急性后循环脑梗死血管内治疗研究进展

急性后循环大血管闭塞引起的脑梗死异常凶险,病死率超过90%。近年来,机械取栓已成为治疗急性前循环大血管闭塞所导致脑梗死的重要方法,然而机械取栓在后循环大血管闭塞所导致的脑梗死治疗中是否有效、安全尚不明确。我们对后循环大血管闭塞性脑梗死的血管内治疗的安全性及有效性做简要综述。     

不同麻醉方式对急性缺血性脑卒中患者行血管内机械取栓治疗影响的回顾性分析

目的：通过回顾性分析初步探讨在不同麻醉方式下急性缺血性脑卒中患者行血管内机械取栓治疗后短期预后的影响及其相关危险因素。方法：回顾2013年5月至2017年7月我院收治并完成血管内机械取栓手术的AIS患者，针对一般资料，疾病状态，对实施全身麻醉的患者与保留自主呼吸的镇静处理或局部麻醉的患者对比，分析手术麻醉相关信息。 结果：术前两组患者脑卒中OCSP分型有不同表现(P＜0.05)，NIHSS分值全麻组高于非全麻组，有明显统计学差异(P＜0.05)，全麻患者意识水平危重比例较非全麻组高(P＜0.05)；术后2h(P＜0.05)及24h(P＜0.05)患者NIHSS评分全麻组得分仍高于非全麻组；比较两组患者从发病到血管再通时间(P＜0.05)及从穿刺到再通时间(P＜0.05)全麻组患者均较长；相较麻醉诱导实施时间全麻组也明显长于非全麻组(P＜0.05)；术后3月患者神经功能评估，结果可见术前NIHSS评分越高术后患者神经功能损伤越严重(OR 1.098, 95% CI 1.037~1.162)，随年龄的增长术后患者康复程度越差(OR 1.030, 95% CI 1.007~1.053)，同时还发现穿刺至血管再通时间越长术后功能损伤越严重( OR 1.006, 95% CI 1.001~1.011)。结论：术前疾病严重程度、年龄及穿刺至血管再通时间严重影响AIS患者预后，是否与麻醉方式相关需进一步更合理完善的研究。     

入院基线血糖水平与接受血管内治疗的急性大血管闭塞性缺血性脑卒中患者预后的相关性分析

目的:探讨入院基线血糖水平与接受血管内治疗的急性大血管闭塞性缺血性脑卒中(AIS-LVO)患者预后的关系.方法:选择2019年1月-2021年1月期间我院收治的131例拟接受血管内治疗的AIS-LVO患者,根据入院基线血糖水平将患者分为血糖≥7.8 mmol/L组(52例)和血糖＜7.8 mmol/L组(79例),再根...     

不同取栓方法治疗急性大血管闭塞性缺血性脑卒中的临床疗效比较

目的 评价支架取栓、抽吸取栓及二者联合取栓治疗急性大血管闭塞性缺血性脑卒中的临床疗效。方法 回顾性分析2021年2月至2022年2月在该院接受治疗的146例急性大血管闭塞性缺血性脑卒中患者的临床资料。根据患者首次取栓手术方法不同,将患者分为抽吸取栓组(抽吸组,n=46)、支架取栓组(支架组,n=58)与支架、抽吸联合取栓组(联合组,n=42)。比较3组患者临床特征,包括性别、年龄、心血管危险因素、舒张压、收缩压、血糖、急性缺血性脑卒中试验(TOAST)分型、卒中项目早期CT评分(ASPECTS)、美国国立卫生研究院卒中量表(NIHSS)评分。比较3组的治疗指标,包括取栓次数、术后改良脑梗死溶栓分级(mTICI分级)、穿刺与血管再通间隔时间、闭塞部位、麻醉方式、发病与穿刺间隔时间等。比较3组的预后指标,包括并发症发生率、颅内出血患者比例与入院时改良Rankin量表(mRS)评分情况。结果 支架组、抽吸组及联合组取栓次数、闭塞部位、麻醉方式、发病与穿刺间隔时间比较,差异均无统计学意义(P>0.05)。抽吸组穿刺与血管再通间隔时间较支架组明显缩短,差异有统计学意义(P<0.01)...     

单纯中间导管抽吸取栓与支架取栓对急性前循环大血管闭塞性脑卒中疗效分析

目的 探讨急性前循环大血管闭塞性脑卒中患者应用单纯中间导管抽吸取栓与支架取栓治疗的临床疗效。方法 选取2019年3月至2021年3月洛阳市第一人民医院接收的急性前循环大血管闭塞性脑卒中患者85例,将行支架取栓治疗的患者设为对照组(n=39),将行单纯中间导管抽吸取栓治疗的患者设为观察组(n=46)。回顾性分析两组患者临床资料,比较其血管再通情况与并发症及手术前后脑卒中量表(NIHSS)、改良Rankin评分量表(MRS)评分。结果 两组患者术后NIHSS评分、MRS评分较术前均明显下降,且术后14 d NIHSS评分明显低于术后7 d NIHSS评分,观察组术后7 d、术后14 d NIHSS评分与术后14 d MRS评分分别为(9.79±6.28)分、(6.68±5.46)分、(1.10±0.70)分,均明显低于对照组(P<0.05);手术后观察组患者血管再通率为93.48%,显著优于对照组患者的76.92%(P<0.05),两组并发症发生率比较,差异无统计学意义(P>0.05)。结论 单纯中间导管抽吸取栓治疗急性前循环大血管闭塞性脑卒中患者效果显著优于支架取栓治疗...     

大血管闭塞性轻型缺血性脑卒中介入治疗的疗效与安全性观察

目的：探讨介入治疗在大血管闭塞性轻型卒中（large vessel occlusion,LVO-MIS）患者中的安全性与有效性,以及可能影响这类患者预后的相关因素。方法：回顾性纳入武汉科技大学附属普仁医院神经内科2020年1月至2023年9月收治的79例LVO-MIS患者,按治疗方法分为单纯药物治疗组49例和介入治疗组30例,主要观察指标为患者90 d时以改良Rankin量表（modified Rankin scale,mRS）评分定义的神经功能恢复情况（mRS≤1分为预后优秀,mRS 1～2分定义为预后良好,mRS>2分定义为预后不良）,次要观察指标为治疗后血管再通情况、早期神经功能恶化,症状性颅内出血及死亡,同时采用Logistic回归分析可能影响LVO-MIS患者预后的因素。结果：介入组28例实现成功再通（93.3%）。治疗后90 d,介入治疗组的预后优秀率高于单纯药物治疗组（P=0.022）。2组患者在早期神经功能恶化、症状性颅内出血及病死率间差异无统计学意义（P>0.05）。多因素Logistic分析结果显示,介入治疗是LVO-MIS患者术后90 d取得优秀预后的...     

Embotrap Ⅱ取栓支架在急性大血管闭塞血管内再通治疗中的应用价值

目的 观察急性缺血性脑卒中大血管闭塞患者血管内再通术中应用Embotrap Ⅱ取栓支架的近期疗效,探讨其安全性。方法 急性缺血性脑卒中大血管闭塞患者31例,均于发病24 h内行血管内再通术,术中首选应用Embotrap Ⅱ取栓支架,根据患者情况给予球囊扩张+支架成形术、双支架(Embotrap+Solitaire)“Y”补救、抽吸术。记录1次再通率、最终再通率、穿刺至再通时间及术后死亡、并发症发生情况;比较术前、术后1、14 d美国国立卫生研究院卒中量表(National Institute of Health Stroke Scale, NIHSS)评分;随防至2022年1月,记录术后90 d预后良好率[改良Rankin量表评分(modified Rankin scale, mRS)≤2分]。结果 术后即刻行血管造影及CT检查,31例中30例(96.8%)血流再通[改良脑梗死溶栓血流分级(modified thrombolysis in cerebral infarction, mTICI)≥2b级],1例(3.2%)mTICI 2a级,穿刺至开通时间(50.5±25.0)min。3...     

急性大血管闭塞性缺血性卒中患者行血管内治疗预后不良的影响因素分析

目的:分析血管内治疗(endovascular treatment,EVT)急性大血管闭塞性缺血性卒中患者预后不良的影响因素。方法:纳入2020年6月至2022年12月期间在山西白求恩医院卒中中心接受EVT的急性大血管闭塞性缺血性卒中患者。收集患者临床资料,进行回顾性分析。根据术后90 d改良Rankin量表(modified Rankin Scale,mRS),将患者分为预后良好组(mRS为0~2分)和预后不良组(mRS为3~6分);根据随访期内患者是否死亡,将患者分为存活组与死亡组;分别比较2组人口统计学资料、手术相关指标和随访结局,采用多因素Logistic回归分析EVT术后患者预后不良的影响因素。结果:本研究共纳入150例患者,其中预后良好组92例(61.33%),预后不良组58例(38.67%);存活组129例(86.00%)和死亡组21例(14.00%)。Logistic回归分析结果显示入院低ASPECT评分(OR=0.575,95%CI 0.391~0.844,P=0.005)、出血转化(OR=4.349,95%CI 1.032~18.329,P=0.045)为预后不良的危险因素;年龄增加(OR=1.054,95%CI 1.003~1.108,P=0.038)、既往心房颤动(OR=3.856,95%CI 1.111~13.378,P=0.033)、术中直接抽吸(OR=7.562,95%CI 2.314~24.715,P=0.001)及发生出血转化(OR=12.112,95%CI 2.269~64.649,P=0.004)是EVT术后患者死亡的危险因素。结论:入院低ASPECT评分、出血转化是急性大血管闭塞性缺血性卒中患者EVT术后预后不良的危险因素;年龄增加、既往心房颤动、术中直接抽吸和发生出血转化是术后死亡的危险因素。     

急性脑静脉窦血栓是否需要血管内治疗？

脑静脉窦血栓较罕见, 发生率不足卒中的1%。其主要治疗方法是全身应用肝素抗凝, 但其中9%~13%的患者效果不佳。在病情快速恶化的患者中, 血管内治疗在技术上是可行的, 并在不同的病例系列分析和前瞻性队列研究中显示出良好的再通率。然而, 与单纯抗凝相比, 其能否改善血管内治疗亚组的临床结果仍不清楚。因此, 急性脑静脉窦血栓是否需要血管内治疗仍存在争议。     

醒后卒中患者的临床诊断学特征及支架取栓技术的临床应用

目的探讨醒后卒中患者的临床诊断学特征及支架取栓治疗的安全性和可行性。 方法选取长治市人民医院神经内科2017年10月至2018年4月收治的3例醒后卒中患者支架取栓治疗的临床资料,分析患者的临床诊断学特征和支架取栓术后血管开通情况、并发症、神经功能改善情况,评估术后90 d时改良Rankin量表评分和Barthel指数评分情况。 结果3例醒后卒中患者均经磁共振血管成像(MRA)证实为颅内前循环大血管闭塞,2例为心源性脑梗死,1例为大动脉粥样硬化性脑梗死,发病时均有意识障碍,美国国立卫生研究院卒中量表评分为13～25分。支架取栓术中闭塞血管均成功再通,脑梗死溶栓血流分级评分≥2b级,术后复查头颅CT未发生颅内出血,梗死灶无扩大,术后30 d时美国国立卫生研究院卒中量表评分较入院时降低10～20分。术后90 d时改良Rankin量表评分1例为3分,2例为2分;Barthel指数评分1例为80分,2例为95分。 结论支架取栓治疗醒后卒中患者有较高的血管再通率,可显著改善患者的临床预后。     

Successful recanalization with multimodality endovascular interventional therapy in acute ischemic stroke

Stroke is an important cause of death and disability in adults. However, effective treatments for patients with acute ischemic stroke are limited. Intravenous recombinant tissue plasminogen activator (iv rtPA) within 4.5 h after onset has been approved as a standard treatment for patients with acute ischemic stroke. However, due to time constraints, less than one percent of acute ischemic stroke patients in Thailand are able to obtain iv rtPA. Although endovascular interventional therapy has not yet been approved as standard treatment in acute ischemic stroke, it is the one of the potentially effective treatment options. There are several reliable methods of endovascular therapy for acute ischemic stroke patients. Endovascular interventional therapy has rarely been done in Thailand. We report seven patients with successful recanalization after endovascular treatment in acute large vessel stroke from a single stroke center in Thailand. Patient screening and selection with multimodal imaging protocol and multimodality methods of endovascular interventional therapy are described.     

Worldwide anaesthesia use during endovascular treatment for medium vessel occlusion stroke

IntroductionThe optimal anaesthesia approach for endovascular treatment (EVT) in acute ischaemic stroke is currently unknown. In stroke due to medium vessel occlusions (MeVO), the occluded vessels are particularly small and more difficult to access, especially in restless or uncooperative patients. In these patients, general anaesthesia (GA) may be preferred by physicians to prevent complications due to patient movement. We investigated physicians’ approaches to anaesthesia during EVT for MeVO stroke.MethodsIn a worldwide, case-based, online survey, physicians’ preferred anaesthesia approach during EVT for MeVO stroke was categorized as “initial GA”, “initial GA if necessary” (depending on patient cooperation), “no initial GA, but conversion if necessary” (start with local anaesthesia or conscious sedation), and “no GA”. Preferred anaesthesia approaches were reported overall and stratified by physician and patient characteristics.ResultsA total of 366 survey participants provided 1464 responses to 4 primary MeVO EVT case-scenarios. One-third of responses (489/1464 [33%]) favoured no initial GA, but conversion if necessary. Both initial GA and initial GA if necessary were preferred in 368/1464 (25%) of responses respectively. No GA was favoured in 244/1464 (17%). Occlusion location, respondent specialization (interventional neuroradiology), higher age, and female respondent sex were significantly associated with GA preference. GA was more often used in Europe than in other parts of the world (p < 0.001).ConclusionsAnaesthesia approaches in MeVO EVT vary across world regions and patient and physician factors. Most physicians in this survey preferred to start with local anaesthesia or conscious sedation and convert to GA if necessary.     

Assessing the efficacy of endovascular therapy in stroke treatments: updates from the new generation of trials

Introduction: For the past 20 years, intravenous recombinant tissue plasminogen activator (rt-PA) has been the only proven treatment for acute ischemic stroke. Large arteries such as the internal carotid artery, the middle cerebral artery and the basilar artery supply blood to large volumes of brain tissue. When occluded, these vessels may have low response rates to rt-PA resulting in devastating injury and death.

Areas covered: In 2013, three trials evaluating the efficacy of mechanical thrombectomy in acute stroke were neutral, however, lessons learned from these trials resulted in a second generation of five trials in 2015 and a sixth in 2016 which all demonstrated significant benefit for select patients. Here we will review the evidence behind these new trials and. introduce new questions such as models of care, techniques of thrombectomy, the role of rt-PA, modes of anesthesia, the management of late presenting and wake up strokes among other real world challenges facing stroke medicine now that the thrombectomy is an evidence based treamtnent

Expert commentary: The mechanical thrombectomy is now the new standard of care and with that comes the need to find ways to provide it to all who will benefit.     

Organizing stroke systems in the field for patients with suspected large vessel occlusion acute stroke

Introduction: The dawn of endovascular stroke therapy has reshaped stroke care. Eligible patients need to be rushed to capable centers for intervention. This may entail bypassing closer hospitals that could confirm the diagnosis, administer thrombolytic therapy, then transfer patients for intervention. This has created a set of challenges: identifying endovascular candidates in the field, determining the best transport destination, and getting patients there quickly.

Areas covered: This review provides a context for these emerging challenges. Current and emerging clinical prediction instruments for large vessel occlusion (LVO) are reviewed. The workflow in the thrombolysis-only primary stroke centers is reviewed, and interventions aimed at minimizing delays are highlighted. Innovations using mathematical modeling and devices for detection of LVO are reviewed.

Expert commentary: More patients are expected to receive endovascular therapy as we push the boundaries for time and imaging criteria. Advances in detection and decision-making aids will improve the speed of treatment. Some patients will arrive at thrombolysis-only centers. This need to be triaged, diagnosed, treated, and transported promptly. Therefore, education of practitioners in these centers is paramount. Creating and facilitating infrastructure for imaging acquisition and sharing in such centers will reflect better care for stroke patients overall.     

不同年龄组急性缺血性脑卒中患者机械取栓治疗有效性和安全性的Meta分析

目的系统评价不同年龄组急性缺血性脑卒中患者机械取栓治疗的有效性和安全性。方法计算机检索PubMed、EMbase、The Cochrane Library、Web of Science、CNKI和WanFang Data数据库,搜集有关不同年龄组急性缺血性脑卒中患者机械取栓治疗的随机对照试验(RCT)和非随机对照试验(non-RCT),检索时限均为建库至2019年8月。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用Stata 12.0软件进行Meta分析。结果共纳入13个研究,包括2995例患者。Meta分析结果显示:80岁及以上患者的再灌注成功率[OR=0.90,95%CI(0.71,1.14),P=0.378]、颅内症状性颅内出血发生率[OR=1.30,95%CI(0.86,1.94),P=0.212]与其他年龄人群的差异均无统计学意义,但颅内任意出血事件发生率[OR=1.61,95%CI(1.28,2.04),P<0.001]、术后3个月死亡率[OR=2.14,95%CI(1.73,2.64),P<0.001]更高,术后3个月良好神经功能预后发生率[OR=0.46,95%CI(0.30,0.71),P<0.001]更低。结论当前证据显示,80岁及以上人群虽然经机械取栓治疗可获得有效灌注,但术后不良结局事件发生率更高,预后相对较差。受纳入研究数量和质量限制,上述结论尚待更多高质量研究予以验证。     

Thrombectomy for distal medium vessel occlusion with a new generation of Stentretriever (Tigertriever 13)

PurposeTo evaluate the safety and efficacy of the Tigertriever 13 (Rapid Medical, Yoqneam, Israel) stent retriever in acute ischemic stroke (AIS) patients with primary or secondary distal, medium vessel occlusions (DMVO).MethodsWe performed a retrospective analysis of all consecutive AIS patients who underwent thrombectomy with the Tigertriever13 for DMVO. Patients’ characteristics were reviewed, procedural complications, angiographic (modified thrombolysis in cerebral infarction score [mTICI]) and clinical (modified Rankin Scale [mRS]) outcomes were documented.ResultsBetween November 2019 and November 2020, 16 patients with 17 DMVO were included (40% female, median age 60 [50–65] years). The Tigertriever13 was used in 11/17 (65%, median NIHSS of 8 [6–15]) primary DMVO and in 6/17 (35%, median NIHSS of 20 [13–24]) cases of secondary DMVO after a proximal thrombectomy. The successful reperfusion rate (mTICI 2b, 2c, 3) was 94% (16/17) for the dedicated vessel. At day 1, CT imaging showed a subarachnoid hemorrhage in 29% of the cases and a parenchymal hematoma in 12%. At 3 months, 65% of the patients (11/17) had a favorable outcome (mRS 0–2).ConclusionMechanical thrombectomy using the Tigertriever13 appears to be safe and effective for DMVO. Clinical and anatomical results are in line with those of patients with proximal occlusions.     

不同方式治疗急性深静脉血栓形成的临床效果和安全性

目的评价单纯抗凝治疗与腔内治疗对急性髂-股静脉血栓形成（I-FVT）的临床效果和安全性。 方法收集2015年1月至2016年9月在新疆维吾尔自治区人民医院接受治疗的142例I-FVT患者,其中接受单纯抗凝治疗40例（抗凝组）,腔内治疗102例（导管溶栓、机械性血栓吸除及机械性血栓吸除联合导管溶栓;腔内组）。比较2组治愈率、有效率、血栓清除程度、不良事件发生情况等。 结果腔内组治愈率（膝上：58.8% vs 12.5%,膝下：53.9% vs 10.0%）、有效率（膝上：96.1% vs 65.0%,膝下：97.1% vs 75.0%）、血栓清除程度（出院时：χ²=75.754,P<0.001;随访3个月：χ²=26.366,P<0.001）均高于抗凝组,差异均具有统计学意义。随访3个月,腔内组7例出现穿刺点血肿,13例发生血尿,2例对侧肢体继发性血栓形成,1例发生对比剂相关性肾病;随访6、12、24个月,腔内组患肢DVT的复发率（7.8% vs 22.5%,12.7% vs 27.5%,18.4% vs 37.8%）、PTS发生率（15.7% vs 37.5%,20.6% vs 42.5%,25.5% vs 54.1%）、Villalta评分［（2.24±2.13）分vs （5.15±2.93）分,（3.32±2.88）分vs （6.90±4.07）分,（4.22±3.93）分vs （8.11±4.85）分］明显低于抗凝组,差异具有统计学意义（P<0.05）。 结论腔内治疗急性I-FVT的疗效明显优于单纯抗凝治疗,但腔内有创操作伴随较多不良事件发生。     

Endovascular and neurosurgical management of acute ischemic stroke

Acute ischemic stroke is recognized as the third leading cause of death in the United States; improved treatments for management are important to reduce disability and death. The standard of care of acute stroke therapy has been reperfusion/recanalization of the occluded vessels using pharmacologic management, endovascular management, or a combination approach. Significant improvements have been made in the management with the use of endovascular therapy. This article reviews the literature on the endovascular and neurosurgical management of patients presenting with acute ischemic stroke and presents current evidence-based guidelines for endovascular or neurosurgical interventions outlined for management of ischemic stroke.     

Clinical practice: intravenous thrombolysis in a patient with active cancer who experienced wake-up stroke

After reviewing the diagnosis and treatment process of a patient with active cancer who experienced wake-up stroke, we have summarized the clinical manifestations, laboratory examination results, imaging features, pathological results, and treatment in this report. Patients with active cancer who experience wake-up stroke often have mild neurological deficits at the time of onset. For the patient in this study, laboratory test results were mainly characterized by abnormal coagulation function and elevated tumor markers. The brain magnetic resonance imaging (MRI) images were characterized by involvement of both the arterial and venous systems. Thrombolytic therapy during the window period can improve the symptoms of neurological deficits. Overall, anticoagulation therapy was safe and effective in our patient.