Anesthetic Management of Cerebrovascular Disease Carotid Endarterectomy,Daniel J.Cole,M.D.Phoenix, Arizona 翻译：福建医科大学附属协和医院麻醉科规培住院医师：曾燕,脑血管疾病颈动脉内膜切除术的麻醉管理,Introduction,Stroke （中风）is the third leading cause of death. carotid artery disease（劲动脉疾病） is a significant anesthetic issue （麻醉问题）for patients over 50 years of age.A stroke occurs due to occlusive or hemorrhagic conditions. Occlusive cerebrovascular disease can be thrombotic, embolic, or stenotic(血栓，栓塞或狭窄)in origin.(闭塞性或出血性中风的发生是由于闭塞性脑血管疾病，血栓，栓塞或起源于狭窄)Patients with a history of prior stroke （既往中风史）or transient ischemic attack（短暂性脑缺血发作） have an increased risk of recurrent perioperative stroke （围术期再次中风的危险）.,简介,Major symptoms of carotid artery disease include changes in vision, headache, changes in speech, or facial(发热) and extremity(四肢) weakness. Signs(体征) suggestive of carotid artery disease include a high-pitched bruit (高亢的杂音)at the origin(起源) of the internal carotid artery, increase in size and pulsation（强度） of the ipsilateral (同侧)superficial temporal artery（颞浅动脉）, and changes in the retinal examination（眼底检查）. Confirmation（确诊） of carotid artery disease is achieved by vascular imaging which may include ultrasound, MR angiography, or catheter angiography.（颈动脉疾病的确认是通过血管成像，其中可能包括超声，磁共振血管造影或导管造影）,Introduction,Presently, there is insufficient （不足的）information to regarding the timing of surgery （手术时机） following an ischemic episode（缺血性发作）. Data（数据） suggests there is a small but real increase in morbidity（发病率） if surgery is performed shortly after the onset of symptoms（症状）.（数据表明，如果进行手术后不久出现症状，有一个小，但真正的发病率增加）Risk may be associated with the presence（存在） of a low density（低密度） lesion （病变）on CT scan, vascular territory（血管壁内） of the infarct（梗塞）, brain shift（脑组织移位）, and level of consciousness（意识）.,Carotid Artery Revascularization（颈动脉再灌注）,Carotid endarterectomy (CEA) （颈动脉内膜切除术）was introduced in 1954 as treatment for occlusive（闭塞性） carotid artery disease. Efficacy（疗效） data on CEA was limited until the 1990s. Analysis of three trials has demonstrated that CEA has a marginal（微小） benefit in symptomatic patients with 50%-69% stenosis of the carotid artery, and was of greatest benefit in patients with 70% stenosis.（三项试验分析表明，CEA在狭窄面积为50-69的颈动脉狭窄症状的患者身上收效甚微，在狭窄 70的患者收益最大。）,Carotid Artery Revascularization（颈动脉再灌注）,Stenting(支架植入术) and angioplasty（血管成形术） of the carotid artery (CAS) has been performed for almost two decades. Potential （潜在） advantages of CAS include avoiding cranial nerve（颅神经） damage, wound hematoma（伤口血肿）, and general anesthesia（全身麻醉）.The anesthetic technique for this procedure involves（ 涉及）minimal sedation(镇静）. This procedure can cause severe （严重）bradycardia（心动过缓） and hypotension, and can result in cerebral hyperperfusion（高灌注）.,Anatomic/Physiologic（解剖/生理学） Considerations（注意事项）,Carotid artery disease is typically（通常是） the result of ather-osclerosis（动脉粥样硬化）at the bifurcation（分支） of the common carotid artery（颈总动脉）or the origin（主支） of the internal carotid artery（颈内动脉）. （颈动脉疾病通常是颈内动脉主支和颈总动脉分支粥样硬化的结果）Ischemia is most often embolic in origin but may also have a hemodynamic basis.（ 缺血最常见的起源于栓塞，但可能也有血液动力学基础）There are three phases（阶段） of the response of various cerebral variables（脑变量） to progressive（进展的） carotid artery disease.（颈动脉疾病的进展在脑变量的反应上分三阶段）During ischemia（缺血）, collateral flow（侧支循环） is a cornerstone（基础） of cerebral blood flow (CBF) compensation（补偿）.,Anatomic/Physiologic（解剖/生理学） Considerations,The principal pathways of collateral flow are the Circle of Willis（侧支循环的主要途径是Willis环）, extracranial anastomotic channels（颅外吻合通道）, and leptomeningeal （脑膜）communications that bridge “watershed”（分水岭） areas between major arteries. During CEA, the risk of ischemia is related to the dependency of the circulation on the ipsilateral（同侧） internal carotid（颈内） artery, and the cerebrovascular（脑血管） reserve（储备） of the contralateral（对侧） hemisphere（半球）.,Preoperative Concerns（术前关注点）,CEA has an inherent（固有） risk of perioperative（围手术期） stroke and cardiovascular（心血管） events.（CEA存在着围术期中风和心血管事件的固有风险） In symptomatic patients, there is a 6.5% rate of stroke and death associated with CEA; while the reported stroke and death rate for patients with asymptomatic disease is 2.3%. The risk for stroke following CEA is most strongly associated with an active neurologic（神经） process（活动） prior to surgical intervention（手术干预）.,Other factors which have been reported to increase neurological risk include:（其他有报道的增加神经系统风险的因素包括）, hemispheric versus retinal transient ischemic attack（半球与视网膜短暂性脑缺血发作） an urgent procedure（紧急手术） a left sided procedure（左侧手术） ipsilateral ischemic lesion on computerized tomography（电脑断层扫描同侧缺血性病变） contralateral carotid occlusion or poor collaterals（对侧的颈动脉闭塞或者侧支循环差） impaired consciousness（意识障碍） an irregular or ulcerated ipsilateral plaque（不规则或者破溃的同侧斑块）,Medical complications occur about 10% of the time after CEA and are associated with the following:（CEA后并发症的发生还与下列有关）, Hypertension (HTN) （高血压病）： the incidence（发病率） of a neurologic deficit（神经功能缺损） is greater in patients with uncontrolled（ 未控制的）HTN preoperatively （术前）and postoperative HTN（术后高血压）.（术前未控制的高血压和术后高血压的神经功能缺损的发病率更高） Cardiac（心脏病）： a cardiac assessment（心脏评估） is indicated in patients who present for CEA. Diabetes（糖尿病）： data indicate（表明） that CEA can be performed safely in patients with diabetes（糖尿病人可以安全的进行CEA） Renal insufficiency（肾功能不全）： patients with renal insufficiency have an overall（整体）increased（增加） risk for stroke, death, and cardiac morbidity（发病率）, associated with CEA,