急性前循环颅内外串联闭塞血管内治疗预后相关因素分析

Analysis of prognostic factors associated with endovascular treatment for acute anterior circulation intracranial and extracranial occlusion

目的 探讨急性前循环颅内外串联闭塞(TO)血管内治疗方法,分析其预后相关因素。方法 回顾性收集2016年1月~2019年4月我院神经外科收治的急性颈内动脉颅内外段闭塞伴同侧大脑中动脉闭塞患者的临床资料,将患者分为预后良好组(90 d mRS评分0~2分)和预后不良组(90 d mRS评分3~6分)。比较两组发病年龄、手术前后NIHSS评分、ASPECT评分、侧支循环、闭塞类型、开通顺序、术中替罗非班使用、有效再通率、术后出血转化率、术后7 d NIHSS评分、术后90 d mRS评分等临床指标,并对结果进行统计学分析。结果 共确认21例[(10.6%(21/198)]急性前循环颅内外串联闭塞患者,其中预后良好组8例(38.1%),预后不良组13例(61.9%)。两组高血压、高脂血症、吸烟和肺部慢性疾病、入院NIHSS评分、术前ASCEPT评分、病因TOAST分型等术前评估指标比较,无统计学差异(P<0.05);与预后不良组相比,预后良好组年龄更低(P=0.009)。两组术后7 d NIHSS评分比较,差异有统计学意义(t=-2.536,P=0.020),术中替罗非班的使用、症状性颅内出血无明显差异(P>0.05)。21例患者有效再通率为(TICI 2b-3)71.5%,死亡率28.6%,仅38.1%的患者预后良好。两组再灌注TICI分级无统计学差异(P=0.336),较低的发病年龄(P=0.009)、良好侧支循环(P=0.037)、术后7 d NIHSS评分(P=0.020)及桥接静脉溶栓(P=0.011)与预后相关。多因素Logistic回归分析显示,侧支循环为预后预测因子(B=3.651,OR=38.5,95%CI为2.951~508.463,P=0.006)。结论 前循环急性颅内外串联闭塞患者进行血管内治疗有一定效果,但总体良好预后率偏低,良好侧支循环为预后较强预测因子。本研究的局限性主要为非随机单中心回顾性研究,TO患者最佳治疗策略需要更多的随机对照进一步研究探索。

Objective To investigate the endovascular treatment of acute anterior circulation intracranial and extracranial occlusion,and to analyze the prognostic factors.Methods The clinical data of patients with acute internal carotid intracranial and extracranial occlusion combined with ipsilateral middle cerebral artery occlusion from January 2016 to April 2019 were retrospectively collected.The patients were divided into two groups,good prognosis group(90 d mRS score 0-2 points)and poor prognosis group(90 d mRS score 3-6 points).The age of onset,preoperative and postoperative NIHSS score,ASPECT score,collateralcirculation,occlusion type,opening sequence,intraoperative tirofiban use,effective recanalization rate,postoperative bleeding conversion rate,postoperative 7-day NIHSS score and mRS scores at 90 days after surgery were compared.And the results were statistically analyzed.Results A total of 21 patients[(10.6%(21/198)]with acute anterior circulation intracranial and extracranial occlusion were identified,8 cases(38.1%)with good prognosis and 13 cases(61.9%)with poor prognosis.There were no significant differences between the two groups in preoperative evaluation indexes such as hypertension,hyperlipidemia,smoking and chronic lung disease,admission NIHSS score,preoperative ASCEPT score,and TOAST classification of cause(P<0.05).Patients with good prognosis were younger(P=0.009).There was a statistically significant difference in the NIHSS score between the two groups at 7 days after operation(t=-2.536,P=0.020).There was no significant correlation between intraoperative tirofiban and symptomatic intracranial hemorrhage(P>0.05).In 21 patients,the effective recanalization rate(TICI 2b-3)was 71.5%,and the mortality rate was 28.6%,and only 38.1%of patients had a good prognosis.There was no statistical difference in the reperfusion TICI grading between the two groups(P=0.336).Lower onset age(P=0.009),good collateral circulation(P=0.037),postoperative 7-day NIHSS score(P=0.020),and bridged intravenous thrombolysis(P=0.011)were associated with prognosis.Multivariate logistic regression analysis showed that collateral circulation was a prognostic predictor(B=3.651,OR=38.5,95%CI 2.951-508.463,P=0.006).Conclusion Endovascular treatment for patients with acute anterior circulation intracranial and extracranial occlusion is effective,but the overall good prognosis rate is lower.Good collateral circulation is a strong predictor of prognosis.The limitations of our study are mainly non-randomized,single-center retrospective studies,and the best treatment strategy for TO patients requires to explore more randomized controlled trials.