目的:评价威利斯环(CoW)解剖变异对对侧颈动脉闭塞(CCO)患者颈动脉内膜切除术(CEA)后即刻神经事件(INE)的影响。
方法:单中心,回顾性研究。前瞻性收集患者的人口统计学和临床结果数据。CoW节段进行了回顾性审查。2013年1月至2018年5月,2090例患者在全身麻醉下接受了CEA,在113例(5.4%)患者中发现了CCO。CoW节段被归类为正常,发育不良(直径为0.8毫米),或基于计算机断层扫描血管造影(CTA)的缺失。我们研究了CoW段作为连接基底动脉和同侧大脑中动脉(MCA)的两个侧支网络:短半圆(同侧大脑后动脉[P1]和后交通动脉[Pcom]段的第一段)和长半圆(对侧P1,Pcom,和大脑前动脉的两个第一部分(A1)前交通动脉(Acom))。INE定义为手术后立即诊断的任何短暂性脑缺血发作(TIA)或中风。
结果:在113名患者中,46例接受了动脉内膜切除术并分流。由于CTA的不可用或质量不足,我们进一步将16例患者从CoW评估中排除。113名患者中,2有中风,一个在手术后数小时发生的分流。除了其他中风病例,观察到4INE,都不用分流.在接受CoW评估的51例患者中,10(19.6%)有一个完整的CoW,而21例(41.2%)患者只有一个完整的半圆(10个短半圆和11个长半圆),这些患者都没有经历过INE。共有20例(39%)患者长半圆和短半圆都不完整,其中4例(7.8%)有INE。在所有INE案例中,至少一个Pcom缺失或发育不良.两个Pcom的缺失是INE事件的强预测因子[比值比=11.10(置信区间:1.04-118.60)]。
结论:患有CCO和CoW侧支血流支持不足的患者发生INE的风险增加,包括中风,在CEA交叉夹紧期间没有分流保护。当CCO患者同侧MCA和基底动脉之间的侧支血流受损时,应始终考虑分流。
BACKGROUND: To evaluate the impact of anatomical variations in the Circle of Willis (CoW) on immediate neurological events (INEs) after carotid endarterectomy (CEA) without shunting in patients with contralateral carotid occlusion (CCO).
METHODS: Single-center retrospective study. Patient\'s demographic and clinical outcomes data were prospectively collected. CoW segments were reviewed retrospectively. Between January 2013 and May 2018, 2090 patients underwent CEA under general anesthesia, CCO was found in 113 (5.4%) patients. CoW segments were classified as normal, hypoplastic (diameter ˂0.8 mm), or absent based on computed tomography angiography. We studied the CoW segments as 2 collateral networks connecting the basilar artery and the ipsilateral middle cerebral artery: a short semicircle (first segment of the ipsilateral posterior cerebral artery [P1] and posterior communicating artery [Pcom] segment) and a long semicircle (contralateral P1, Pcom, and both first segments of the anterior cerebri artery (A1) anterior communicating artery (Acom)). INE was defined as any transient ischemic attack or stroke diagnosed immediately after the procedure.
RESULTS: Out of the 113 patients, 46 underwent endarterectomy with shunting. We further excluded 16 patients from the assessment of the CoW due to unavailability or inadequate quality of computed tomography angiography. Of the 113 patients, 2 had strokes, 1 with shunting that occurred hrs after surgery. Besides the other stroke case, 4 INE were observed, all without the use of a shunt. Of the 51 patients with CoW assessment, 10 (19.6%) had a complete CoW, while 21 (41.2%) patients had only 1 semicircle intact (10 short and 11 long intact semicircles), and none of these patients experienced an INE. A total of 20 (39%) patients had both the long and short semicircles incomplete, of which 4 (7.8%) cases had an INE. In all INE cases, at least 1 of the Pcom was absent or hypoplastic. The absence of both Pcom was a strong predictor of incident INE [odds ratio = 11.10 (confidence interval: 1.04-118.60)] for INE.
CONCLUSIONS: Patients with CCO and insufficient CoW collateral flow support are at an increased risk of INE, including stroke, in the absence of shunt protection during CEA cross-clamping. Shunting should always be considered when the collateral flow between the ipsilateral middle cerebral artery and the basilar artery is compromised in CCO patients.