自发性颈动脉夹层的药物及血管内治疗疗效分析

Efficacy analysis of medical and endovascular treatment for spontaneous carotid artery dissection

目的 探讨自发性颈动脉夹层（CAD）的药物及血管内治疗的疗效.方法 回顾性汇总山东大学附属省立医院、福建省立医院、解放军第三○六医院及首都医科大学宣武医院于2010年6月-2013年6月诊治的CAD患者的临床资料,共32例.其中29例采用抗凝治疗（低分子肝素5000 U 皮下注射,1次/12 h,治疗5～7 d,后改为口服华法林,出院后继续服用3个月）.3例给予抗血小板聚集治疗[1例给予阿司匹林,100 mg/d,治疗3个月;1例给予氯吡格雷,75 mg/d,治疗3个月;1例给予阿司匹林（100 mg/d）6个月,仍有卒中发作,再联合氯吡格雷（75 mg/d）治疗3个月].7例给予支架置入术.随访观察6个月.结果 （1）29例行抗凝治疗的患者中,20例有效,9例无效.无效者中6例行血管内支架置入术（共治疗了6支血管、置入12枚支架）,手术均成功,术后CAD病变完全消失.3例行抗血小板聚集治疗的患者中,2例有效（其中1例为夹层动脉瘤,置入1枚覆膜支架,动脉瘤消失）,1例无效.（2）32例入院时美国国立卫生研究院卒中量表评分（NIHSS）0分的有7例（21.9%,均为TIA患者）,1～3分的有15例（46.9%）,≥4分的有10例（31.2%）.出院时0分的有12例（37.5%）,与入院时比较,评分无变化的有13例（40.6%）;7例评分呈不同程度下降.32例无一例发生颅内及外周出血.（3）6个月时行CTA或DSA检查,4例病变的颈动脉闭塞;27例CAD消失,管腔通畅;1例夹层动脉瘤患者动脉瘤完全消失.结论抗凝治疗是CAD的首选治疗措施,抗凝治疗无效者行血管内支架置入术是安全有效的.

Objective To investigate the efficacy of medical and endovascular treatment for spontaneous carotid artery dissection （CAD）. Methods The clinical data of 32 patients with CAD diagnosed by Shandong Provincial Hospital ,Fujian Provincial Hospital,306th Hospital of PLA,and Xuanwu Hospital,Capital Medical University from June 2010 to June 2013 were collected retrospectively.Twenty-nine of them were treated with anticoagulants （subcutaneous injection of low molecular weight heparin 5000 IU,1/12 h for 5 to 7 days,later changed to oral warfarin for 3 months）.Three patients were treated with antiplatelet agents （1 took Bayer aspirin,100 mg/d for 3 months;1 took clopidogrel,75 mg/d for 3 months;and 1 took Bayer aspirin 100 mg/d for 6 months,but he still had stroke,and then he was treated with clopidogrel 75 mg/d for 3 months）.Seven patients were treated with stenting.They were followed up for 6 months. Results （1）In 29 patients treated with anticoagulants,20 were effective and 9 were ineffective.Of the 9 nonresponders,6 were treated with endovascular stenting （a total of six vessels were treated and a total of 12 stents were implanted）.All the procedures were successful.The carotid artery stenoses at the sites of CAD lesion were disappeared completely after procedures.In 3 patients treated with anti-platelet aggregation agents,2 were effective （One of them was dissecting aneurysm.The aneurysm disappeared after one covered stent was implanted）,and 1 was ineffective.（2）The National Institutes of Health Stroke Scale （NIHSS） score was 0 in 7 of 32 patients at admission （21.9%,all of them were TIA patients）.The scores of 15 patients （46.9%） were 1 - 3 and 10 patients （31.2%） were ≥4.The score of 12 patients （37.5%） was 0 at discharge.Compared with admission,the scores of 13 patients （40.6%） did not have any change.The scores of 7 patients were decreased to varying degrees.None of the 32 patients had intracranial hemorrhage and peripheral hemorrhage.（3）The patients were reexamined with CTA or DSA at 6 month,4 patents had carotid artery occlusion.The CAD of 27 patients disappeared completely and the arteries were patent.The aneurysm disappeared completely in one patient with dissecting aneurysm. Conclusion Anticoagulant therapy is the preferred treatment for CAD.Endovascular stenting is safe and effective in patients whose anticoagulation therapy is ineffective.