颈内动脉颅外段伴同侧大脑中动脉急性串联闭塞的血管内治疗

Endovascular management of acute tandem occlusion of extracraniai internal carotid artery and middle cerebral artery

目的探讨颈内动脉颅外段伴同侧大脑中动脉急性串联闭塞的血管内治疗方法，评价其效果和安全性。方法回顾性分析2011年1月至2017年1月常州市第一人民医院神经外科收治的25例行血管内治疗的颈内动脉颅外段伴同侧大脑中动脉急性串联闭塞患者的临床资料。其中，颈内动脉颅外段夹层闭塞伴同侧大脑中动脉串联闭塞患者共10例，均以导引导管越过闭塞的夹层先行大脑中动脉支架取栓术（逆行治疗）。颈内动脉颅外段粥样斑块性闭塞伴同侧大脑中动脉串联闭塞患者共15例，首先使用球囊扩张和支架置人治疗近端闭塞，再行大脑中动脉支架取栓术（顺行治疗）。术中即刻血管再通情况根据脑梗死溶栓（TICI）分级判断。采用美国国立卫生研究院卒中量表评分（NIHSS）和改良Rankin量表评分（mRS）评估患者的预后。结果血管有效再通（TICI分级2b-3级）24例（96％）。所有病例随访3个月以上，均无卒中复发。术后90d预后良好（mRS≤2分）15例（60％）。结论血管内治疗颈内动脉颅外段伴同侧大脑中动脉急性串联闭塞安全、有效，对夹层所致的串联闭塞采取逆行治疗、对粥样斑块所致的串联闭塞采用顺行治疗为合理方案。

Objective To investigate the endovascular management strategy as well as its efficacy and safety for acute ischemic stroke caused by tandem occlusion of the extracranial internal carotid artery （ICA） and middle cerebral artery （MCA）. Methods From January 2011 to January 2017, 25 patients with acute tandem occlusion of the ICA/MCA were admitted to Department of Neurosurgery, the First Peopleg Hospital of Changzhou, the Third Affiliated Hospital of Soochow University and were treated by endovascular procedures. A retrograde approach （i. e. , treating intracranial lesion first） was applied in 10 patients with pathological type of ICA dissection （ICAD） whereas an antegrade approach （ i. e. , treating extracranial lesion first ） was used in 15 patients with pathological type of ICA atherosclerotic stenosis （ICAS）. The degree of recanalization immediately after the procedure was estimated by the thrombolysis in cerebral infarction （ TICI ） scale. The National Institutes of Health stroke scale （ NIHSS ） and modified Rankin Scale （mRS） were used to estimate the prognosis. Results Successful recanalization, defined as modified TICI score of 2b or 3, was achieved in 24 （ 96% ） patients. The follow-up period was over 3 months. None of the patients had recurrent stroke. Good functional outcome, defined as mRS score of 0 - 2 at 90 days, was reported in 15 （60%） patients. Conclusions Endovascular management seems to be effective and safe for acute tandem occlusion of ICA/MCA. The retrograde and antegrade approaches might be suitable for tandem occlusion with ICAD and ICAS, respectively.