论著睡眠呼吸暂停与型Chiari畸形关系的研究.doc

睡眠呼吸暂停与Ⅰ型Chiari畸形关系研究
首都医科大学隶属北京天坛医院 呼吸科
刘义 张杰
[摘要] 目: 了解Chiari畸形I型（Chiari I type malformation,CM I）患者睡眠呼吸暂停发病率以及睡眠监测图表现; CM I患者合并症对睡眠呼吸暂停影响; CM I患者MRI表现与睡眠呼吸暂停严重程度之间关系; 手术干预对CM I患者睡眠呼吸暂停疗效, 方便愈加好指导临床工作。 方法: 7月至12月全部天坛医院住院诊疗Chiari畸形患者, 经MRI检验符合CM I诊疗标准者42例, 于手术前行整夜多导睡眠仪（Polysomnography, PSG）监测, 同时统计患者通常资料, 填写Epworth嗜睡程度问卷表（Epworth sleepiness scale score, ESS）; 对数据进行统计分析。其中14例PSG监测阳性（AHI≥5）者于术后复查PSG; 比较术前术后PSG结果。利用SIEMENS工作站对入选患者磁共振图像进行分析, 在正中矢状位上测量小脑扁桃体下疝达枕骨大孔以下长度、 枕骨大孔前后径、 延髓脊髓腹侧面成角角度, 比较上述各测量径线与睡眠呼吸暂停严重程度之间关系。应用SPSS11.5统计软件对全部数据进行统计学分析。 结果: CM I患者42人, 其中男18人、 女24人, 男女百分比1: 1.33。发病年纪在15－72岁之间, 平均年纪40.57±13.50岁, 其中15－25岁占7.89％, 25－55岁占81.58％, 55－72岁占10.53％。平均BMI 24.18±2.71 kg/m2,颈围平均为37.70±3.26 cm(14.84±1.28英寸)。 PSG阳性组（24例）与PSG阴性组（18例）在年纪、 BMI、 颈围、 性别及合并症等危险原因方面是相匹配。CM I患者合并睡眠相关主诉发生率高达83.33％, PSG阳性组和PSG阴性组多种睡眠相关主诉发生率均较高, 二者之间差异无统计学意义。PSG监测发觉CM I患者睡眠呼吸暂停患病率为57.14%（24/42）, 与正常人群（正常人群发病率2－4％）相比显著增高。即使男性患者平均年纪低于女性患者, 但男性患病率（66.67％）却高于女性（50.00％）, 表明男性更易发生睡眠呼吸暂停。PSG阳性（AHI≥5）率为57.14％, ESS阳性（≥7.6分）率为52.38％, 二者阳性率统计学上无差异; 而且睡眠呼吸暂停低通气指数（apnea-hypopnea index, AHI）与ESS存在正相关性。CM I患者睡眠图结果: AHI 13.80, AH% 10.95, LAT(S) 81.65, MSaO2(%) 94.12, LSaO2(%) 83.62, ΔSaO2(%) 8.21, SIT90(%) 15.24, ArI 18.62, SⅠ-Ⅱ% 64.39, SⅢ-Ⅳ% 15.25, REM% 20.35, SE(%)76.77。PSG阳性组与PSG阴性组睡眠结构均大致正常, 但ArI均高于正常, SE(%)均显著降低。PSG阳性组CM I患者AHI平均为22.83, 以阻塞性睡眠呼吸暂停占优势, 其中23例表现为阻塞性睡眠呼吸暂停, 仅有1例表现为中枢性睡眠呼吸暂停。睡眠呼吸暂停最常发生在REM期。小脑扁桃体自枕骨大孔向椎管内疝出长度为5.13～19.25mm, 最常见并发症为脊髓空洞症（ 71.43％）, 其次为颅底陷入症（16.67％）和齿状突后突延髓成角畸形（16.67％）。合并脊髓空洞症者与不合并脊髓空洞症者其AHI、 LSaO2、 SIT90%、 LAHT不一样; 合并颅底陷入症者与不合并颅底陷入症者其AHI、 LSaO2、 SIT90%、 LAHT也不一样; 脊髓空洞症和颅底陷入症能够加重睡眠呼吸暂停。AHI与枕骨大孔前后径呈负相关（P＜0.01）, 即枕骨大孔越狭窄, AHI越高, 睡眠呼吸暂停程度越严重。AHI和延髓脊髓成角角度也呈负相关（P＜0.05）, 即延髓脊髓受压成角角度越小, AHI越高, 睡眠呼吸暂停程度越严重。但AHI与单纯小脑扁桃体下疝长度无显著相关性。手术能够改善患者睡眠呼吸暂停。睡眠期间呼吸抑制是最严重术后并发症。 结论: CM I患者睡眠呼吸暂停发病率为57.14％, 83.33％CM I患者伴有白天睡眠相关主诉, CM I是睡眠呼吸暂停独立危险原因。CM I患者睡眠呼吸暂停以阻塞性睡眠呼吸暂停占优势, 伴睡眠片断化（睡眠效率＜90％)。合并脊髓空洞症和颅底陷入症能够加重CM I患者睡眠呼吸暂停, 颅底陷入症影响最大。经过影像学测量, 睡眠呼吸暂停严重程度与枕大孔狭窄以及延髓腹侧面受压程度呈正相关, 与单纯小脑扁桃体下疝程度无相关性。手术诊疗确能够有效地改善睡眠呼吸暂停和低氧血症, 缩短呼吸暂停低通气连续时间。睡眠期间呼吸抑制是最严重术后并发症, 对于术后患者应亲密监测睡眠呼吸功效。
关键词: 睡眠呼吸暂停 睡眠呼吸暂停低通气指数 Chiari畸形I型 磁共振 多导睡眠监测图

Study on the relationship between sleep apnea and Chiari I type malformation
[Abstract] Object: To evaluate the incidence about sleep apnea and the polysomnographic findings in a group of patients with Chiari I type malformation（CM I）. To understand the influence of complication by the CM I on the sleep apnea. To investigate a possible relationship between MRI findings and severity of sleep apnea of patients with CM I. To evaluate the effect of operation and in order to guide clinical trials on Chiari I type malformation. Method: All the patients with Chiari malformation who were admitted in TianTan hospital from July to December in , of whom Forty-two patients with CM I were diagnosed by magnetic resonance imaging (MRI). All patients were submitted to clinical history, physical examination with sleep questionnaires and scored on the Epworth Sleepiness Scale (ESS). Full night monitoring by polysomnoguaphy(PSG) were performed in the sleep laboratory of respiratory department in TianTan Hospital . Then the data were analyzed by statistic method. Fourteen patients with positive results in PSG (AHI≥5) were submitted to overnight’s PSG after operation, and the post-operation results be compared with pre-operation PSG results. In order to investigate the relationship between the above-mentioned datas and the severity of sleep apnea, we using SIEMENS image work station to measure the anatomical position (length mm) of cerebellar tonsils below the foramen magnum, the distance from basion to opisthion and the adjacent angle of medulla and spinal cord. Finally, the data was processed using SPSS 11.5. Result: Forty-two patients (twenty-four females and eighteen males) with Chiari I type malformation. The age between 15 to 72 years old, the average age is 40.57±13.50 years old, and the ratio between males and females is 1:1.33. 7.89% cases onset at 15-25 years old, 81.58% at 25-55 years old, 10.53% at 55-72 years old. Average BMI is 24.18±2.71kg/m2, average neck collar is 37.7 ±3.26cm (14.84±1.28 inchs). CM I patients whose AHI≥5 belonged to the group with positive results in PSG; and the others whose AHI＜5 belonged to the group with negtive results in PSG. The CM I patients in both group were matched in risk factors for age, sex, neck collar, BMI and complications. 83.33% patients with CM I complained of sleep problems, There are high incidence of sleep problems both in the group with negative or positive results in PSG , and there are no statistic difference in the two groups. The AHI was enhance(AHI≥5) in 57.14% CM I patients according to overnight sleep recording, it is higher than in normal crowds(2-4%). The average age of males is lower than females, but the incidence of sleep apnea of males (66.67%) is higher than females (50.00%). that is, male patients with CM I is more prone to have sleep apnea. 57.14%CM I patients have positive results (AHI≥5) in PSG and 52.38% presented diurnal hypersomnolence(ESS＞7.6), they have no statistic difference, AHI was positive correlated with ESS scores in these patients. The PSG findings of CM I patients showed: AHI 13.80, AH% 10.95, LAT(S) 81.65, MSaO2(%) 94.12, LSaO2(%) 83.62, ΔSaO2(%) 8.21, SIT90(%) 15.24, ArI 18.62, SⅠ-Ⅱ% 64.39, SⅢ-Ⅳ% 15.25, REM% 20.35, SE(%)76.77. Sleep patterns were almost normal both in positive group and negative group in PSG, but the ArI were higher and SE was significant lower than normal. The average AHI was 22.83 in patients with CM I, with a predominance of obstructive apnea. PSG findings showed obstructive apnea in 23 patients and central apnea in 1 patient. Most apneas occur in REM sleep. The average length of cerebellar tonsils below the foramen magnum was 5.13～19.25mm. 71.43% cases showed Chiari I type malformation with syringomyelia, 16.67% CM I patients with basilar invagination and the same incidence with an adjacent angle malformation caused by medulla and spinal cord. AHI, LSaO2, SIT90% and LAHT were different in the CM I patients with or without syringomyelia and basilar invagination. Basilar invagination and syringomyelia can worsen sleep apnea. AHI was negative correlated with the distance from basion to opisthion (P＜0.01). It means that the more small of foramen magnum’s diameter, the more high of AHI and the more worse in sleep apnea. At the meantime, AHI was negative correlated with the adjacent angle of medulla and spinal cord( P＜0.05). It means that the more small of angle caused by medulla and spinal cord, the more high of AHI and the more worse in sleep apnea. But there is no correlation between AHI and the level of cerebellar tonsils hernia. Surgical decompression can improve sleep apnea in patients with CM I.Respiratory depression during sleep was the worst complications associated with operations. Conclusions: The incidence of sleep apnea in the patients with CM I was 57.14%, 83.33% patients with CM I complained of sleep symptoms, Chiari malformation is a risk factor of sleep apnea. There was a predominance of obstructive apnea in these patients with CM I and with sleep fragment (SE＜90%). syringomyelia and basilar invagination can worsen sleep apnea, especially with basilar invagination. AHI was negative correlated with the distance of basion-opisthion and the adjacent angle of medulla and spinal cord, but there is no correlation between AHI and the level of cerebellar tonsils hernia. Posterior cranial fossa decompression in these patients with CM I was effective in improving the AHI, hypoxemia and apnea duration. Respiratory depression during sleep was the worst complications associated with operations. We should give a monitoring of sleep respiratory function in these patients post-operation.
Keywords: Sleep apnea, sleep apnea/hypopnea index, Chiari I type malformation, MRI, polysomnogram