经颅多普勒超声在动脉瘤性蛛网膜下腔出血患者颅内压及脑灌注压评估中的应用价值  

Application value of transcranial Doppler in intracranial pressure and cerebral perfusion pressure of the patients with aneurysmal subarachnoid hemorrhage

作　　者：刘帅 王淑雅 徐珊珊 田莹 陈晓霖[2] 张琳琳 石广志[1] 周建新 Liu Shuai;Wang Shuya;Xu Shanshan;Tian Ying;Chen Xiaolin;Zhang Linlin;Shi Guangzhi;Zhou Jianxin(Department of Critical Care Medicine,Beijing Tiantan Hospital,Capital Medical University,Beijing 100070,China)

机构地区：[1]首都医科大学附属北京天坛医院重症医学科,北京100070 [2]首都医科大学附属北京天坛医院神经外科,北京100070 [3]首都医科大学附属北京世纪坛医院重症医学科,北京100038

出　　处：《中国急救医学》2024年第9期822-828,F0003,共8页Chinese Journal of Critical Care Medicine

基　　金：首都临床诊疗技术研究及转化应用项目(Z201100005520050)。

摘　　要：目的探索动脉瘤性蛛网膜下腔出血(aSAH)患者经颅多普勒超声(TCD)参数及衍生参数与颅内压(ICP)及脑灌注压(CPP)的相关性和一致性。方法本研究为单中心回顾性观察性研究,纳入aSAH术后行ICP监测及TCD检查患者,收集大脑中动脉(MCA)收缩期血流速度(FVs)、舒张期血流速度(FVd),计算平均血流速度(FVm)、搏动指数(PI),并记录平均动脉压(MAP)和ICP,然后采用基于FVd公式计算得到无创颅内压(nICP)、无创脑灌注压(nCPP)。采用Spearman相关系数评价TCD参数及衍生参数与ICP和CPP的相关性,根据TCD结果分为血流速度正常组、轻度TCD诊断的血管痉挛(TCD-VS)组和中重度TCD-VS组,并进行亚组分析。采用Bland-Altman法评估nICP和ICP以及nCPP和CPP的一致性,绘制受试者工作特征(ROC)曲线并计算曲线下面积(AUC),以确定nICP检测ICP>22 mmHg以及nCPP检测CPP<60 mmHg的能力。结果纳入95例aSAH术后患者共201例次TCD参数、衍生参数和对应的ICP。nICP与ICP显著正相关(r=0.240,P<0.001),FVd、FVm与ICP显著负相关(r分别为-0.154、-0.142,P<0.05)。PI与CPP显著负相关(r=-0.161,P<0.05),nCPP、脑血流指数(CBFi)与CPP显著正相关(r分别为0.695、0.734,P<0.001)。亚组分析结果显示,在血流速度正常组和轻度TCD-VS组中,nICP与ICP显著正相关(r分别为0.238、0.539,P<0.05),中重度TCD-VS组nICP与ICP无相关性(P>0.05)。当出现任何程度的TCD-VS时,FVs、FVd、FVm、PI、CBFi与ICP均无相关性(P>0.05)。无论是否诊断为TCD-VS,三组nCPP与CPP均存在显著正相关性(r分别为0.659、0.828、0.781,P<0.001),CBFi与CPP存在显著正相关性(r分别为0.709、0.856、0.795,P<0.001)。在Bland-Altman图分析中,ICP和nICP在总体人群中的平均差异为(-2.35±9.22)mmHg,CPP和nCPP在总体人群中的平均差异为(2.38±9.23)mmHg。nICP的AUC为70.1%(95%CI 60.0%~80.3%,P<0.001),预测ICP>22 mmHg的截断值为21.5 mmHg,敏感度、特异度分别为80.6%、53.9%。在TCD血流速度正常组中Objective To evaluate the correlation and agreement of transcranial Doppler(TCD)-related/derived parameters with intracranial pressure(ICP)and cerebral perfusion pressure(CPP)in the patients with aneurysmal subarachnoid hemorrhage(aSAH).Methods This was a single-center retrospective observational study.All the patients were diagnosed with aSAH and received TCD examination and ICP monitoring after microsurgery clipping.Systolic flow velocity(FVs),diastolic flow velocity(FVd)in middle cerebral artery(MCA)were collected,and mean flow velocity(FVm),pulsatility index(PI)were calculated.Mean arterial pressure(MAP)and ICP values were recorded,and noninvasive intracranial pressure(nICP),noninvasive cerebral perfusion pressure(nCPP)were calculated by formula based on FVd.Spearman correlation coefficients were used to evaluate the correlation of TCD-related/derived parameters with the ICP as well as CPP.According to the TCD results,the patients were divided into normal blood flow velocity group,mild TCD vasospasm(TCD-VS)group,and moderate to severe TCD-VS group,and subgroup analysis was conducted.The agreement between nICP and ICP,between nCPP and CPP were assessed by Bland-Altman plots.Finally,the area under the receiver operating characteristic(AUC)curve was used to determine the ability of nICP to predict ICP>22 mmHg and nCPP to predict CPP<60 mmHg.Results A total of 95 patients were included,201 data of TCD-related/derived parameters and ICP were recorded.The nICP showed a significantly positive correlation with ICP(r=0.240,P<0.001),FVd and FVm showed a significantly negative correlation with ICP(r=-0.154 and-0.142,respectively,P<0.05).PI showed a significantly negative correlation with CPP(r=-0.161,P<0.05),nCPP and cerebral blood flow index(CBFi)showed a significantly positive correlation with CPP(r=0.695 and 0.734,respectively,P<0.001).In subgroup analysis,the nICP had a significantly positive correlation with ICP in normal group and mild TCD-VS group(r=0.238 and 0.539,respectively,P<0.05),and there was no significan

关 键 词：经颅多普勒超声 颅内动脉瘤 蛛网膜下腔出血 颅内压 无创颅内压 脑灌注压 无创脑灌注压 

分 类 号：R445.1[医药卫生—影像医学与核医学] R743.35[医药卫生—诊断学]