机械联合动静脉多途径血管再通术治疗急性颅内大动脉闭塞的临床研究
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摘要
目的探讨机械联合动静脉多途径血管再通术治疗急性颅内大动脉闭塞患者的临床效果及安全性。方法选择急性颅内大动脉闭塞患者38例,其中颈内动脉闭塞患者9例,大脑中动脉闭塞患者18例,基底动脉闭塞患者11例,均采用机械联合动静脉多途径血管再通术治疗,观察其临床效果及安全性。结果根据卒中类型及血管情况,使用机械碎栓3例,动脉溶栓13例,机械取栓23例,球囊扩张3例,支架治疗5例。术后血管再通33例,再通率为86.8%,完全再通22例(57.9%),部分再通11例(28.9%)。术后脑梗死溶栓分级靶血流可达2b～3级。术后症状性颅内出血4例,额叶出血1例,基底节、颞叶出血1例,死亡6例。存活的32例患者治疗后,随时间延长,美国国立卫生研究院卒中量表评分逐渐降低,日常生活能力量表评分逐渐升高,差异有统计学意义(P<0.05),出院时改良Rankin量表评分与出院6个月改良Rankin量表评分差异无统计学意义(P>0.05)。结论对发病4.5 h内的急性颅内大动脉闭塞患者行机械联合动静脉多途径血管再通术是安全有效的。
Objective To investigate the efficacy and safety of mechanical thrombolysis with intra-venous and intra-arterial thrombolysis in patinets with acute intracranial large artery occlusion. Methods The clinical data of 38 patients with acute intracranial large artery occlusion by using the combined mechanical thrombolysis with intra-venous and intra-arterial thrombolysis were analyzed retrospectively. There were 9 cases in internal carotid artery,18 cases in middle cerebral artery,11 cases in basilar artery.The clinical effects and safety were analyzed. Results According to the stroke type and vascular condition, mechanical thrombolysis was used in 3 patiens. Arterial thrombolysis was used in 13 patients. Mechanical thrombectomy was used in 23 patients. Balloon dilatation was used in 3 patients. Stenting was used in 5 patients. Occluded large arteries of 33 patients were dredged totally or partialy,the recanalization rate or partial recanalization rate of blocked blood vessel was 86.8%,including 22 cases with total recanalization(57.9%),11 cases with partial recanalization(28.9%). The target blood flow evaluated by modified thrombolysis in cerebral infarction can reached form 2b-3 grade. After operation four cases suffered from cerebralhemorrhage,including 1 case of frontal lobe hemorrhage, 1 case of basal ganglia and temporal lobe hemorrhage,6 cases died. 32 patients were survived from treatment. Over time,the ranks of National Institute of Health Stroke Scale gradually decreased, the ranks of Activity of Daily Living Scale gradually increased, and the difference was statistically significant(P<0.05). The degree of modified Rankin Scale showed no significant difference between leaving and 6 months after departure from the hospital(P>0.05). Conclusion Mechanical thrombolysis with intra-venous and intra-arterial thrombolysis in patinets with acute intracranial large artery occlusion is a safe and an effective therapy within 4.5 h intravenous thrombolysis time window.
Objective To investigate the efficacy and safety of mechanical thrombolysis with intra-venous and intra-arterial thrombolysis in patinets with acute intracranial large artery occlusion. Methods The clinical data of 38 patients with acute intracranial large artery occlusion by using the combined mechanical thrombolysis with intra-venous and intra-arterial thrombolysis were analyzed retrospectively. There were 9 cases in internal carotid artery,18 cases in middle cerebral artery,11 cases in basilar artery.The clinical effects and safety were analyzed. Results According to the stroke type and vascular condition, mechanical thrombolysis was used in 3 patiens. Arterial thrombolysis was used in 13 patients. Mechanical thrombectomy was used in 23 patients. Balloon dilatation was used in 3 patients. Stenting was used in 5 patients. Occluded large arteries of 33 patients were dredged totally or partialy,the recanalization rate or partial recanalization rate of blocked blood vessel was 86.8%,including 22 cases with total recanalization(57.9%),11 cases with partial recanalization(28.9%). The target blood flow evaluated by modified thrombolysis in cerebral infarction can reached form 2b-3 grade. After operation four cases suffered from cerebralhemorrhage,including 1 case of frontal lobe hemorrhage, 1 case of basal ganglia and temporal lobe hemorrhage,6 cases died. 32 patients were survived from treatment. Over time,the ranks of National Institute of Health Stroke Scale gradually decreased, the ranks of Activity of Daily Living Scale gradually increased, and the difference was statistically significant(P<0.05). The degree of modified Rankin Scale showed no significant difference between leaving and 6 months after departure from the hospital(P>0.05). Conclusion Mechanical thrombolysis with intra-venous and intra-arterial thrombolysis in patinets with acute intracranial large artery occlusion is a safe and an effective therapy within 4.5 h intravenous thrombolysis time window.
引文
[1] 张丽,梅君素,朱红雯,等.同型半胱氨酸水平与急性缺血性脑卒中老老年患者溶栓预后相关性分析[J].河北医科大学学报,2018,39(8):872-876.
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[9] 中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组,中华医学会神经病学分会神经血管介入协作组.中国急性缺血性脑卒中早期血管内介入诊疗指南2018[J].中华神经科杂志,2018,51(9):683-691.
[10] Pereira VM,Gralla J,Davalos A,et al.Prospective,multicenter,single-arm study of mechanical thrombectomy using Solitaire Flow Restoration in acute ischemic stroke[J].Stroke,2013,44(10):2802-2807.
[11] Ostrowski RP,Colohan AR,Zhang JH.Molecular mechanisms of early brain injury after subarachnoid hemorrhage[J].Neuro Res,2006,28(4):399-414.
[12] Rha JH,Saver JL.The impact of recanalization on ischemic stroke outcome:a meta-analysis[J].Stroke,2007,38(3):967-973.
[13] 孙丰兵,李铁,荆朝晖,等.Solitaire AB型支架机械取栓治疗急性缺血性卒中[J].中国急救医学,2016,36(12):1069-1073.
[14] Wang X,You S,Sato S,et al.Current status of intravenous tissue plasminogen activator dosage of acute ischaemic stoke:an updated systematic review[J].Strke Vasc Neurol,2018,3(1):28-33.
[15] Wang H,Wang H,Zi W,et al.Direct endovascular treatmnet:an alternative for bridging therapy in anterior circulation large-vessel occlusion stroke[J].Eur J Neurol,2017,24(7):935-943.
[16] 蒋芳,赵文博,吴川杰,等.急性缺血性卒中静脉阿替普酶溶栓后出血转化的治疗和结局:美国心脏协会/美国卒中协会科学声明[J].中国脑血管病杂志,2018,15(7):386-392.
[17] 叶晨,韦琛琛,刘鸣.静脉溶栓后出血转化风险评估及处理[J].中国实用内科杂志,2018,38(8):693-698.
[18] 温宏峰,涂隽,贺大权,等.血管内质量前循环不同部位及原因血管闭塞导致的急性脑梗死5例分析[J].中风与神经疾病杂志,2017,34(4):356-358.
[2] 中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组.中国急性缺血性脑卒中诊治指南2018[J].中华神经科杂志,2018,51(9):666-682.
[3] Powers WJ,Rabinstein AA,Ackerson T,et al.2018 Guidelines for the early management of patients with acute ischemic stroke:a guideline for healthcare professionals from the american heart association/american stroke association[J].Stroke,2018,49(3):e46-110.
[4] Kim S,Choi JH,Kang M,et al.Safety and efficancy of intravenous tirofiban as antiplatelet premedication for stent-assisted coiling in acutely ruptured intracranial aneurysms[S].AJNR Am J Neuroradiol,2016,37(3):508-514.
[5] Anadani M,Alawieh A,Vargas J,et al.First attempt recanalization with ADAPT:rate,predictors,and outcome[J].J Neurointerv Surg,2018[Epub ahead of print].
[6] 李桂林,杜世伟,李静伟,等.静脉溶栓桥接动脉内取栓治疗颅内大动脉急性闭塞的效果分析[J].中国脑血管病杂志,2017,14(3):122-126.
[7] Hacke W,Kaste M,Bluhmki E,et al.Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke[J].N Engl J Med,2008,359(13):1317-1329.
[8] 张磊,李子付,邢鹏飞,等.桥接治疗和直接血管内治疗对急性大血管闭塞性卒中的疗效对比分析[J].中华神经外科杂志,2018,34(3):221-225.
[9] 中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组,中华医学会神经病学分会神经血管介入协作组.中国急性缺血性脑卒中早期血管内介入诊疗指南2018[J].中华神经科杂志,2018,51(9):683-691.
[10] Pereira VM,Gralla J,Davalos A,et al.Prospective,multicenter,single-arm study of mechanical thrombectomy using Solitaire Flow Restoration in acute ischemic stroke[J].Stroke,2013,44(10):2802-2807.
[11] Ostrowski RP,Colohan AR,Zhang JH.Molecular mechanisms of early brain injury after subarachnoid hemorrhage[J].Neuro Res,2006,28(4):399-414.
[12] Rha JH,Saver JL.The impact of recanalization on ischemic stroke outcome:a meta-analysis[J].Stroke,2007,38(3):967-973.
[13] 孙丰兵,李铁,荆朝晖,等.Solitaire AB型支架机械取栓治疗急性缺血性卒中[J].中国急救医学,2016,36(12):1069-1073.
[14] Wang X,You S,Sato S,et al.Current status of intravenous tissue plasminogen activator dosage of acute ischaemic stoke:an updated systematic review[J].Strke Vasc Neurol,2018,3(1):28-33.
[15] Wang H,Wang H,Zi W,et al.Direct endovascular treatmnet:an alternative for bridging therapy in anterior circulation large-vessel occlusion stroke[J].Eur J Neurol,2017,24(7):935-943.
[16] 蒋芳,赵文博,吴川杰,等.急性缺血性卒中静脉阿替普酶溶栓后出血转化的治疗和结局:美国心脏协会/美国卒中协会科学声明[J].中国脑血管病杂志,2018,15(7):386-392.
[17] 叶晨,韦琛琛,刘鸣.静脉溶栓后出血转化风险评估及处理[J].中国实用内科杂志,2018,38(8):693-698.
[18] 温宏峰,涂隽,贺大权,等.血管内质量前循环不同部位及原因血管闭塞导致的急性脑梗死5例分析[J].中风与神经疾病杂志,2017,34(4):356-358.