本文選題：顱內(nèi)大動脈 + 狹窄��； 參考：《南方醫(yī)科大學》2016年博士論文

【摘要】：第一章壓力導絲技術對顱內(nèi)大動脈狹窄的嚴重性評估——可行性研究研究背景及目的：在亞洲特別是東南亞包括中國漢族人群中,顱內(nèi)大動脈粥樣硬化性狹窄是缺血性腦卒中的主要發(fā)病原因之一。目前針對顱內(nèi)大動脈粥樣硬化性狹窄的治療方法主要包括球囊擴張成形術、支架植入術和積極的藥物干預等。2011年發(fā)布的SAMMPRIS研究比較了單純積極藥物治療與積極藥物治療聯(lián)合球囊擴張成形及其支架植入術(PTAS)對于癥狀性顱內(nèi)大動脈粥樣硬化性狹窄(狹窄率70%-99%)的療效。該研究的長期隨訪發(fā)現(xiàn),單純積極藥物治療對顱內(nèi)大動脈粥樣硬化性狹窄高�；颊叩脑缙谑找鎯�(yōu)于Wingspan支架植入。然而,也有其他研究發(fā)現(xiàn)對于高風險的顱內(nèi)大動脈粥樣硬化性狹窄患者,Wingspan支架植入優(yōu)于單純藥物治療。因此,如何篩選高風險的顱內(nèi)大動脈粥樣硬化性狹窄病變可能相比追求卓越的治療技術更重要。在篩選高風險的顱內(nèi)大動脈粥樣硬化性狹窄病變時,不能簡單將血管病變的狹窄率與臨床癥狀及其預期預后直接關聯(lián),傳統(tǒng)地單純依靠狹窄率來判定狹窄的功能性意義的評估方法必然受到挑戰(zhàn)。當缺少了血流動力學評估的數(shù)據(jù),慢性狹窄的病變的管理常常變得異常困惑,尤其是狹窄率為40%-69%的臨界病變。因此,對于腦血管造影提示的形態(tài)學狹窄,其功能意義的評估具有極大的臨床指導價值。血流儲備分數(shù)(Fraction flow reserve, FFR)指導的血運重建策略在心血管介入治療中已經(jīng)得到廣泛應用。目前,在2010版歐洲心肌血運重建指南中,FFR已作為IA級建議推薦指導冠脈狹窄血運重建,它將傳統(tǒng)的依據(jù)冠脈狹窄的形態(tài)學特征判斷病變的嚴重性上升到依據(jù)狹窄的功能性意義來判斷病變的嚴重性,從而真正的從病理生理層面來制定治療策略。但是,這一采用壓力導絲進行的有創(chuàng)血流動力學評估技術在顱內(nèi)大動脈粥樣硬化性狹窄評估中的可行性如何,尚不明確。方法：我們從2013年3月至2014年5月,連續(xù)入組了12例準備行球囊擴張成形及其支架植入術(PTAS)治療或狹窄程度在40%-69%的顱內(nèi)大動脈粥樣硬化性狹窄的患者(包括頸內(nèi)動脈顱內(nèi)段、大腦中動脈M1段、椎動脈顱內(nèi)段和基底動脈)。在球囊擴張成形及其支架植入術(PTAS)之前和/或術后,分別使用壓力導絲技術測量跨狹窄壓力差,并與狹窄程度進行比較。顱內(nèi)大動脈狹窄率的計算采用WASID標準測量：狹窄率=[(1-(狹窄病變處管腔直徑/正常管腔直徑))]×100,狹窄病變處的管腔直徑指的是病變最嚴重處的管腔直徑,正常管腔直徑指的是病變處附近正常管腔的直徑。測定了所有待評估顱內(nèi)大動脈狹窄病變的Pd/Pa值,采用Pd/Pa比值≤0.7作為存在顯著血流動力學障礙的界值,提示需要支架植入治療；當該值大于0.8時,對該病變采用優(yōu)化藥物治療方案；當該值在0.7和0.8之間時,是否需要支架植入由術者綜合患者其他臨床特征進行決策。對于支架植入的患者,當支架植入后,再次測量病變處的Pd/Pa值。分別在患者入組時、壓力導絲評估后24h、出院時、術后30天、90天和180天進行隨訪。記錄基線臨床資料(包括年齡、性別、NIHSS評分等)、器械相關及其手術相關的嚴重不良事件,并觀察遠期腦缺血事件的復發(fā)情況(TIA或者缺血性卒中)。結(jié)果：在所有入組的12例患者中,壓力導絲均能夠到達待評估血管病變部位,沒有發(fā)生器械相關及其手術相關的嚴重不良事件。其中狹窄病變位于前循環(huán)的有10例,位于后循環(huán)的有2例。本研究中,壓力導絲技術能夠獲得非常準確的血流動力學參數(shù)：Pa、Pd、Pd/Pa和△P。其中行PTAS的7例患者,跨狹窄壓力差△P從術前的59.0±17.2mmHg下降到術后的13.3±13.6mmHg(P0.01)。將MCA重度狹窄(狹窄率≥70%)和非重度狹窄病變(狹窄率70%)的△P進行比較,可見在重度狹窄組的最低跨狹窄壓力階差AP為31mmHg,而在非重度狹窄組中,最高的跨狹窄壓力階差△P才18mmHg。在隨訪期間,只有一例患者在研究期間發(fā)生TIA復發(fā),考慮可能與該患者拒絕行支架植入術相關。其他患者均未出現(xiàn)缺血事件復發(fā)。結(jié)論：這種新的腦血流動力學評估方法,使得我們能夠直接在術中即時獲得Pa、Pd和Pd/Pa值,并且可以快速計算得到跨狹窄壓力階差AP。這種便捷高效地腦血流動力學評估方法,可以幫助腦血管介入醫(yī)師更好地認識腦動脈狹窄的功能性意義,從而更加準確的選擇合適的治療方案,并且有助于在PTAS后即刻術中觀察PTAS的治療效果,以判斷是否需要后續(xù)補救治療。第二章壓力導絲技術對畢格犬顱外段頸動脈狹窄嚴重性評估的理論探索研究背景及目的：腦血管病已上升成為我國城鄉(xiāng)居民的首位致死原因。按照累積的病變血管分布劃分,顱內(nèi)、外大動脈狹窄導致的缺血性腦血管疾病所占比例最大。流行病學相關研究表明,頸總動脈、頸內(nèi)動脈頸段(C1段)狹窄及閉塞導致的缺血性事件大約占到所有腦卒中的25%。頸動脈狹窄病變行頸動脈重建的目的主要還是預防腦卒中的發(fā)生。從病理生理層面來看,頸動脈支架置入起到預防腦卒中的作用,可能與血流動力學的改善和/或狹窄局部易損斑塊被支架覆蓋有關。但是,目前臨床操作中,頸動脈支架植入術的主要適應癥之一：無癥狀患者選擇狹窄程度70%以上的標準,更多是基于對狹窄后血流動力學的擔心。從血流動力學角度分析,對于狹窄程度在70%以上,如果狹窄局部血管壁并沒有易損斑塊的患者是否一定需要置入支架,尚不明確。本研究擬通過球囊擴張制作頸動脈狹窄直至閉塞的過程,模擬不同程度的頸動脈狹窄,從而獲得狹窄／閉塞遠端壓力Pd值、狹窄近端壓力Pa值以及Pd/Pa值等血流動力學參數(shù),觀察所獲得的參數(shù)是否能夠用來指導篩選具有功能意義的頸動脈狹窄病變；并且觀察頸動脈狹窄／閉塞后,willis動脈環(huán)在代償血流的重新分配中的作用及其可能機制。方法：選擇清潔級健康成年畢格犬5只,均為雄性,體重13-18 kg。使用速眠新(劑量0.1ml/kg)聯(lián)合硫酸阿托品(劑量0.5mg)進行誘導麻醉,麻醉后固定于自制操作臺上,經(jīng)口氣管插管,插管后采用自主通氣；術中使用丙泊酚靜脈泵注射維持麻醉(劑量1mg/kg/h)給予持續(xù)吸氧,氧流量控制在2ml/min,根據(jù)實驗動物的角膜反射消失、及呼吸節(jié)律保持在12至16次/min控制麻醉深度。先選擇一側(cè)頸總動脈(CCA)進行壓力導絲血流動力學評估,將6F指引導管置于CCA下段近開口處,指引導管頭端與CCA開口距離小于2cm。將球囊(規(guī)格4.0x20 mm)近端mark置于頸總動脈的中段,球囊置入使用壓力導絲作支撐；將壓力導絲的壓力感受器置于球囊遠端約3cm處,通過球囊擴張壓力的調(diào)整,獲得不同Pd/Pa值(從1.0逐步將至0.95、0.9、0.8、0.7和閉塞,允許誤差范圍±0.01),每個節(jié)點待穩(wěn)定后維持3分鐘以上,對應的使用TCD觀察雙側(cè)MCA血流速度、頻譜的變化,由兩位熟練的超聲診斷醫(yī)師同時經(jīng)畢格犬的雙側(cè)顳窗來完成TCD血流動力學參數(shù)的采集,包括收縮期峰值流速Vs、平均流速Vm、舒張期末流速Vd、阻力指數(shù)RI、搏動指數(shù)PI。然后觀察對側(cè)頸內(nèi)動脈,操作方法與前相同。術中在不同節(jié)點觀察血流動力學參數(shù)變化的同時,采用TCD觀察大腦中動脈血流速度、頻譜的變化,記錄球囊擴張的同側(cè)和對側(cè)MCA的血流動力學參數(shù)。結(jié)果：Pd/Pa值從1.0降至0.95期間,TCD血流參數(shù)包括收縮期峰值流速、平均流速和舒張期末流速均沒有明顯的變化(同側(cè)兩組間Vs、Vm和Vd值的比較分別為：40.6±9.7 vs 39.7±9.6,P=0.837；28.4±7.2 vs 27.9±7.3,P=0.879；23.4±7.6 vs 23.2±7.7,P=0.954；對側(cè)兩組間Vs、Vm和Vd值的比較分別為：46.1±6.6 vs 45.9±6.3,P=0.946；29.9±4.4 vs 30.2±4.3,P=0.879；24.0±6.0 vs23.9±6.3,P=0.971)。繼續(xù)將Pd/Pa值從0.95逐步降至0.9、0.8、0.7,直至球囊完全閉塞頸總動脈,分別待每個節(jié)點的Pd/Pa值穩(wěn)定后,維持三分鐘以上,記錄相應的TCD血流動力學參數(shù),TCD參數(shù)改變顯著(P0.05)。當Pd/Pa從1.0降至0.95時,TCD沒有發(fā)現(xiàn)同側(cè)或者對側(cè)MCA顯著的血流動力學變化。當Pd/Pa繼續(xù)下降至0.9及以下時,隨著Pd/Pa比值的逐步下降,可以觀察到同側(cè)MCA血流動力學參數(shù)進行性下降,最終達到最小值；對側(cè)MCA血流動力學參數(shù)進行性上升,最終達到最大值。結(jié)論：本研究證實了在頸動脈顱外段狹窄的評估中,用于區(qū)分功能性顱外段頸動脈狹窄的Pd/Pa值的截點可能在0.95-0.9之間；在Pd/Pa值下降至0.95-0.9之間時,willis動脈環(huán)代償功能開始激活,并且在代償血流的重新分配中起到重要作用。未來在頸動脈顱外段狹窄的評估中,使用壓力導絲技術獲得的Pd/Pa值可能是一個重要的血流動力學參數(shù)。第三章綜述腦血管狹窄的血流動力學評估腦卒中的發(fā)生機制主要包括栓塞和血流動力學障礙,以及兩者共同作用的混合性機制。腦血管閉塞部位的不同,位于遠端還是近端,串聯(lián)病變還是小血管病變,臨床表現(xiàn)形式多種多樣,其中無不摻雜著血流動力學障礙的因素。傳統(tǒng)的腦血管狹窄評估更傾向于狹窄的形態(tài)學判定,對于狹窄的功能性意義,特別是血流動力學認識不足。近年來,在腦血流動力學評估方面的有了很大的發(fā)展,但是我們現(xiàn)有臨床指南對于腦血管狹窄病變的決策更多地是基于形態(tài)學評估,無論是無創(chuàng)的彩色多普勒超聲、經(jīng)顱多普勒超聲、CT動脈成像、MR動脈成像,還是有創(chuàng)的腦血管造影DSA檢查,往往采用狹窄率來衡量狹窄的嚴重性。這更多地是對結(jié)構(gòu)上的評定,對于狹窄的功能性意義評估較少,因此對于特定狹窄病變是否會導致遠期的不良終點事件的判斷顯得依據(jù)不足。這樣,可能導致部分需要介入治療的狹窄病變被遺漏,或者部分不需要介入治療的狹窄病變被放置了支架/球囊成形術。功能性評估方面,傳統(tǒng)的腦血流儲備評估方法如CT灌注成像、MRI灌注成像、PET灌注成像、SPECT灌注成像以及其他無創(chuàng)試驗通�？商崾径嘀а懿∽兓颊叽嬖谌毖�,但卻不能判斷特定的缺血區(qū)域以及準確定位引起該區(qū)域缺血的狹窄病變部位,對血管病變的空間分辨率較差,不能夠很好地指導介入治療決策。近來在在冠脈狹窄評估中興起的FFR理論,具有許多獨一無二的特性,使得該指數(shù)特別適合用于指導冠脈狹窄的功能性評估,并有助于介入醫(yī)師在導管室做出合適的治療決策。其主要優(yōu)點包括：1、具備參考值明確,正常血管的FFR值等于1.0；2、缺血病變評估的臨界值相當明確,小于0.75時建議支架治療,大于0.80時建議可推遲支架治療,介于0.75和0.80之間的灰色區(qū)間較窄；3、其評估過程,不會受到全身血流動力學參數(shù)變化的影響；4、該參數(shù)充分考慮到了側(cè)枝循環(huán)的貢獻率；5、FFR值可以在狹窄嚴重程度與待灌注組織區(qū)域之間建立起特殊聯(lián)系；6、FFR具有極好的空間分辨率,有助于臨床實時動態(tài)評估。使用壓力導絲行血管內(nèi)血流動力學評估在冠脈介入已經(jīng)得到了成熟的應用,對冠脈狹窄的評估具有極高的指導價值,越來越受到臨床醫(yī)師的重視,并且已經(jīng)推廣用于指導嚴重腎動脈狹窄的血管內(nèi)介入治療策略,但是目前在腦血流儲備評估中的應用仍然是空白。未來我們是否能夠?qū)⑿难茉u估中得到廣泛應用的FFR理論推廣到腦血管狹窄的評估中。目前,已經(jīng)有研究者開始了初步探索。本章節(jié)將針腦血管狹窄的血流動力學評估展開綜述及展望。
[Abstract]:Evaluation of the severity of intracranial large artery stenosis in the first chapter: the feasibility study background and objective: in Asia, especially in Southeast Asia, including Chinese Han population, intracranial large atherosclerotic stenosis is one of the main causes of ischemic stroke. Narrower therapies include balloon dilatation, stent implantation, and active drug intervention in the.2011 years of SAMMPRIS studies comparing simple active drug therapy and active drug therapy combined with balloon dilatation and stent implantation (PTAS) for symptomatic intracranial large atherosclerotic stenosis (70%-99%) Long term follow-up of this study found that the early benefit of simple active drug therapy for patients at high risk of intracranial atherosclerotic stenosis is better than Wingspan stent implantation. However, there are other studies that have found that Wingspan stent implantation is superior to simple drug therapy for high-risk patients with large atherosclerotic stenosis. Therefore, how to screen high risk intracranial large atherosclerotic stenosis may be more important than the pursuit of excellent treatment. In screening high risk intracranial large atherosclerotic stenosis, the stenosis rate of vascular lesions can not be directly related to the clinical symptoms and the prognosis, and the narrowing of the stenosis is simply dependent on the narrowing of the stenosis. The assessment of the rate to determine the narrow functional significance is inevitably challenged. When the data of the hemodynamic assessment are lacking, the management of chronic stenosis is often abnormally perplexed, especially the critical lesion of the stenosis rate of 40%-69%. Therefore, the assessment of the functional significance of the cerebral angiography hints of the morphological stenosis is extremely important. Large clinical guidance. Blood flow reserve score (Fraction flow reserve, FFR) has been widely used in cardiovascular interventional therapy. Currently, in the 2010 edition of the European myocardial revascularization guide, FFR has been recommended as a IA recommendation to guide coronary narrow and narrow blood revascularization, which is traditionally based on coronary stenosis. The morphological features determine the severity of the lesion to judge the severity of the disease according to the narrow functional significance, so as to make a real treatment strategy from the pathophysiological level. However, the feasibility of the invasive hemodynamic assessment of the pressure wire in the assessment of intracranial large atherosclerotic stenosis Methods: from March 2013 to May 2014, 12 patients with intracranial large atherosclerotic stenosis (intracranial segment, M1 segment of middle cerebral artery, intracranial segment of vertebral artery, and basal arteriosclerosis) were enrolled in 12 consecutive patients who were prepared for balloon dilatation and stent implantation (PTAS) for the treatment of intracranial large atherosclerotic stenosis in 40%-69%. Pressure conductance measurements were used before and after balloon dilatation and / or stent implantation (PTAS) and compared with the degree of stenosis. The stenosis rate of intracranial large arteries was measured by WASID standard: stenosis = [(1- (stenosis of lumen diameter / normal lumen diameter)] * 100, stenosis The diameter of the lumen in the variable cavity refers to the diameter of the lumen in the most serious lesion. The diameter of the normal lumen refers to the diameter of the normal lumen near the lesion. The Pd/Pa value of all the lesions of the intracranial large artery stenosis is measured. The value of the Pd/Pa ratio is less than 0.7 as the boundary value of the significant hemodynamic obstacle, suggesting the need for stent implantation. When the value is greater than 0.8, an optimized drug treatment scheme is used for the lesion. When the value is between 0.7 and 0.8, the stent implantation is required to make decisions on the other clinical features of the patient. For the patient with the stent implantation, the Pd/Pa value of the lesion is measured again after the stent implantation. When the patient enters the group, the pressure wire is evaluated by 24. H, follow up at 30 days, 90 days and 180 days after discharge. Record baseline clinical data (age, sex, NIHSS score, etc.), instrument related and surgical related serious adverse events, and observe the recurrence of ischemic events (TIA or ischemic stroke). Results: in all 12 patients, the stress conductance could be found. There were no apparatus related and severe adverse events related to the site of vascular lesions to be assessed. There were 10 cases of narrow lesions located in the anterior circulation and 2 in the posterior circulation. In this study, pressure wire technique was able to obtain very accurate hemodynamic parameters: Pa, Pd, Pd/Pa, and delta P. in 7 patients with PTAS, The span of trans stenosis Delta P decreased from 59 + 17.2mmHg before operation to 13.3 + 13.6mmHg (P0.01) after operation. Compared the severe stenosis (stricture rate 70%) to non severe stenosis (70%), the lowest cross stenosis pressure order AP was 31mmHg in the severe stenosis group, and the highest cross stenosis pressure in the non severe stenosis group. The order difference Delta P was only 18mmHg. during the follow-up period, only one patient had a recurrence of TIA during the study. It was considered possible to be associated with the patient's refusal of stent implantation. Other patients had no recurrence of the ischemic event. Conclusion: this new method of cerebral hemodynamic assessment enables us to directly obtain Pa, Pd, and Pd/Pa values during the operation. And the rapid and efficient method of estimating the cross narrow pressure order difference AP. can help the cerebrovascular interventional physicians to better understand the functional significance of cerebral artery stenosis, so as to choose the appropriate treatment more accurately, and help to observe the therapeutic effect of PTAS in the immediate postoperative period of PTAS. To determine the need for subsequent remedial treatment. The second chapter of the theoretical exploration of the evaluation of the severity of cranial carotid artery stenosis by pressure guided wire technique: cerebrovascular disease has been the leading cause of death in urban and rural areas in China. According to the cumulative distribution of the lesion vessels, intracranial and external major artery stenosis Ischemic cerebrovascular disease accounts for the largest proportion. Epidemiological studies have shown that the common carotid artery, the cervical segment of the carotid artery (C1 segment) and occlusion caused by ischemic events account for approximately the 25%. carotid artery stenosis in all stroke. The purpose of the carotid artery reconstruction is mainly to prevent the occurrence of stroke. The effect of carotid artery stenting on stroke prevention may be associated with improvement of hemodynamics and / or narrowing of localized vulnerable plaque by stent coverage. However, one of the main indications of carotid artery stenting in clinical operation is that asymptomatic patients choose more than 70% of the stenosis degree based on stricture. The concern of hemodynamics. From a hemodynamic point of view, it is not clear whether the stenosis degree is above 70%, if the stenosis of the local vessel wall and no vulnerable plaque needs to be placed, it is not clear. This study is to make the carotid stenosis and closure by balloon dilatation, and to simulate different degrees of carotid stenosis. The hemodynamic parameters, such as narrowed / obliterated distal pressure Pd, narrowed proximal pressure Pa and Pd/Pa value, were observed to determine whether the obtained parameters could be used to guide the screening of functional carotid stenosis and to observe the redistribution of the compensatory blood flow of the Willis artery ring after carotid stenosis / occlusion. Methods: 5 healthy adult beagle dogs were selected, all of which were male and 13-18 kg., with a new (dose of 0.1ml/kg) combined with atropine sulfate (dose 0.5mg) for induction of anesthesia. After anesthesia, it was fixed on the self-made operation table, intubated through the mouth trachea, after intubation, and propofol was used in the operation. Pulse injection maintenance anesthesia (dose 1mg/kg/h) was given to continuous oxygen inhalation, oxygen flow was controlled at 2ml/min, the corneal reflex of the experimental animals disappeared, and the respiratory rhythm was maintained at 12 to 16 times of /min control depth. First, one side of the common carotid artery (CCA) was selected to conduct the pressure guide blood flow mechanics assessment, and the 6F guiding tube was placed in the near opening of the lower CCA segment. The head end of the catheter and the CCA opening distance are less than 2cm. to place the proximal mark of the balloon (specification 4.0x20 mm) into the middle part of the common carotid artery, and the balloon is placed with a pressure guide wire. The pressure guide is placed at the distal end of the balloon about 3cm, and the different Pd/Pa values are gradually obtained from 1 to 0.95,0.9,0.8 by the adjustment of the balloon dilatation pressure. 0.7 and occlusion, allowable error range of 0.01), each node remained stable for more than 3 minutes. The corresponding TCD was used to observe the blood flow velocity of bilateral MCA and the change of frequency spectrum. The hemodynamic parameters of TCD were collected by two skilled ultrasound diagnostics at the same time by the bilateral temporal window of the Beagle, including the peak systolic flow velocity Vs, the average velocity of flow. Vm, the end diastolic flow velocity Vd, the resistance index RI, the pulsation index PI. and then observe the contralateral internal carotid artery. The operation method is the same as before. During the observation of the changes in the hemodynamic parameters at different nodes, the blood flow velocity of the middle cerebral artery, the change of the spectrum, the hemodynamic parameters of the balloon dilatation and the contralateral MCA are recorded by TCD. Results: when the Pd/Pa value decreased from 1 to 0.95, the TCD parameters included the peak systolic flow velocity, the average velocity and the end velocity of diastolic phase (Vs, Vm and Vd, respectively: 40.6 + 9.7 vs 39.7 + 9.6, P=0.837; 28.4 + 7.2 vs 27.9 + 0.95, P=0.879; 23.4 + 7.6 vs 23.2 + + +, P=0.954; contralateral The comparison of the values of Vs, Vm and Vd between groups were 46.1 + 6.6 vs 45.9 + 6.3, P=0.946, 29.9 + 4.4 vs 30.2 + 4.3, P=0.879, 24 + 6 vs23.9 + 6.3, P=0.971). The Pd/Pa values were gradually reduced from 0.95 to 0.9,0.8,0.7 until the balloon completely blocked the common carotid artery. After the Pd/Pa values of each node were stable, the records were maintained for more than three minutes and the corresponding records were recorded accordingly. TCD hemodynamic parameters and TCD parameters changed significantly (P0.05). When Pd/Pa was reduced from 1 to 0.95, TCD did not find significant hemodynamic changes on the ipsilateral or contralateral MCA. When the Pd/Pa continued to fall to 0.9 and below, with the gradual decrease of the Pd/Pa ratio, the same side MCA hemodynamic parameters could be observed to be reduced and finally reached the level. Minimum value of the contralateral MCA hemodynamic parameters up and up to the maximum. Conclusion: This study confirms that in the assessment of the stenosis of the extracranial carotid artery, the Pd/Pa value used to distinguish functional extracranial carotid stenosis may be between 0.95-0.9; when the Pd/Pa value falls to 0.95-0.9, the Willis artery rings are compensated. Function begins to activate and plays an important role in redistribution of compensatory blood flow. In the future assessment of the stenosis of the carotid artery, the Pd/Pa value obtained by using the pressure wire technique may be an important hemodynamic parameter. In the third chapter, the main package of cerebral vascular stenosis is reviewed to evaluate the mechanism of cerebral apoplexy. The combination of embolism and hemodynamic disorders, as well as the common mechanism of the two interactions. The different parts of the cerebral vascular occlusion, located at the distal or proximal end, in tandem or in small vascular lesions, are varied in clinical manifestations, including the factors of hemodynamic disorders. The traditional assessment of cerebral vascular stenosis is more prone to stenosis. In recent years, there has been a great development in the assessment of cerebral hemodynamics, but our existing clinical guidelines are more based on morphologic assessment for the decision-making of cerebral vascular stenosis, whether non-invasive color Doppler ultrasound, Cranial Doppler ultrasound, CT arteriography, MR arteriography, or invasive cerebral angiography DSA examination, often using the narrowing rate to measure the severity of stenosis. This is more of a structural assessment, less assessment of the narrow functional significance, and therefore whether a specific narrow lesion can lead to a long-term adverse terminal event. It appears to be inadequate. This may lead to partial loss of stenosis that requires interventional therapy, or partial stenosis requiring no interventional therapy.

【學位授予單位】：南方醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2016
【分類號】：R743.3

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5 吳e，

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