臺灣博碩士論文加值系統

提要 由於社會進步(醫療現代化, 臺灣人民平均年齡有老化趨勢. 老
年失智 (senile dementia)為越趨重要之社會問題. 而正常壓水腦(
normal pressure hydrocephalus)為老年失智之一重要成因. 然而臨床上
與退化性老年失智(degenerative brain atrophy)不易區分,且術前預估
手術結果並不容易. 本研究目的是探討正常壓水腦病患引流手術前後,腦
血管血流流速與二氧化碳激發反應之改變, 期望對正常壓水腦病患,術後
改善之成因與手術結果預估有所助益.10位臨床上診斷為正常壓水腦之老
年失智病患進入本研究. 於引流手術前及術後3個月, 每位病患都接受經
顱超音波 (transcranial Doppler sonography)檢查,測定腦血管血流流
速 (bloodflow velocity) 及利用過度換氣(hyperventilation)(5%二氧
化碳吸入法(CO2 inhalationmethod)來測定腦血管二氧化碳激發反應. 每
位病患亦都接受手術前及術後3個月頭部電腦斷層檢查(臨床評估(及神經
心理測試. 同時於同時期另外7位因腰椎手術入院之病患接受同樣腦血管
血流流速及腦血管二氧化碳激發反應之測定,以建立正常比較組(control
subjects).同正常比較組比較, 於引流手術前正常壓水腦老年失智之病患
並無顯注之前大腦動脈 (anteriorcerebral artery; ACA)及中大腦動脈
(middle cerebral artery; MCA) 之腦血管血流流速降低(mean of Vm
(cm/sec) ( S.E.M.: 33.3 ( 4.3 vs. 35.4 ( 1.1 in the ACA and 38.4
( 4.1vs. 41.1 ( 1.0 in the MCA; P > 0.05, Mann-Whitney U test
for both comparisons). 引流手術後3個月,腦血管血流流速與手術前流
速之比較亦無顯注改變 (38.3 ( 3.3 in the ACAand 40.0 ( 2.4 in the
MCA; P > 0.05, Wilcoxon singed rank test for both comparisons).
而同正常比較組比較, 正常壓水腦老年失智病患術前則有顯注較差之前大
腦動脈及中大腦動脈之腦血管二氧化碳激發反應 (mean (%) ( S.E.M.:
28.3 ( 6.3 vs. 61.1 ( 3.0 on the ACA and33.5 ( 5.2 vs. 63.6 (
1.9 on the MCA; P < 0.05, Mann-Whitney U test for
bothcomparisons). 引流手術後3個月,前大腦動脈之二氧化碳激發反應相
較術前之值有顯注較高,而於中大腦動脈則無顯注較高之值 (ACA = 51.6
( 8.3, p < 0.05 and MCA = 53.6 ( 8.1,p > 0.05; Wilcoxon signed
rank test for both comparisons). 7位實驗組病患於術後有顯注智力或
更多症狀之進步, 歸類為引流有效 (responsive to shunt), 另3位無顯
注術後症狀進步之病患且無引流管問題則被歸類為引流失敗 (shunt
failure). 與引流失敗組比較, 引流有效病患術後除了有顯注較高前大腦
動脈之二氧化碳激發反應外, 其中大腦動脈之二氧化碳激發反應術後增加
值 (post-shunting increase) 亦顯注較高 (mean (%) ( S.E.M.: 61.7
(9.3 vs. 28.2 ( 5.6 and 29.9 ( 7.1 vs. -3.0 ( 5.1; p < 0.05 for
both comparisons).另外與5位無顯注步態進步病患比較,於5位有顯注步
態進步之病患, 術後除了有顯注較高前大腦動脈之二氧化碳激發反應外,
其前大腦動脈及中大腦動脈之二氧化碳激發反應術後增加值亦顯注較高
(mean (%) ( S.E.M.: 71.0 ( 10.1 vs. 32.2 ( 4.6, 40.5 ( 5.6 vs.
6.2 ( 8.4and 34.2 ( 9.2 vs. 5.8 ( 6.5; p < 0.05, respectively).
我們的結果支持正常壓水腦老年失智之病患因有不同程度受損之前大腦動
脈及中大腦動脈腦血管血管運動反應能力 (vasomotor reserve), 對腦缺
血有較差反應能力而有潛在性腦缺血危險. 引流手術可增加腦血管血管運
動反應能力, 進而預防此潛在性危險. 引流術後二氧化碳激發反應增加值
同臨床上症狀進步有密切關係, 術後中大腦動脈之二氧化碳激發反應增加
值同智力進步有關, 而前大腦動脈及中大腦動脈之二氧化碳激發反應增加
值同步態進步有關.此密切關係對於正常壓水腦老年失智病患之預後及生
理病理可提供進一步瞭解.

ABSTRACTOBJECTIVE:The aim of the study was to evaluate the
hemodynamic changes and their correlationwith the clinical
results by measurement of cerebral blood flow velocity (CBFV)
andcerebral vasomotor reserve before and after shunt placement
in normal pressurehydrocephalus (NPH).METHODS:Ten demented
patients with clinical signs suggestive of NPH received
examinationsof blood flow velocity (BFV) and vasomotor
reactivity (VMR) of the anterior cerebralartery (ACA) and the
middle cerebral artery (MCA) by transcranial Doppler
sonographywith carbogen testing before and after shunt
treatment. Computerized tomography (CT),clinical assessment and
neuropsychological grading were performed prior to and at
3months following surgery. A control group consisting of 7
patients, who underwentlumbar spine surgery, was included to
establish baseline data for BFV and VMR values.RESULTS:Compared
to the control group, the preoperative CBF studies revealed the
NPH patienthad no significant decrease of BFVs in both the MCA
and the ACA (P > 0.05), but hadsignificant decrease of carbogen
VMR in both those two vessels (P < 0.05). Aftershunting, there
were no significant changes of the BFVs in the 2 vessels as
comparedto the pre-shunting data (P > 0.05). The post-shunting
VMR of ACA was significantlyhigher than the pre-shunting one (p
< 0.05), but there was no significance in thatof MCA (p > 0.05).
Seven of the ten patients shown mentality or more
symptomsimprovement were considered as good results (responsive
to shunt). The remaining 3patients, who had consistent symptoms
without recognizable problems, were consideredas bad results
(shunt failure). Both the value of post-shunting VMR in ACA and
thepost-shunting improvement of VMR in MCA of the 7 shunt-
responsive patients weresignificantly higher than those of
shunt-failure patients (p < 0.05). Within the tenpatients, five
patients with gait improvement showed significantly in the value
ofpost-shunting VMR of ACA and the post-shunting improvement of
VMR for both ACA andMCA by comparing those patients without gait
improvement (p < 0.05, respectively).CONCLUSION:Our results
support that the patient with NPH did not have decreased BFVs,
but hadvarious degrees of impaired vasomotor reserve in both the
ACA and the MCA, increasingthe risk of ischemic brain insult.
Shunt placement improves the VMR in responsivepatients,
consequently preventing from the ischemic insult. Post-shunting
increaseof VMR accompanies with the improvement of functional
state in shunt-responsivepatients; however, post-shunting
increase of VMR in the MCA only, and in both the ACAand the MCA
are associated with symptomatic improvement in mentality, and
improvementin gait, respectively. These close relationships have
implications for prognosticimportance and pathophysiology in
NPH.Key Words: Normal pressure hydrocephalus, Cerebral blood
flow velocity, Vasomotorreactivity.