临床症状与弥散加权成像不匹配的基底动脉急性闭塞患者的血管内再通治疗

Endovascular recanalization therapy of basilar artery occlusion based on clinical-diffusion mismatch

目的探讨临床症状与弥散加权成像不匹配(CDM),且起病时间≥24h的基底动脉急性闭塞(BAO)患者行血管内再通治疗(ERT)的可行性。方法共纳入11例起病时间≥24 h入院时格拉斯哥昏迷量表(GCS)评分<8分、弥散加权成像(DWI)未发现脑干网状结构和双侧丘脑有损害的患者。单独或联合使用重组组织型纤溶酶原激活剂(rt-PA)动脉内接触溶栓(IAT)、球囊血管成形术(PTA)和支架置入术。同时,根据急性心肌梗死溶栓治疗标准(TIMI)评价血管再通程度,观察并发症,3个月后采用改良Rankin量表(mRS)进行评估。结果①11例患者的平均起病时间和昏迷时间分别为42(25～73)h和11(2～24)h。入院时平均GCS评分为6(3～7)分,出院时为14(3～15)分。②9例成功行ERT(2例TIMI 2级,7例TIMI 3级),2例治疗失败(TIMI0级);无出血等并发症,患者在9～27 h内恢复意识。③3个月后随访,7例患者转归良好(mRS评分为0～2分),2例(mRS评分为3分)转归不良;ERT失败2例,分别于术后5 d和21d死亡。死亡患者均无侧支循环。结论对CDM、≥24 h时间窗的基底动脉急性闭塞患者,行ERT治疗可能获得较高的血管再通率和相对良好的临床转归,存在侧支循环的患者转归较好。

Objective To investigate the feasibility of performing endovascular recanalization therapy （ERT） in patients with acute basilar artery occlusion （BAO） of broadened time window （ ≥24 hours） based on clinical-diffusion mismatch （CDM）. Methods A total of 11 CDM patients whose Glasgow Co- ma Scale （GCS） score 〈 8 at admission were recruited and the diffusion-weighted imaging （DWI） did not find their brainstem reticular formation and bilateral damage to hypothalamus. Intra-arterial thrombolysis （IAT） with rt-PA alone or in combination with IAT, percutaneous transluminal angioplasty （PTA） and stenting were used. At the same time, the degree of recanalization was evaluated according to the thrombolysis in myocardial infarction （TIMI） criteria and the complications were observed. The modified Rankin scale （mRS） was used to assess after 3 months. Results ①The mean onset time and duration of coma of the 11 patients were 42 hours （range 25 to 75 hours） and 11 hours （range 2 to 24 hours）, respectively. The mean GCS score at admission was 6 （range 3 to 7） and that was 14 （range 3 to 15） at discharge. ②Nine patients performed ERT successfully （n = 2, TIMI grade 2, n = 7, TIMI grade 3） and 2 failed （TIMI 0）. There were no complications such as bleeding. The patients regained consciousness within 9 to 27 hours. ③The patients were followed up after 3 months, 7 had good outcome （mRS, 0 to 2） and 2 had poor outcome （ mRS, 3）. ERT failed in 2 patients and they died at day 5 and day 21 after the procedures. Conclusion The patients with broadened time window on CDM who performed ERT may have a higher recanalization rate and relatively good clinical outcome. The patients with collateral circulation has good outcome.