替罗非班在支架辅助栓塞颅内动脉瘤中的初步应用

Clinical observation of preliminary application of tirofiban in stent-assisted embolization of intracranial aneurysms

目的评价替罗非班在支架辅助栓塞治疗颅内动脉瘤时的效果和安全性。方法 2010年1月—2011年12月,采用支架辅助弹簧圈栓塞或单纯行载瘤动脉内支架置入治疗颅内宽颈动脉瘤42例(46个动脉瘤)。在成功置入支架后,应用替罗非班(8～10μg/kg,静脉推注,3～5 min,继而以0.1～0.15μg.kg-1.min-1持续泵入24 h,然后降为0.05～0.07μg.kg-1.min-1,持续泵入24～48 h)行抗血小板聚集治疗。术后次日逐渐过渡到常规剂量口服阿司匹林和氯吡格雷。对其临床资料进行回顾性分析。结果①46个动脉瘤中,破裂动脉瘤18个,未破裂动脉瘤28个;在支架辅助下用弹簧圈栓塞40个,单纯行载瘤动脉内支架置入6个。术中出现支架内血栓形成3例,均经导引导管动脉内注射替罗非班(150～250μg,3～5 min)后恢复再通;术中微导丝穿破动脉瘤1个,为次全栓塞动脉瘤,术后患者苏醒,但2h后突发脑疝死亡。②本组34例患者血小板计数在术前、术后3 d的平均值分别为(150±53)×109/L和(142±43)×109/L(t=1.738,P=0.092);部分活化凝血酶时间(APTT)在术前、术后3 d的平均值分别为(25±6)s和(26±4)s(t=-1.087,P=0.285),差异均无统计学意义。有41例患者在术后48～72 h成功过渡到口服抗血小板聚集药物。在应用替罗非班期间无出血并发症、出血倾向及脑血栓、短暂性脑缺血发作等。结论选择性使用替罗非班,对支架辅助栓塞颅内动脉瘤的患者,较为便捷、有效;但对动脉瘤出血急性期患者应用时需慎重,其安全性有待进一步观察。

Objective To evaluate the application efficacy and safety of tirofiban during the stent-assisted embolization of intracranial aneurysms.Methods Forty-two patients with 46 wide-necked intracranial aneurysms were treated by using stent-assisted coil embolization or stent deployment in the parent only artery from January 2010 to December 2011.After successful stenting,tirofiban was used（intravenous bolus injection 8-10 μg/kg for 3-5 min,then continuous pumping of 0.1-0.15 μg/kg/min for 24 hours,after that it was decreased to 0.05-0.07 μg/kg/min for 24-48 hours） for antiplatelet aggregation.Then gradually changed to conventional oral administration of aspirin and clopidogrel.The clinical and imaging data of these patients were analyzed retrospectively.Results ①Of the 46 aneurysms,18 were ruptured aneurysms and 28 were unruptured aneurysms;40 were treated with stent-assisted coil embolization and 6 with stent deployment in the parent artery only.The intraoperative in-stent thrombosis was observed in 3 patents,they were all recanalized after intra-arterial injection of tirofiban（150-250 μg,3-5 min） via guiding catheter;1 aneurysm was perforated by micro-guide wire during the procedure.The aneurysm was not fully embolized.The patient woke up after the procedure,but died of sudden herniation 2 hours later.②The mean values of the platelet count in 34 patients in this group at 3 days before and after procedure were 150±53×109/L and 142±43×109/L（t=1.738,P=0.092） respectively;the mean values of the activated partial thromboplastin time（APTT） at 3 days before and after procedure were 25±6 s and 26±4 s（t=-1.087,P=0.285） respectively.There was no significant difference.Within 48-72 hours after procedure,41 patients changed to oral administration of antiplatelet drugs.No bleeding complications or bleeding tendency as well as cerebral thrombosis and transient ischemic attack occurred during the administration of tirofiban.Conclusion The selective use of tirofiban in patients treated with stent-assisted embolization of intracranial aneurysms is more convenient and effective,but it need take care when it is used in acute stage of aneurysmal hemorrhage,its security need to be further studied.