顱骨修補(bǔ)術(shù)后血管反應(yīng)性與認(rèn)知功能改善的相關(guān)性研究

焦明義 盛建春 趙明光 郭學(xué)軍 宋振全 梁國標(biāo)

(1遼寧醫(yī)學(xué)院沈陽軍區(qū)總醫(yī)院研究生培養(yǎng)基地; 2沈陽軍區(qū)總醫(yī)院神經(jīng)外科,遼寧 沈陽 110840)

·功能神經(jīng)外科疾病研究·

顱骨修補(bǔ)術(shù)后血管反應(yīng)性與認(rèn)知功能改善的相關(guān)性研究

焦明義1盛建春2趙明光2*郭學(xué)軍2宋振全2梁國標(biāo)2

(1遼寧醫(yī)學(xué)院沈陽軍區(qū)總醫(yī)院研究生培養(yǎng)基地;2沈陽軍區(qū)總醫(yī)院神經(jīng)外科,遼寧 沈陽 110840)

目的探討創(chuàng)傷性顱骨缺損修補(bǔ)對(duì)認(rèn)知功能及腦血管反應(yīng)性(CVR)的影響， 并對(duì)其相關(guān)性進(jìn)行分析。方法選擇2014年4月至2015年2月在我院神經(jīng)外科住院的54例顱腦損傷術(shù)后顱骨缺損且欲行顱骨修補(bǔ)的患者為研究對(duì)象，于術(shù)前1天及術(shù)后2周應(yīng)用聯(lián)合型瑞文智力測驗(yàn)(CRT) 評(píng)價(jià)其認(rèn)知功能，屏氣試驗(yàn)評(píng)價(jià)CVR，采用配對(duì)t檢驗(yàn)和Pearson相關(guān)分析進(jìn)行統(tǒng)計(jì)分析。結(jié)果顱骨修補(bǔ)術(shù)后，患者在CRT6個(gè)單元的評(píng)定分顯著高于術(shù)前(Plt;0.05)；比較修補(bǔ)術(shù)前、后患者患側(cè)屏氣指數(shù)(BHI)及總BHI，其差異均有統(tǒng)計(jì)學(xué)意義(Plt;0.05)；相關(guān)分析顯示，BHI與CRT6個(gè)單元評(píng)分均呈正相關(guān)(Plt;0.05)。結(jié)論顱骨修補(bǔ)術(shù)可明確改善患者的認(rèn)知功能、CVR，并且患者的認(rèn)知水平隨CVR的提高而得到明顯改善。

顱骨缺損; 認(rèn)知功能; 屏氣指數(shù); 血管反應(yīng)性

近年來研究表明，顱骨缺損患者的認(rèn)知功能障礙并非完全由原發(fā)腦損傷造成，其顱骨缺損本身對(duì)認(rèn)知功能也存在一定的影響[1]。Chibbaro等[2]對(duì)43例患者進(jìn)行分析，結(jié)果顯示其中91%患者的認(rèn)知功能得到明顯改善，簡易精神狀態(tài)量表(MMSE)評(píng)分均值由顱骨缺損時(shí)的18分(16～20分)上升至顱骨修補(bǔ)術(shù)后的25分(19～30分)；顱骨修補(bǔ)后全部患者的腦灌注血流量均得到改善。此外，還有研究明確指出，顱骨修補(bǔ)術(shù)可明顯改善患者缺損區(qū)域局部腦組織的血流及循環(huán)速度[3,4]。因此可推斷顱骨修補(bǔ)術(shù)后患者認(rèn)知功能的改善與腦血流量的增加有一定的相關(guān)性，然而血流量的增加是否與腦血管自我調(diào)節(jié)能力的變化所引起，認(rèn)知功能的改善與血管調(diào)節(jié)能力的提高是否存在直接關(guān)系目前仍不清楚；因此本研究于2014年4月至2015年2月對(duì)我院神經(jīng)外科住院的54例顱骨缺損患者進(jìn)行調(diào)查研究，對(duì)顱骨缺損患者行修補(bǔ)術(shù)前后的血管反應(yīng)性、認(rèn)知功能及其相關(guān)性進(jìn)行分析。

對(duì)象與方法

一、研究對(duì)象

選擇2014年4月至2015年2月在我院神經(jīng)外科住院的54例顱腦損傷術(shù)后顱骨缺損患者為研究對(duì)象，其中男性40例，女性14例；年齡12～60歲，平均(41.30±12.55)歲；術(shù)前GOS評(píng)分3～5分，平均(4.35±0.77)分；顱骨缺損部位分別為：雙側(cè)額部、左側(cè)顳頂部2例(3.7%)，雙側(cè)額顳頂部1例(1.9%)，雙額顳部1例(1.9%)，右側(cè)額顳部2例(3.7%)，右側(cè)額顳頂部23例(42.6%)，右額顳部、左額部1例(1.9%)，左側(cè)頂枕部2例(3.7%)，左側(cè)額顳頂部22例(40.7%)。顱腦損傷去骨瓣減壓術(shù)后行修補(bǔ)術(shù)的時(shí)間窗最短為2個(gè)月12 d，最長為2年3個(gè)月，平均時(shí)間(113.2±28.7)d。所有患者均于入院后行三維鈦網(wǎng)修補(bǔ)術(shù)。并于手術(shù)前1天完善相關(guān)檢查并于術(shù)后2周復(fù)查。所有患者既往無腦血管病、精神病及認(rèn)知缺陷病史，無檢查不配合的患者。

二、聯(lián)合型瑞文智力測驗(yàn)(combined raven's test,CRT)

主要用于評(píng)估患者的認(rèn)知功能，共由72題組成，分為AB、A、B、C、D、E六個(gè)單元，每單元12題。題目難度逐組增加，每組內(nèi)部題目也是由易到難排列。具體情況如下：AB主要測試圖形比較與想象能力；A組題測驗(yàn)知覺辨別力；B組測驗(yàn)類同、比較、圖形組合等；C組測驗(yàn)比較、推理、圖形組合；D組測驗(yàn)系列關(guān)系、圖形套合；E組測驗(yàn)套合、互換等抽象推理能力。前3個(gè)單元圖形為彩色型，后3個(gè)圖形為黑白型。計(jì)分時(shí)對(duì)照標(biāo)準(zhǔn)答案，每答對(duì)1題記1分，先將每個(gè)單元分別計(jì)分，各單元滿分為12分。測驗(yàn)時(shí)間為20～40 min。

三、屏氣試驗(yàn)

主要用于評(píng)價(jià)患者的腦血管反應(yīng)性(cerebrovascular reactivity,CVR)。在安靜舒適的環(huán)境下，患者取仰臥位，通過經(jīng)顱多普勒儀器，檢測大腦中動(dòng)脈平靜呼吸狀態(tài)下的血流情況，然后平靜吸氣末屏氣25 s再次測量，恢復(fù)平靜呼吸10 min后檢測對(duì)側(cè)，分別記錄雙側(cè)靜息狀態(tài)及屏氣后的血流速度，取3次測量值的平均值，計(jì)算屏氣指數(shù)(breath holding indexes,BHI)=(屏氣后平均血流速度-靜息狀態(tài)平均血流速度)/靜息狀態(tài)平均血流速度×100/屏氣時(shí)間。及計(jì)算總BHI=雙側(cè)BHI的平均值。

四、統(tǒng)計(jì)學(xué)分析

采用SPSS 13.0軟件包對(duì)資料進(jìn)行分析，采用配對(duì)t檢驗(yàn)對(duì)修補(bǔ)術(shù)前后患側(cè)與健側(cè)BHI和VMCA的差異進(jìn)行分析，并對(duì)修補(bǔ)術(shù)后BHI與認(rèn)知功能進(jìn)行Pearson相關(guān)分析，Plt;0.05為差異有統(tǒng)計(jì)學(xué)意義。

結(jié) 果

一、顱骨修補(bǔ)術(shù)前后CRT情況

顱骨修補(bǔ)前患者在AB、A、B、C、D、E6個(gè)單元的平均得分是(9.26±2.73)分、(9.87±2.58)分、(7.80±2.79)分、(5.74±2.85)分、(4.91±3.25)分、(2.57±2.16)分；修補(bǔ)術(shù)后患者在該6個(gè)單元的評(píng)分存在統(tǒng)計(jì)學(xué)提高，其分值分別為(10.65±0.85)分、(10.65±0.71)、(10.11±1.63)分、(8.04±2.50)分、(7.44±3.47)分、(4.17±3.62)分。其CRT各單元測試結(jié)果變化(圖1)。

二、修補(bǔ)前后BHI變化

顱骨缺損術(shù)前患側(cè)BHI明顯低于健側(cè)(t=3.095,P=0.004)；修補(bǔ)術(shù)前后患者患側(cè)BHI及總BHI差異均有統(tǒng)計(jì)學(xué)意義，而健側(cè)BHI改變差異無統(tǒng)計(jì)學(xué)意義(表1)。

三、修補(bǔ)術(shù)后BHI與認(rèn)知功能的關(guān)系

BHI與CRT6個(gè)單元評(píng)分均呈正相關(guān)(Plt;0.05)，即BHI改善，認(rèn)知功能也隨之發(fā)生好轉(zhuǎn)。

圖1 顱骨缺損修補(bǔ)術(shù)前后CRT各單元得分分布情況
Fig 1 Distributions of the pre- and post-cranioplasty scores of each unit of the CRT
aPlt;0.05,vspre-operation.

ItemnBeforecranioplastyAftercranioplasty Affectedside4966．54±20．8877．84±11．45a Un?affectedside4974．46±16．5978．68±16．43a TotalBHI5470．53±17．1578．26±13．17a

aPlt;0.05,vspre-operation

討 論

自1905年首次行去骨瓣減壓術(shù)救治顱腦損傷患者以來，該手術(shù)方式已成為顱腦外傷后惡性顱高壓，特別是腦疝患者的首選治療手段，但因顱骨缺損導(dǎo)致的眩暈、頭痛、易疲勞、記憶力下降、抑郁等一系列癥狀也越來越受到人們關(guān)注。顱骨修補(bǔ)術(shù)不但可以進(jìn)行美容修復(fù)，而且可以改善這些癥狀并保護(hù)腦組織，尤其患者的認(rèn)知功能及腦血流動(dòng)力學(xué)方面也可得到很大的改善[5～9]。

CRT是全圖、非文字性的一種測驗(yàn)方法，它克服了文化背景影響和語言交往困難,具有操作簡單、省時(shí)省力、可集體施測等優(yōu)點(diǎn)，使用范圍較廣，故本研究應(yīng)用CRT檢測患者修補(bǔ)術(shù)前、后的認(rèn)知功能。結(jié)果顯示，修補(bǔ)術(shù)后圖形比較與想象能力，知覺辨別能力，類同、比較、圖形組合能力，比較、推理、圖形組合能力，系列關(guān)系、圖形套合能力，套合、互換等抽象推理能力均有改善。究其原因是修補(bǔ)術(shù)后使患者的顱內(nèi)壓趨于穩(wěn)定、腦脊液循環(huán)改善，腦血流速度加快，促進(jìn)腦細(xì)胞代謝，改善腦神經(jīng)生理功能，從而使患者的認(rèn)知功能得到較大程度的提高[10～12]。本研究結(jié)果還顯示套合、互換等抽象推理能力得分仍然較低，僅為(4.17±3.62)分，這說明患者的高級(jí)推理能力還需進(jìn)一步加強(qiáng)，究其原因可能是患者術(shù)后大腦血流的不對(duì)稱性還未得到完全糾正，腦功能仍處于修復(fù)狀態(tài)，但也可能是因?yàn)樘缀稀⒒Q等抽象推理單元的圖形比較繁瑣、難度較大且屬于最后一個(gè)單元，患者因生理原因或心理厭倦并不能集中精力去做題，導(dǎo)致分?jǐn)?shù)較低。

既往研究認(rèn)為顱骨缺損造成血管受壓，增加血流阻力，修補(bǔ)術(shù)降低舒張期血管的收縮，使腦微小血管舒張能力增加，小血管阻力降低，使腦血流量增加[13,14]。相對(duì)血流速度而言，CVR可更好地體現(xiàn)血管自身的收縮及舒張性，BHI作為CVR的評(píng)價(jià)指標(biāo)可以更好的反映腦血管的擴(kuò)張性及儲(chǔ)備能力，而且操作簡單、屬無創(chuàng)性檢查，患者也能夠配合。高永哲等通過對(duì)55例阿爾茨海默病( Alzheimer's disease,AD)患者的對(duì)比研究發(fā)現(xiàn)AD 腦存在廣泛的皮質(zhì)及皮質(zhì)下區(qū)域的局部腦血流量下降，同時(shí)，特征性地在前腦特別是額葉皮質(zhì)表現(xiàn)為CVR的下降，從而證實(shí)了缺血會(huì)造成認(rèn)知功能的損害[15]。本研究結(jié)果顯示，修補(bǔ)術(shù)后患者患側(cè)BHI及總BHI值高于術(shù)前，這說明顱骨缺損后大氣壓使缺損部位的皮瓣下陷，導(dǎo)致血管外周阻力顯著增加，腦血流減少，血管的收縮能力受限，而術(shù)后有效地降低了血管外周阻力和血管壁張力，使腦血流量的代償能力恢復(fù)，維持了的腦組織正常灌注，促進(jìn)腦血流循環(huán)代謝恢復(fù)，進(jìn)而改善認(rèn)知功能[16]；有學(xué)者認(rèn)為，行顱骨修補(bǔ)后，受損的腦微小血管舒張能力得以恢復(fù)，可更好地發(fā)揮腦血管儲(chǔ)備能力的功能，使腦血流量增加，減少了對(duì)局部微血管的壓迫，減輕微循環(huán)障礙，從而使腦血流循環(huán)灌注改善，促進(jìn)能量代謝、葡萄糖利用、蛋白合成等功能提高，使皮層對(duì)信息認(rèn)識(shí)、整合等過程得以恢復(fù)、認(rèn)知反應(yīng)和處理能力提升，最終使認(rèn)知功能得到最大程度的改善[17]。這與本研究的BHI與CRT6個(gè)單元評(píng)分正相關(guān)基本相符。

綜上所述，顱骨修補(bǔ)術(shù)可改善創(chuàng)傷性顱骨缺損患者缺損區(qū)域的VMCA及整體CVR，并能提高其認(rèn)知功能，對(duì)于顱骨缺損患者可采取適當(dāng)治療措施，增加患者腦部血流，及早改善患者的認(rèn)知功能。

1Di Stefano C,Sturiale C,Trentini P,et al. Unexpected neuropsychological improvement after cranioplasty:a case series study [J]. Br J Neurosurg,2012,26(6):827-831.

2Chibbaro S,Vallee F,Beccaria K,et al. The impact of early cranioplasty on cerebral blood flow and its correlation with neurological and cognitive outcome. Prospective multi-centre study on 24 patients [J]. Rev Neurol (Paris),2013,169(3):240-248.

3Honeybul S,Ho KM,Lind CR,et al. Observed versus predicted outcome for decompressive craniectomy:A population based study [J]. J Neurotrauma,2010,27(7):1225-1232.

4Mokri B. Orthostatic headaches in the syndrome of the trephined:resolution following cranioplasty [J]. Headache,2010,50(7):1206-1211.

5Honeybul S,Janzen C,Kruger K,et al. The impact of cranioplasty on neurological function [J]. Br J Neurosurg,2013,27(5):636-641.

6Ferro JM,Crassard I,Coutinho JM,et al. Decompressive surgery in cerebrovenous thrombosis:a multicenter registry and a systematic review of individual patient data [J]. Stroke,2011,42(10):2825-2831.

7李鑫,李晶,李京生. 外傷性顱骨缺損修復(fù)前后灌注 CT 評(píng)價(jià)腦血流變化的研究 [J]. 中華神經(jīng)外科雜志,2015,31(7):702-706.

8倫鵬,劉鵬,王剛,等. CT灌注評(píng)價(jià)顱骨修補(bǔ)術(shù)后腦灌注與神經(jīng)功能改善 [J]. 中華神經(jīng)外科疾病研究雜志,2014,13(3):272-273.

9Won YD,Yoo DS,Kim KT,et al. Cranioplasty effect on the cerebral hemodynamics and cardiac function [J]. Acta Neurochir Suppl,2008,102:15-20.

10Jelcic N,De Pellegrin S,Cecchin D,et al. Cognitive improvement after cranioplasty:a possible volume transmission-related effect [J]. Acta Neurochir,2013,155(8):1597-1599.

11Di Stefano C,Sturiale C,Trentini P,et al. Unexpected neuropsychological improvement after cranioplasty:a case series study [J]. Br J Neurosurg,2012,26(6):827-831.

12Ho CL,Wang CM,Lee KK,et al. Cerebral oxygenation,vascular reactivity,and neurochemistry following decompressive craniectomy for severe traumatic brain injury [J]. J Neurosurg,2008,108(5):943-949.

13Vicenzini E,Ricciardi MC,Altieri M,et al. Cerebrovascular reactivity in degenerative and vascular dementia:a transcranial Doppler study [J]. Eur Neurol,2007,58(2):84-89.

14Silvestrini M,Pasqualetti P,Baruffaldi R,et al. Cerebrovascular reactivity and cognitive decline in patients with Alzheimer disease [J]. Stroke,2006,37(4):1010-1015.

15高永哲,章軍建,吳光耀,等. 阿爾茨海默病患者局部腦血流量及腦血管反應(yīng)性研究 [J]. 中風(fēng)與神經(jīng)疾病雜志,2013,30(2):120-123.

16Weiner GM,Lacey MR,Mackenzie L,et al. Decompressive craniectomy for elevated intracranial pressure and its effect on the cumulative ischemic burden and therapeutic intensity levels after severe traumatic brain injury [J]. Neurosurgery,2010,66(6):1111-1118.

17Villeneuve S,Belleville S,Massoud F,et al. Impact of vascular risk factors and diseases on cognition in persons with mild cognitive impairment [J]. Dement Geriatr Cogn Disord,2009,27(4):375-381.

AbstractOBJECTIVEThe authors' group recently published a novel technique for a navigation-guided frameless stereotactic approach for the placement of depth electrodes in epilepsy patients. To improve the accuracy of the trajectory and enhance the procedural workflow,the authors implemented the iSys1 miniature robotic device in the present study into this routine.METHODSAs a first step,a preclinical phantom study was performed using a human skull model,and the accuracy and timing between 5 electrodes implanted with the manual technique and 5 with the aid of the robot were compared. After this phantom study showed an increased accuracy with robot-assisted electrode placement and confirmed the robot's ability to maintain stability despite the rotational forces and the leverage effect from drilling and screwing,patients were enrolled and analyzed for robot-assisted depth electrode placement at the authors' institution from January 2014 to December 2015. All procedures were performed with the S7 Surgical Navigation System with Synergy Cranial software and the iSys1 miniature robotic device.RESULTSNinety-three electrodes were implanted in 16 patients (median age 33 years,range 3～55 years; 9 females,7 males). The authors saw a significant increase in accuracy compared with their manual technique,with a median deviation from the planned entry and target points of 1.3 mm (range 0.1～3.4 mm) and 1.5 mm (range 0.3～6.7 mm),respectively. For the last 5 patients (31 electrodes) of this series the authors modified their technique in placing a guide for implantation of depth electrodes (GIDE) on the bone and saw a significant further increase in the accuracy at the entry point to 1.18±0.5 mm (mean±SD) compared with 1.54±0.8 mm for the first 11 patients (P=0.021). The median length of the trajectories was 45.4 mm (range 19～102.6 mm). The mean duration of depth electrode placement from the start of trajectory alignment to fixation of the electrode was 15.7 minutes (range 8.5-26.6 minutes),which was significantly faster than with the manual technique. In 12 patients,depth electrode placement was combined with subdural electrode placement. The procedure was well tolerated in all patients. The authors did not encounter any case of hemorrhage or neurological deficit related to the electrode placement. In 1 patient with a psoriasis vulgaris,a superficial wound infection was encountered. Adequate physiological recordings were obtained from all electrodes. No additional electrodes had to be implanted because of misplacement.CONCLUSIONSThe iSys1 robotic device is a versatile and easy to use tool for frameless implantation of depth electrodes for the treatment ofepilepsy. It increased the accuracy of the authors' manual technique by 60% at the entry point and over 30% at the target. It further enhanced and expedited the authors' procedural workflow.

J Neurosurg. 2016 Aug 5:1-7. [Epub ahead of print]

Acorrelativestudyonimprovementsincerebrovascularreactivityandcognitivefunctionaftercranioplasty

JIAOMingyi1,SHENGJianchun2,ZHAOMingguang2,GUOXuejun2,SONGZhenquan2,LIANGGuobiao2

1LiaoningMedicalUniversity,GeneralHospitalofShenyangMilitaryCommand,Shenyang110840;2DepartmentofNeurosurgery,GeneralHospitalofShenyangMilitaryCommand,Shenyang110840,China

ObjectiveThe effects of cranioplasty for traumatic skull defects on cognitive function and cerebrovascular reactivity (CVR) are discussed and the correlations between them are analyzed.MethodsA total of 54 patients with skull defects after operation of traumatic brain injury who admitted to the General Hospital of Shenyang Military Command from April 2014 to February 2015 were enrolled in the study. All the subjects underwent three-dimensional (3D) titanium mesh cranioplasty following admission. The combined Raven's test (CRT) was conducted to evaluate the cognitive function of each patient at 1 d pre-operation and 2 w after operation. The breath-holding test was conducted to evaluate CVR. The statistical analysis was made by the pairedt-test and Pearson correlation analysis.ResultsThe evaluation scores of the six units of the CRT,the breath holding indexes (BHIs),and total BHIs of the patients after cranioplasty were significantly higher than those before cranioplasty (Plt;0.05). The correlation analysis showed that the BHI was positively correlated with the evaluation scores of the six units of the CRT (Plt;0.05).ConclusionCranioplasty can definitively improve the cognitive function and CVR of patients. The patients' cognitive function is dramatically improved with the increase of CVR.

Skull defects; Cognitive function; Breath holding indexes; Cerebrovascular reactivity

A novel miniature robotic device for frameless implantation of depth electrodes in refractory epilepsy

DorferC1,MinchevG1,CzechT1,StefanitsH1,FeuchtM2,PataraiaE3,BaumgartnerC4,KronreifG5,WolfsbergerS1

1DepartmentofNeurosurgery;2DepartmentsofPediatricsandAdolescenceMedicine;3DepartmentofNeurology,EpilepsyMonitoringUnit,MedicalUniversityVienna;4SecondNeurologicalDepartment,GeneralHospitalHietzing,Vienna;5AustrianCenterofMedicalInnovationandTechnology(ACMIT),WienerNeustadt,Austria

1671-2897(2016)15-305-04

R 749.1+2

A

焦明義，碩士研究生，E-mail：jiaomingyi123@163.com

*通訊作者：趙明光，副教授，副主任醫(yī)師，E-mail:zhaomingguang1972@hotmail.com

2015-10-31；

2016-02-20)