AnestheticManagementofCerebrovascularDiseaseCarotidEndarterectomyDanielJ.Cole,M.D.Phoenix,Arizona翻譯：福建醫(yī)科大學(xué)附屬協(xié)和醫(yī)院麻醉科規(guī)培住院醫(yī)師：曾燕腦血管疾病頸動脈內(nèi)膜切除術(shù)的麻醉管理Introduction

Stroke（中風(fēng)）is

the

third

leading

causeof

death.

carotidarterydisease（勁動脈疾?。﹊s

a

significant

anestheticissue（麻醉問題）forpatients

over

50

years

ofage.Astrokeoccursduetoocclusiveorhemorrhagicconditions.Occlusivecerebrovasculardiseasecanbethrombotic,embolic,orstenotic(血栓，栓塞或狹窄)inorigin.(閉塞性或出血性中風(fēng)的發(fā)生是由于閉塞性腦血管疾病，血栓，栓塞或起源于狹窄)Patientswithahistoryofpriorstroke（既往中風(fēng)史）ortransientischemicattack（短暫性腦缺血發(fā)作）haveanincreasedriskofrecurrentperioperativestroke（圍術(shù)期再次中風(fēng)的危險）.簡介

Majorsymptomsofcarotidarterydiseaseincludechangesinvision,headache,changesinspeech,orfacial(發(fā)熱)andextremity(四肢)

weakness.Signs(體征)suggestiveofcarotidarterydiseaseincludeahigh-pitchedbruit(高亢的雜音)attheorigin(起源)oftheinternalcarotidartery,increaseinsizeandpulsation（強(qiáng)度）oftheipsilateral(同側(cè))superficialtemporalartery（顳淺動脈）,andchangesintheretinalexamination（眼底檢查）.Confirmation（確診）ofcarotidarterydiseaseisachievedbyvascularimagingwhichmayincludeultrasound,MRangiography,orcatheterangiography.（頸動脈疾病的確認(rèn)是通過血管成像，其中可能包括超聲，磁共振血管造影或?qū)Ч茉煊埃㊣ntroduction

Presently,thereis

insufficient（不足的）information

to

regarding

the

timing

of

surgery（手術(shù)時機(jī)）following

an

ischemic

episode（缺血性發(fā)作）.

Data（數(shù)據(jù)）

suggests

thereis

a

small

but

real

increase

in

morbidity（發(fā)病率）

if

surgeryisperformed

shortly

after

the

onset

of

symptoms（癥狀）.（數(shù)據(jù)表明，如果進(jìn)行手術(shù)后不久出現(xiàn)癥狀，有一個小，但真正的發(fā)病率增加）Riskmaybeassociatedwiththepresence（存在）ofalowdensity（低密度）lesion（病變）onCTscan,vascularterritory（血管壁內(nèi)）oftheinfarct（梗塞）,brainshift（腦組織移位）,andlevelofconsciousness（意識）.CarotidArteryRevascularization（頸動脈再灌注）

Carotidendarterectomy(CEA)（頸動脈內(nèi)膜切除術(shù)）wasintroducedin1954astreatmentforocclusive（閉塞性）carotidarterydisease.Efficacy（療效）dataonCEAwaslimiteduntilthe1990s.AnalysisofthreetrialshasdemonstratedthatCEAhasamarginal（微?。゜enefitinsymptomaticpatientswith50%-69%stenosisofthecarotidartery,andwasofgreatestbenefitinpatientswith>70%stenosis.（三項試驗分析表明，CEA在狹窄面積為50％-69％的頸動脈狹窄癥狀的患者身上收效甚微，在狹窄>70％的患者收益最大。）CarotidArteryRevascularization（頸動脈再灌注）Stenting(支架植入術(shù))andangioplasty（血管成形術(shù)）ofthecarotidartery(CAS)hasbeenperformedforalmosttwodecades.Potential（潛在）advantagesofCASincludeavoidingcranialnerve（顱神經(jīng)）damage,woundhematoma（傷口血腫）,andgeneralanesthesia（全身麻醉）.Theanesthetictechniqueforthisprocedureinvolves（涉及）minimalsedation(鎮(zhèn)靜）.Thisprocedurecancausesevere（嚴(yán)重）bradycardia（心動過緩）andhypotension,andcanresultincerebralhyperperfusion（高灌注）.Anatomic/Physiologic（解剖/生理學(xué)）Considerations（注意事項）

Carotidarterydiseaseistypically（通常是）theresultofather-osclerosis（動脈粥樣硬化）atthebifurcation（分支）ofthecommoncarotidartery（頸總動脈）ortheorigin（主支）oftheinternalcarotidartery（頸內(nèi)動脈）.（頸動脈疾病通常是頸內(nèi)動脈主支和頸總動脈分支粥樣硬化的結(jié)果）

Ischemiaismostoftenembolicinoriginbutmayalsohavea

hemodynamicbasis.（缺血最常見的起源于栓塞，但可能也有血液動力學(xué)基礎(chǔ)）

Therearethreephases（階段）oftheresponseofvariouscerebralvariables（腦變量）toprogressive（進(jìn)展的）carotidarterydisease.（頸動脈疾病的進(jìn)展在腦變量的反應(yīng)上分三階段）Duringischemia（缺血）,collateralflow（側(cè)支循環(huán)）isacornerstone（基礎(chǔ)）ofcerebralbloodflow(CBF)compensation（補償）.Anatomic/Physiologic（解剖/生理學(xué)）

Considerations

TheprincipalpathwaysofcollateralflowaretheCircleofWillis（側(cè)支循環(huán)的主要途徑是Willis環(huán)）,extracranialanastomoticchannels（顱外吻合通道）,andleptomeningeal（腦膜）communicationsthatbridge“watershed”（分水嶺）areasbetweenmajorarteries.DuringCEA,theriskofischemiaisrelatedtothedependencyofthecirculationontheipsilateral（同側(cè)）internalcarotid（頸內(nèi)）artery,andthecerebrovascular（腦血管）reserve（儲備）ofthecontralateral（對側(cè)）hemisphere（半球）.PreoperativeConcerns（術(shù)前關(guān)注點）

CEAhasaninherent（固有）riskofperioperative（圍手術(shù)期）strokeandcardiovascular（心血管）events.（CEA存在著圍術(shù)期中風(fēng)和心血管事件的固有風(fēng)險）Insymptomaticpatients,thereisa6.5%rateofstrokeanddeathassociatedwithCEA;whilethereportedstrokeanddeathrateforpatientswithasymptomaticdiseaseis2.3%.

TheriskforstrokefollowingCEAismoststronglyassociatedwithanactiveneurologic（神經(jīng)）process（活動）priortosurgicalintervention（手術(shù)干預(yù)）.

Otherfactorswhichhavebeenreportedtoincreaseneurologicalriskinclude:（其他有報道的增加神經(jīng)系統(tǒng)風(fēng)險的因素包括）?hemisphericversusretinaltransientischemicattack（半球與視網(wǎng)膜短暫性腦缺血發(fā)作）?anurgentprocedure（緊急手術(shù)）?aleftsidedprocedure（左側(cè)手術(shù)）?ipsilateralischemiclesiononcomputerizedtomography（電腦斷層掃描同側(cè)缺血性病變）?contralateralcarotidocclusionorpoorcollaterals（對側(cè)的頸動脈閉塞或者側(cè)支循環(huán)差）?impairedconsciousness（意識障礙）?anirregularorulceratedipsilateralplaque（不規(guī)則或者破潰的同側(cè)斑塊）Medicalcomplicationsoccurabout10%ofthetimeafterCEAandareassociatedwiththefollowing:（CEA后并發(fā)癥的發(fā)生還與下列有關(guān)）?Hypertension(HTN)（高血壓?。簍heincidence（發(fā)病率）ofaneurologicdeficit（神經(jīng)功能缺損）isgreaterinpatientswithuncontrolled（未控制的）HTNpreoperatively（術(shù)前）andpostoperativeHTN（術(shù)后高血壓）.（術(shù)前未控制的高血壓和術(shù)后高血壓的神經(jīng)功能缺損的發(fā)病率更高）?Cardiac（心臟?。篴cardiacassessment（心臟評估）isindicatedinpatientswhopresentforCEA.?Diabetes（糖尿?。篸ataindicate（表明）thatCEAcanbeperformedsafelyinpatientswithdiabetes（糖尿病人可以安全的進(jìn)行CEA）?Renalinsufficiency（腎功能不全）：patientswithrenalinsufficiencyhaveanoverall（整體）increased（增加）riskforstroke,death,andcardiacmorbidity（發(fā)病率）,associatedwithCEAMonitoring（監(jiān)控）BasicMonitoring：thisshouldincludebasicASAmonitoringandintra-arterialbloodpressuremonitoring.（基本監(jiān)控應(yīng)包括基礎(chǔ)麻醉的監(jiān)測和動脈內(nèi)血壓監(jiān)測）CNSMonitoring：nospecialcerebralmonitorisrequiredinawakepatientswithregionalanesthesia.specialcerebralmonitor（腦監(jiān)測）isemployed（用于）whengeneralanesthesia（全麻）.Monitoring（監(jiān)控）

Electrophysiological（電生理）Monitoring:The16-channelEEG（腦電圖）remainsasensitiveindicator（指標(biāo)）ofinadequate（不足）cerebralperfusion（腦灌注）.Ipsilateral（單）orbilateral（雙）attenuation（降低）ofhighfrequencyamplitude（高頻壓力）ordevelopment（增長）oflowfrequencyactivityseenduringcarotidcross-clampingisindicativeofinadequatecerebralperfusion.IntraoperativeneurologiccomplicationshavebeenshowntocorrelatewellwithEEGchangesindicativeofischemia.（同側(cè)或雙側(cè)高頻衰減幅度或開發(fā)低頻活動期間看到頸動脈交叉夾緊是反映腦灌注不足，術(shù)中已顯示出良好的相關(guān)性腦電圖改變，預(yù)示缺血的神經(jīng)系統(tǒng)并發(fā)癥）

MoststudiessuggestthatSSEPsareusefulformonitoringcerebralperfusionduringcross-clampingandhavesimilarorsuperiorsensitivityandspecificitytoconventionalEEG.(SSEPs在監(jiān)測夾閉動脈的腦灌注上有類似或優(yōu)于常規(guī)腦電圖的敏感性和特異性）

StableanesthesiamustbemaintainedtominimizetheinfluenceofanestheticsontheSSEPamplitude.Ingeneral,>50%reductionofamplitudeofthecorticalcomponentisconsideredtobeasignificantindicatorofinadequatecerebralperfusion.IncontrasttoconventionalEEG,SSEPmonitorsthecortexaswellasthesubcorticalpathwaysintheinternalcapsule,anareanotreflectedinthecorticalEEG.（必須維持麻醉平穩(wěn)麻醉藥對體感誘發(fā)電位的振幅的影響減到最小。在一般情況下，減少>50％的振幅皮質(zhì)成分被認(rèn)為是腦灌注不足一個重要的指標(biāo)。與常規(guī)腦電圖相反，體感誘發(fā)電位監(jiān)測皮層和皮層下通路，而沒有反映在皮層腦電圖Monitoring（監(jiān)控）

MeasurementofStump（殘端）Pressure:

Sinceoneimportant

determinantof

CBF

isperfusion

pressure,

itseems

reasonabletoassumethatthedistal（遠(yuǎn)端）arterial

pressureintheipsilateral（同側(cè)）hemisphere（半球）duringcarotidocclusion（頸動脈閉塞）would

providesomeindication（跡象）ofcollateral（側(cè)枝的）CBF.Stumppressureinvolvesdirectmeasurementoftheretrogradeinternalcarotidarterypressurefollowingocclusionofthemoreproximalcommonandexternalcarotidarteries.（由于CBF的一個重要的決定因素是灌注壓，這似乎是合理的假設(shè)，在同側(cè)半球在頸動脈閉塞遠(yuǎn)端動脈壓會提供一些補償，CBF樹樁壓力涉及直接測量閉塞的逆行頸內(nèi)動脈的近端壓力和頸外動脈壓力）TranscranialDoppler（經(jīng)顱多普勒超聲）(TCD):

TCD

hasbeenutilized（利用）asa

monitoring（監(jiān)控）tool

bymeasuring

blood

flow

velocity（速度）in

themiddle

cerebral

artery（中腦動脈）duringCEA.（TCD被用來作為監(jiān)測工具，通過測量CEA過程中大腦中動脈血流速度）AnestheticManagement

General

anesthesiaispreferredinpatientswithanatomy/pathologythat

maymakethesurgicalconditionsdifficult.（全麻是那些在解剖/病理學(xué)上有手術(shù)困難的患者的首選）Onecaveatthatisoftennotappreciatedregards

nitrousoxide.Itisverydifficulttoplaceashuntinthecarotidartery,ortoreleasethecarotidarterycross-clamp,withoutexposingthedistalcerebralcirculationtoairbubbles.（需要注意的一點是氧化亞氮是不被推薦的。放置頸動脈分流器或釋放頸動脈交叉鉗時不暴露前端而使氣泡進(jìn)入到腦循環(huán)，這是非常困難的）AnestheticManagementSevofluraneanddesfluranehavebeenshowntoresultinquickerextubationtimesandrecoveryprofilesafterCEA,

comparedto

isoflurane,withnosignificant

perioperativedifference

in

cardiacmorbidity.（與異氟烷相比，七氟烷和地氟烷被證明CEA術(shù)后更快的拔管時間、更好的蘇醒質(zhì)量，而無圍術(shù)期心臟事件發(fā)生率的不同。）

Propofol

and

narcoticsmaybeassociatedwithbetterhemodynamicstabilitythanisoflurane,andremifentanil/propofolmayhave

lessevidenceof

myocardialischemiathan

isoflurane/fentanyl.（與異氟烷相比，丙泊酚和阿片類可能有更好的血流動力學(xué)穩(wěn)定性，瑞芬太尼/丙泊酚與異氟烷/芬太尼相比可能更少的心肌缺血發(fā)生）AnestheticManagement

AregionaltechniqueforCEArequiresanesthesiaofcervicalnerves2-4.（CEA的區(qū)域麻醉需要麻醉頸神經(jīng)2-4）Superficialcervicalplexusblock,

deepcervicalplexusblock,epiduralanesthesia,straightlocal,andcombinationsofthesetechniqueshave

allbeen

usedsuccessfully.（頸淺神經(jīng)叢阻滯、頸深神經(jīng)叢阻滯、硬膜外麻醉、單純局麻或以上技術(shù)的結(jié)合都被成功的使用過）Untilrecently,non-randomizedstudiessuggested

that

theuseof

aregionaltechniquemaybe

associatedwithreductions(approximately50%)

intheoddsofstroke,death,myocardialinfarctionandpulmonarycomplications.（直到最近，非隨機(jī)研究提示區(qū)域性技術(shù)可能與術(shù)后中風(fēng)、死亡、心肌梗死、肺部并發(fā)癥的減少（近50%）相關(guān)。）ModalitiesofCerebralProtection

腦保護(hù)的方式Surgical（外科）：as