 DSA檢查結(jié)果及分組 135例頸內(nèi)動(dòng)脈重度狹窄或閉塞患者根據(jù)側(cè)支循環(huán)開(kāi)放情況分為前交通動(dòng)脈(AcoA)開(kāi)放組(31例)、后交通動(dòng)脈(PcoA)開(kāi)放組(20例)、AcoA+PcoA開(kāi)放組(19例)、初級(jí)側(cè)支循環(huán)開(kāi)放組(即AcoA、PcoA、AcoA+PcoA開(kāi)放)(70例)、次級(jí)側(cè)支循環(huán)開(kāi)放組(主要包括眼動(dòng)脈、軟腦膜吻合支和新生供血血管)(15例)、初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組(13例)和無(wú)側(cè)支循環(huán)開(kāi)放組(37例)。

2.2 各組TCD參數(shù)的比較 見(jiàn)表1、表2。與對(duì)照組比較，其余各組患者的Vs、Vd、Vm和PI均顯著降低(均P<0.05)。與無(wú)側(cè)支循環(huán)開(kāi)放組比較，AcoA開(kāi)放組、初級(jí)側(cè)支循環(huán)開(kāi)放組的Vd及AcoA+PcoA開(kāi)放組的Vd、Vm均明顯升高，AcoA開(kāi)放組、AcoA+PcoA開(kāi)放組、初級(jí)側(cè)支循環(huán)開(kāi)放組及初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組的PI均明顯降低(均P<0.05)。與PcoA開(kāi)放組比較，AcoA開(kāi)放組、AcoA+PcoA開(kāi)放組的PI均明顯降低(均P<0.05)。與次級(jí)側(cè)支循環(huán)開(kāi)放組比較，初級(jí)側(cè)支循環(huán)開(kāi)放組的Vs、Vd、Vm和初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組的Vd、Vm均明顯升高，初級(jí)側(cè)支循環(huán)開(kāi)放組和和初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組的PI均明顯降低 (均P<0.05)。

表1 AcoA、PcoA開(kāi)放的TCD參數(shù)的特點(diǎn)(x±s)組別例數(shù)VsVdVmPIAcoA開(kāi)放組3139.26±13.46*25.49±8.95*△29.34±9.80*0.48±0.13*△▲PcoA開(kāi)放組2038.85±15.73*22.96±8.85*28.40±11.25*0.55±0.10*AcoA+PcoA開(kāi)放組1942.16±9.61*27.85±6.70*△33.26±8.64*△0.43±0.14*△▲無(wú)側(cè)支循環(huán)開(kāi)放組3735.84±14.26*20.77±8.01*26.76±11.24*0.56±0.08*對(duì)照組3097.31±23.3244.33±9.6161.98±13.760.85±0.13 注:與對(duì)照組比較*P<0.05;與無(wú)側(cè)支循環(huán)開(kāi)放組比較△P<0.05;與PcoA開(kāi)放組比較▲P<0.05

表2 初、次級(jí)側(cè)支循環(huán)開(kāi)放的TCD參數(shù)比較的特點(diǎn)(x±s)組別例數(shù)VsVdVmPI初級(jí)側(cè)支循環(huán)開(kāi)放組7039.93±14.30*▲25.40±8.46*△▲30.14±9.99*▲0.49±0.13*△▲次級(jí)側(cè)支循環(huán)開(kāi)放組1530.07±13.74*17.07±6.64*22.20±10.66*0.57±0.11*初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組1338.62±9.63*24.65±6.99*▲30.47±7.63*▲0.47±0.09*△▲無(wú)側(cè)支循環(huán)開(kāi)放組3735.84±14.26*20.77±8.01*26.76±11.24*0.56±0.08*對(duì)照組3097.31±23.3244.33±9.6161.98±13.760.85±0.13 注:與對(duì)照組比較*P<0.05;與無(wú)側(cè)支循環(huán)開(kāi)放組比較△P<0.05;與次級(jí)側(cè)支循環(huán)開(kāi)放組比較▲P<0.05

2.3 各組CPT指標(biāo)的比較 見(jiàn)表3、表4。與對(duì)照組比較，其余各組患者的遺漏數(shù)、認(rèn)錯(cuò)數(shù)和平均反應(yīng)時(shí)均顯著增加(均P<0.05)。與無(wú)側(cè)支循環(huán)開(kāi)放組比較，AcoA開(kāi)放組、AcoA+PcoA開(kāi)放組及初級(jí)側(cè)支循環(huán)開(kāi)放組的遺漏數(shù)、認(rèn)錯(cuò)數(shù)和平均反應(yīng)時(shí)均明顯減少；初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組的遺漏數(shù)和認(rèn)錯(cuò)數(shù)均明顯減少(均P<0.05)。與PcoA開(kāi)放組比較，AcoA開(kāi)放組的遺漏數(shù)和認(rèn)錯(cuò)數(shù)均明顯減少；AcoA+PcoA開(kāi)放組的遺漏數(shù)、認(rèn)錯(cuò)數(shù)和平均反應(yīng)時(shí)均明顯減少(均P<0.05)。與AcoA+PcoA開(kāi)放組比較，AcoA開(kāi)放組的遺漏數(shù)、認(rèn)錯(cuò)數(shù)和平均反應(yīng)時(shí)均明顯增加(均P<0.05)。與次級(jí)側(cè)支循環(huán)開(kāi)放組比較，初級(jí)側(cè)支循環(huán)開(kāi)放組的遺漏數(shù)、認(rèn)錯(cuò)數(shù)和平均反應(yīng)時(shí)均明顯減少；初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組的遺漏數(shù)和認(rèn)錯(cuò)數(shù)均明顯減少(均P<0.05)。

2.4 頸內(nèi)動(dòng)脈重度狹窄或閉塞患者TCD參數(shù)與CPT指標(biāo)的相關(guān)性 對(duì)各側(cè)支循環(huán)開(kāi)放組的TCD參數(shù)與CPT指標(biāo)進(jìn)行Pearson相關(guān)性分析顯示，AcoA開(kāi)放組、初級(jí)側(cè)支循環(huán)開(kāi)放組和次級(jí)側(cè)支循環(huán)開(kāi)放組的PI與CPT平均反應(yīng)時(shí)呈正相關(guān)(r=0.441,r=0.364,r=0.552；均P<0.05)。PcoA開(kāi)放組和無(wú)側(cè)支循環(huán)開(kāi)放組的PI與CPT遺漏數(shù)呈正相關(guān)(r=0.668,r=0.397；均P<0.05)；與CPT認(rèn)錯(cuò)數(shù)呈正相關(guān)(r=0.509,r=0.480；均P<0.05)。

表3 AcoA、PcoA開(kāi)放的CPT指標(biāo)的特點(diǎn)(x±s)組別例數(shù)遺漏數(shù)(次)認(rèn)錯(cuò)數(shù)(次)平均反應(yīng)時(shí)(ms)AcoA開(kāi)放組3110.10±4.06*△▲○26.81±10.57*△▲○417.68±23.74*△○PcoA開(kāi)放組2013.10±5.56*37.40±15.67*426.35±30.41*AcoA+PcoA開(kāi)放組197.26±4.31*△▲20.26±8.10*△▲396.68±27.10*△▲無(wú)側(cè)支循環(huán)開(kāi)放組3714.70±5.77*38.46±15.77*434.19±32.88*對(duì)照組304.23±2.4215.00±4.84366.80±37.47 注:與對(duì)照組比較*P<0.05;與無(wú)側(cè)支循環(huán)開(kāi)放組比較△P<0.05;與PcoA開(kāi)放組比較▲P<0.05;與AcoA+PcoA開(kāi)放組比較○P<0.05

表4 初、次級(jí)側(cè)支循環(huán)開(kāi)放的CPT指標(biāo)的特點(diǎn)(x±s)組別例數(shù)遺漏數(shù)(次)認(rèn)錯(cuò)數(shù)(次)平均反應(yīng)時(shí)(ms)初級(jí)側(cè)支循環(huán)開(kāi)放組7010.19±5.03*△▲28.06±13.27*△▲414.46±28.70*△▲次級(jí)側(cè)支循環(huán)開(kāi)放組1515.40±7.60*38.93±16.93*439.93±39.14*初級(jí)+次級(jí)側(cè)支循環(huán)開(kāi)放組1310.23±3.68*△▲27.92±9.08*△▲419.38±29.75*無(wú)側(cè)支循環(huán)開(kāi)放組3714.70±5.77*38.46±15.77*434.19±32.88*對(duì)照組304.23±2.4215.00±4.84366.80±37.47 注:與對(duì)照組比較*P<0.05;與無(wú)側(cè)支循環(huán)開(kāi)放組比較△P<0.05;與次級(jí)側(cè)支循環(huán)開(kāi)放組比較▲P<0.05

3 討 論

持續(xù)注意是注意的基本組成部分，是更高層次的注意和認(rèn)知功能基礎(chǔ)。CPT反映注意維持能力、抑制能力和沖動(dòng)性，是目前應(yīng)用較廣泛測(cè)查持續(xù)注意功能的方法。影像學(xué)研究[4]提示，執(zhí)行CPT任務(wù)時(shí)，功能MRI活化區(qū)域主要位于額葉、頂葉和枕葉。由于頸內(nèi)動(dòng)脈狹窄或閉塞后腦血管血流減慢減少，慢性低灌注可致腦組織能量代謝障礙、神經(jīng)元缺失變性導(dǎo)致腦萎縮、腦白質(zhì)病變。另外，頸動(dòng)脈斑塊脫落可形成腔隙性梗死或靜息性微栓塞，從而導(dǎo)致認(rèn)知功能障礙[5-6]。當(dāng)病變累及持續(xù)注意功能區(qū)域時(shí)表現(xiàn)為CPT遺漏數(shù)和認(rèn)錯(cuò)數(shù)增多，反應(yīng)時(shí)延長(zhǎng)。AcoA+PcoA開(kāi)放組和AcoA開(kāi)放組的CPT指標(biāo)相對(duì)優(yōu)于PcoA開(kāi)放組和無(wú)側(cè)支循環(huán)開(kāi)放組，說(shuō)明持續(xù)注意功能與側(cè)支循環(huán)開(kāi)放類(lèi)型相關(guān)。有研究[7]證實(shí)當(dāng)AcoA和PcoA同時(shí)開(kāi)放時(shí)，頸內(nèi)動(dòng)脈閉塞側(cè)大腦半球的血流量與健側(cè)比較無(wú)統(tǒng)計(jì)學(xué)差異。焦力群等[8]提出，AcoA代償對(duì)血流動(dòng)力學(xué)有積極意義，可明顯改善MCA分布區(qū)的血供，且AcoA和PcoA共同代償更優(yōu)于單支代償。而本研究中雖然患側(cè)MCA血流速度AcoA+PcoA開(kāi)放組>AcoA開(kāi)放組>PcoA開(kāi)放組，但差異無(wú)統(tǒng)計(jì)學(xué)意義，可能是由于本研究通過(guò)TCD檢測(cè)血流速度，而焦力群等[8]研究的是磁共振灌注成像的達(dá)峰時(shí)間，二者有一定差異。由于AcoA和PcoA同時(shí)開(kāi)放對(duì)CPT功能區(qū)域腦血流灌注影響較小，因此CPT指標(biāo)優(yōu)于PcoA開(kāi)放組和無(wú)側(cè)支循環(huán)開(kāi)放組。AcoA開(kāi)放組的CPT指標(biāo)優(yōu)于AcoA未開(kāi)放的病例組，可能是由于AcoA未開(kāi)放的患者額葉血流量降低[9]，不能代償腦組織對(duì)血流量的需求。次級(jí)側(cè)支循環(huán)開(kāi)放組的CPT指標(biāo)差于其他側(cè)支循環(huán)開(kāi)放組，說(shuō)明次級(jí)側(cè)支循環(huán)代償作用有限，當(dāng)初級(jí)側(cè)支循環(huán)代償不充分時(shí)，次級(jí)側(cè)支循環(huán)才發(fā)揮代償作用。本研究通過(guò)比較還發(fā)現(xiàn)，初級(jí)+次級(jí)側(cè)支循環(huán)的遺漏數(shù)和認(rèn)錯(cuò)數(shù)較單純次級(jí)側(cè)支循環(huán)開(kāi)放組低，可能是由于部分患者的AcoA開(kāi)放，對(duì)額葉血供有改善作用，持續(xù)注意功能部分保留。趙新宇等[10]的研究提出，單純頸內(nèi)-外動(dòng)脈側(cè)支循環(huán)開(kāi)放較AcoA/PcoA與頸內(nèi)-外動(dòng)脈同時(shí)開(kāi)放的患側(cè)MCA下降率升高，而MCA的血流速度與腦缺血的程度密切相關(guān)。本研究中單純次級(jí)側(cè)支循環(huán)開(kāi)放組患側(cè)的MCA血流速度低于其他側(cè)支循環(huán)開(kāi)放組，也與該研究結(jié)果一致。

PI值主要反映動(dòng)脈的順應(yīng)性和彈性，PI增高提示腦血管阻力增加、腦灌注下降、腦血流量減少等腦血管病理生理改變。由于MCA走行平直，易于用TCD測(cè)定，因此本文選取MCA進(jìn)行研究。雖然頸內(nèi)動(dòng)脈重度狹窄或閉塞者患側(cè)MCA均為低搏動(dòng)性血流，但PcoA、次級(jí)側(cè)支循環(huán)和無(wú)側(cè)支循環(huán)開(kāi)放組的 PI相對(duì)較高，提示其遠(yuǎn)端循環(huán)的有效灌注壓較低，局部腦組織代謝能力較差。目前對(duì)于PI值與認(rèn)知功能的關(guān)系尚無(wú)定論：有研究[11]發(fā)現(xiàn)MCA的高PI值與某些認(rèn)知領(lǐng)域的功能損傷有關(guān)；Post等[12]發(fā)現(xiàn)高PI值可反映血液透析患者的認(rèn)知功能損害，而Shim等[13]提出有認(rèn)知障礙者的PI并無(wú)改變。本研究發(fā)現(xiàn)多數(shù)病例組患側(cè)PI值與CPT指標(biāo)呈正相關(guān)，提示在病理?xiàng)l件下，PI增高可反映持續(xù)注意功能損害。原因可能是其相應(yīng)區(qū)域的供血?jiǎng)用}彈性較差，自動(dòng)調(diào)節(jié)能力受損，動(dòng)脈遠(yuǎn)端血供不足。此外，顱內(nèi)腔隙性梗死等慢性缺血性病理改變也可有PI增高的表現(xiàn)。對(duì)照組的PI較病例組升高，說(shuō)明PI在腦缺血的狀態(tài)下相對(duì)增高才能反映注意功能受損。

綜上所述，側(cè)支循環(huán)類(lèi)型是頸內(nèi)動(dòng)脈重度狹窄或閉塞患者顱內(nèi)血流動(dòng)力學(xué)和注意功能水平的重要影響因素，在進(jìn)行臨床治療時(shí)，應(yīng)盡早發(fā)現(xiàn)患者的側(cè)支循環(huán)開(kāi)放方式，對(duì)認(rèn)知功能作出客觀評(píng)估，并及時(shí)給予干預(yù)，以提高患者生活質(zhì)量。本研究不足之處在于只研究了MCA的PI值，在今后的研究中將對(duì)更多動(dòng)脈的PI值和其他TCD參數(shù)進(jìn)行分析，以便于全面分析頸內(nèi)動(dòng)脈重度狹窄或閉塞的血流動(dòng)力學(xué)變化與注意功能的相關(guān)性。

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Studyonrelationshipamongpulsatilityindex,sustainedattentionfunctionandcollateralcirculationinpatientswithseverestenosisorocclusionofinternalcarotidartery

WEIWei,LUOHua,XUZhi-bin.

theAffiliatedHospitalofSouthwestMedicalUniversity,Luzhou646000,China

ObjectiveTo investigate the relationship among pulsatility index (PI), sustained attention function and collateral circulation in patients with severe stenosis or occlusion of internal carotid artery.MethodsOne hundred and thirty-five patients with severe stenosis or occlusion of internal carotid artery were examined by DSA and were divided into different groups according to the type of collateral circulation. Meanwhile, 30 healthy aged people were selected as a control group. The peak systolic velocity (Vs), and diastolic velocity (Vd), mean velocity (Vm) and PI of bilateral middle cerebral artery were obtained by TCD. Sustained attention was evaluated by missed and mistaken scores as well as average reaction time of continuous performance test. The results were compared and analyzed.Results(1)According to the type of collateral circulation, 135 patients with severe stenosis or occlusion of internal carotid artery were divided into groups with patency of anterior communicating artery (AcoA)(31 cases),posterior communicating artery (PcoA)(20 cases), AcoA+PcoA (19 cases), primary collateral circulation (with AcoA, PcoA and AcoA+PcoA)(70 cases), secondary collateral circulation (including ophthalmic artery, leptomeningeal collateral vessel and new blood vessels)(15 cases), primary+secondary collateral circulation (13 cases) and group without collateral circulation (37 cases). (2)Compared with control group, Vs,Vd,Vm and PI all decreased significantly in every other group (allP<0.05). Compared with group without collateral circulation, Vd of group with AcoA or primary collateral circulation, Vd and Vm of group with AcoA+PcoA all increased significantly; PI of groups with AcoA, AcoA+PcoA, primary collateral circulation and primary+secondary collateral circulation all decreased (allP<0.05). Compared with group with PcoA, PI of groups with AcoA and AcoA+PcoA both decresed significantly (allP<0.05). Compared with group with secondary collateral circulation, Vs,Vd and Vm of group with primary collateral circulation, Vd and Vm of group with primary+secondary collateral circulation all increased significantly; PI of groups with primary collateral circulation and primary+secondary collateral circulation both decreased (allP<0.05).(3)Compared with control group, the missed, mistaken scores and average reaction time of CPT in every other group increased significantly (allP<0.05). Compared with group without collateral circulation, the missed, mistaken scores and average reaction time in groups with AcoA, AcoA+PcoA and primary collateral circulation all decreased significantly; the missed and mistaken scores of group with primary+secondary collateral circulation decreased significanly (allP<0.05). Compared with group with PcoA, the missed and mistaken scores of group with AcoA decreased significantly while the missed, mistaken scores and average reaction time of group with AcoA+PcoA all decreased significantly (allP<0.05). Compared with group with AcoA+PcoA, the missed, mistaken scores and average reaction time in group with AcoA increased sinificantly (allP<0.05).Compared with group with secondary collateral circulation, the missed, mistaken scores and average reaction time in group with primary collateral circulation all decreased significantly; the missed and mistaken scores in primary+secondary collateral circulation both decreased significantly (allP<0.05).(4) PI positively related to average reaction time in groups with AcoA, primary and secondary collateral circulation (r=0.441,r=0.364,r=0.552; allP<0.05). PI positively related to missed scores in group with PcoA and group without collateral circulation (r=0.668,r=0.397; allP<0.05). PI also positively related to mistaken scores in the above groups (r=0.509,r=0.480; allP<0.05).ConclusionHigh PI on the affected side of patients with severe stenosis or occlusion of internal carotid artery may reflect impairment of sustained attention function.

carotid stenosis;collateral circulation;pulsatility index;continuous performance test

R741.04

A

1004-1648(2017)05-0350-05

瀘州醫(yī)學(xué)院附屬醫(yī)院青年基金項(xiàng)目(2015-QS-034)

646000瀘州，西南醫(yī)科大學(xué)附屬醫(yī)院神經(jīng)內(nèi)科

羅華

2016-12-02

2016-12-27)