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颅外-颅内动脉旁路手术：历史、现状与展望EXTRACRANIAL-INTRACRANIALBYPASSSURGERYPAST,PRESENTANDFUTUREPioneersofBypassProcedures●Jacobson(1960)(Vermont)Reconstructedcarotid

arteriesofdogsandrabbits,achievinga100%patencyrate●Donaghy(Vermont)Establishedmicrosurgicallab,reconstructedvessels<

1mmindiameter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HISTORYOF

BYPASSPROCEDURES旁路手术历史M.G.Yasargil&HisContributions●Interestwasstimulatedwhenhewasaskedtoperformanembolectomyofacorticalar

tery,notyetmastered.●Enthusiasmtocerebralrevas-cularizationincreasedafterthereportofanEC-ICbypassM.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●1964InternationalCongressofN

euroradiologistsDrs.SweetandRasmussenadvisedhimtocontactprof.Donaghy1965YasargilbeganhistraininginDonagh’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。●InitialattemptstointerposeafemoralvasculargraftfromCCAtoMCA.Thegraftw

ouldprogresstothrombosis.TheideaofperformingSTA-MCAbypasswasthenborn.●Bytheendof1966morethan30STA-MCAbypassind

ogshadbeenperformed●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Oct.30,1967Yasargilperforme

dthefirstSTA-MCAbypass,inapatientwithMarfansyndromeandcompleteocclusionofMCAAmajorstepwasmadeintothefieldofrecon

structiveintracranialvascularmicroneurosurgery.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！●CerebralIschemia●Sinc

e1967STA-MCAbypasshadbeenwideaccepted,althoughtheindicationsremainedcontroversialbytheendof1960’.⚫Dr.ZangrenheperformedthefirstcaseofSTA-MCAbypas

sinChina(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●197

7NorthAmericanEC-ICBypassStudy(byDr.HenryBarnett)●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-MCAwasineffectivei

npreventingcerebralischemia结论：STA-MCA不能防止脑缺血●Failureofextracranial-intra-cranialarterialbypasstoreducetheriskofischemicstroke.Result

sofaninter-nationalrandomizedtrial.TheEC/ICBypassStudyGroup.NEnglJMed313:1191-1200,1985●Markeddecreasein

thenumberofSTA-MCAbypassperformedforcerebralischemia●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●Criticismto

EC/ICBypassStudy▲Patientswerenotevaluatedpreoperativelycerebrovascularhemodynamicstatus▲Bothpatienta

ndtherapistwerenotblined▲Onlyhalfofthepatientsreceivingantiplateletagents▲Alargepercentageofpatientshadnosympto

msbeforeentry▲Alargenumberofpatientsunderwentsurgeryoutsidethestudy●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●Thestudyinvestigatorspointedoutthatrandomizedtrialsinvolveonlyasmallfract

ionofthepopulationatriskandthatthisfactordoesnotpreventastudyfrombe-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●TheCa

rotidOcclusionSurgeryStudyRandomizedTrial(COSS)U.SandCanada,49clinicalcenters18PETcenters(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-ICbypassd

idnotreducetheriskofrecurrentipsilateralischemicstrokeat2years.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●Forpatientswithsymptomaticextracranialcarotidocclusion,EC/ICbypassisnotroutinelyrecommended(ClassⅢEvidenceA)●ForpatientswithstrokeorTIAdueto50%

to99%stenosisofamajorintracranialartery,EC/ICbypassisnotrecommended(ClassⅢEvidenceB)AHA/ASAGuidelinesforthePreventionofstroke2011●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●Extracranial-IntracranialBypassforStroke—IsThistheEndoftheLin

eoraBumpintheRoad?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●AlthoughgeneralexpansionofEC/ICbypassusew

ouldnotbesupported,aselectsubsetofpatientswithmedicallyrefractoryhemodynamicsymptomsmaywellbenefitfromsur

gery.●Limitedapplicationandfurtherstudywithaneyetofuturedevelopments,ratherthancompleteabandonment,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。Acutestroke●Emergentcerebralrevascula-rization

isveryrationalEncouragingresultswerereported.●ButothersconsideredtheacuteischemiaarelativecontraindicationConclusion:

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●Withtheadventofinterv

entionalneuroradiologyandthrombolytictherapies,emergentEC/ICbypassforacutestrokedecreased●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。SAHandCerebralVa

sospasm●STA-MCAbypasshasbeenperformed●Thisindicationdidnotgainwideacceptance.Endovasculartechniquescombinedwith“3H

”therapyassumedapivotalroleSAH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Forty-two-year-oldabuserwithSAHfromamycoticleftmiddlecerebralaneurysm.A,preoperativelateralcarotidinjectionshowspro

ximalcarotidspasm.B,lateralcommoncarotidangiogram2weeksafterbypassshowsmaturationofbypass.C,lateralcommoncarotidangiogram3we

eksafterbypassshowsimprovementincarotidspasmanddiminishedcaliberofbypass.Aneurysms●Carotidarteryocclusionremainedt

hemainstayforsomeaneurysms,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2

4%~32%●Yasargil(1967)2casesofSTA-MCAforgiantsupraclinoidICAaneurysm●Lougheed(1971)FirstEC/ICbypass(CCA-saphenousvein-intracranialICA)wasperf

ormed●Sundt(1982)Pioneeredtheuseofveingrafts(SVGs)fromext-racranialarteriestointracran-ialarteriesfortreatmentofunclip

pableaneurysms●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（19

82）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●Ausman（1978）Firstdescribedtheuseofradialarterygrafts(RAGs)●Morimoto(1988)UseofRAGforaneurysms●Au

sman(1978)首次介绍用桡动脉作移植物。●Morimoto(1988)将之用于动脉瘤手术45M,ECA-MCAbypassfollowedbytrappingofthegiantsupraclinoidICAaneurysmwithpreserva-tionOfanteriorchor

oidalartery(arrow)65,F,CervicalICA-SVG-MCA2bypasswasperformedfollowedbytrappingofthegiantintracavernousaneurysm●Spetzler(1990’)Developed

severalinnovations▲thebonnetbypass▲multiplearterialanastomosis▲useofmetabolicbrainprotection▲useofheparin▲petrousICA-SVG-supraclinoidI

CAbypass●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Case1M,55,Leftcommoncarotidarteryaneurysm,nofill

ingoftheexternalcarotidartery.RSTA-LMCAbypasswasperformed.●Sekhar’sinnovations▲placementofdistalanastomosisofSVGintotheM1orM2bifurcation▲us

eofICAorECAfortheproximalanastomosis▲useofintraoperativeDSAtostudythebypassgraft▲ECA-petrousICAgrafts▲extracranialVA-MCA

orintracranialVAgrafts▲BA-veingraft-BA(underhypothermiccirculatoryarrest)●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）SaphenousVeinGraftReconstructionofanU

nclippableGiantBasilarArteryAneurysmPerformedwiththePatientunderDeepHypothermicCirculatoryArrest.●Otherinnovations▲useofinternalmaxillaryarteryasdono

rvessel▲useoftunnelthroughthefloorofmiddlefossaratherthansubcutaneousone▲endoscopicharvestofsaphenousvein▲excimerlaser-assistednon-occlusiveana

stomosis(ELANA)▲bloodfolwevaluationbytheuseofnon-invasiveoptimalvesselanalysis(NOVA)andintraopera-tivequantitativeflowm

easure-ment▲intraoperativeevaluationusingindocyaninegreen●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SchematicdiagramdepictstheendoscopicSVGharvest.A:Thefiberoptictrocarisusedtoinitiallyloca

teanddissectthesaphenousvein.B:Insufflationisperformedwithcarbondioxidetocreateroomforfurtherdissect

ion.C:Thecauteryscissorsareusedtocoagulateandtransecttributaryveins.D:Theveincradleisusedtorunthelengthoftheveinbeforetheveingraftre

moval.ExcimerLaser-AssistedNonocclusiveAnastomosis(ELANA)TechniqueCase1ECA-SVG-ICAbifercationbypassfortreatmentofagiantcavernousICAaneurysm.T

heintracranialanastomosiswasperformedwiththeaidofELANACase2PetrousICA-SVG-MCAbypassfortreatmentofapreviouslycoiledpara-ophthalmicane

urysm.BothanastomsiswereperformedwiththeaidofELANASkullBaseTumors●Theuseofbypasstoenableoperationsondifficultskullbasetumorsisgenerallyacce

ptedbutisnotwithoutdetractors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,t

heintracavernousICAwasruptured.EmergencyradialarterybypassgraftwasperformedfromcervicalICAtoMCA2.Case247,FIntracavernousandsupracavernousmeningio

maencasingandnarrowingtheleftICAECA-RAG-MCA2andcervicalICA-SVG-MCA2●Theuseofbypassforskullbasetumorshasgreatlydeclinedbecauseofuseofradiosurg

eryfortumorremnants.However,thistechniqueremainsavaluabletool●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●Whenamajo

rvesselisinvadedorencasedbytumors,therearetwocontroversies:Whetheronetrytoskeletonizethetumororwhethertheve

sselshouldberesected?Whetherthepatientshouldberevascularizeduniversallyorselectively?●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？●WhetherthevesselshouldbeleftinsitudependsupontheattitudeofsurgeonandthenatureoftumorBeni

gntumorsotherthanmeningiomamayusuallybedissectedawayfromvessel.Chordomaandchondrosarco-ma,mostcanbedissectedawayfromve

ssel,butinsomepatientsgraftingwillbeneeded.●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。●Whetherornotabypasss

houldbeperformedinallpatientswhoseICAorVAhasbeensacrificed?－controversialSelectiveapproachonthebasisofpreoperativeocclusiontestUniversal

approachonthebasisofargumentthatevenifadequatecollateralcirculationpresent,patientsmaystillsustainastrokeaf

tervascularocclusion●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Moyamo

yaDisease●Yasargil(1972)FirstcaseofSTA-MCAfora4-yearoldchildwithmoyamoyadisease●Spetzler(1980)IndirectSTA-MCAforbi

lateralocclusionofsupraclinoidICA(directSTA-MCAwasplanned,butnosuitablerecipientcorticalvesselwasfoundatsurgery）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）●Theefficacyofdirectandindirectbypasswasdemonstratedinpatien

tswithischemicmoyamoyadisease●Theeffectivenessofre-vascularizationinpre-ventinghemorrhageremainsacontroversy●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%●ForpatientswithocclusivecarotidorMCAdi

sease,limitedapplicationandfurtherstudywithaneyetofutuneiswarranted●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●Newimagingmodalitiesforevalu

ationofacutestroke▲acuteinfarctionorpenumbra?▲withinthepenumbrazone,theareaswillbecomeinfarctedorsurvivewithoutperfusion?●现代影像技术（DMR,P

MR,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。CoregisteredimagesofPW/DWMRIandmultitracerPETinapatientwithanacuteright-sidehemipa

resis.TheROIswereplacedaccordingtotheMRIcriteriaandthentransferredtothePETimages(ROIcolors:redindicatesDWIlesion;blue,mismatch;yellow,ol

igemia;green,referenceregion).VolumetriccomparisonofTTP(MRI)andOEF(PET)imagesin2patientsmeasuredinthechronicphaseofstroke.Inbot

hpatients,aTTPdelayof>4secondsindicatesaconsiderablemismatchvolume(redcontouronTTPimages).Themismatchvolumeswere473cm3forpatienta

and199.7cm3forpatientb.However,onlypatientbhadacorrespondingvolumeofpenumbra(260cm3).ThreeROIswereplacedma

nuallyattherCBFmap(topleft):ROI1coveredtheischemiccoreasdetectedfromtheDWI(bottomleft),ROI2coveredthepenumbrathatprog

ressedtoinfarctionatthefinalT2-weightedimage(T2WI,bottomright),andROI3coveredthepenumbrathatrecovered.Ma

psofMTT(topmiddle)showedprolongedMTTinthetotalrightmiddlecerebralarteryterritory,whereasrCBV(topright)wasmarkedlyreduced

intheinternalcapsulebutonlymildlyreducedintherestofthemiddlecerebralarteryterritory.TheADCmap(bottommiddle)demonstratesseverelyreduce

dADCinthecoreoftheinfarction.Acute(4-hour)andchronic(28-day)MRIofa56-year-oldmanwhopresentedwithlefthemiparesis,facialparesis,andgazepalsy.Womanwitha

phasiaandright-sidedweaknessimagedinitiallyat6hoursfromstrokeonset.A–G,ImagesareDW(A),ADC(B),FA(C),rCBF(D),MTT(E),rCB

V(F),and6-dayfollow-upT2-weighted.ThreeregionsofinterestareshownontherCBFmapinD.Region1,“infarctcore”coverstheareath

athashyperintensityontheDWimage,abnormalityonrCBFandMTTimages,andhyperintensityonfollow-upT2-weightedimage.Region2,“penumbratha

tinfarcts”coverstheareathathasnoabnormalityonDWimage,butthatisabnormalonrCBFandMTTimagesandhashyperintensityonfollow-upT2-weightedimage.Region3,“hy

poperfusedtissuethatremainsviable,”coverstheareathathasabnormalityonrCBFandMTTimagesbutthatisnormalonDWimageandisnormalonfo

llow-upT2-weightedimage.●Withfurtherdevelopmentsinimagingmodalitiesandbetterdefinitionsofischemicbutviabletissu

re(OEF)thresholds,therewillbemorethoughtsonemergentsurgicalproceduresforacutestroke.●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●Bypassprocedu

reremainsanadjuvantforaneurysmandskullbasetumortreatmentAdvancedimagingperfusiontechniquesmayimprovetheaccuracy

ofballoonocclusivetest.Newbypasstechniquesmaybeuseful.●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●Theroleofbyp

assformoyamoyadiseaseawaitstheresultsoflargerandomizedtrials.Moredetailedstudiesonthepreventionofhemorrhagiceven

tsareexpected●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THANKS