颅内前循环远端分支动脉闭塞机械取栓的疗效观察

The safety and efficacy of mechanical thrombectomy for anterior circulation small vessel occlusion

目的观察急性缺血性脑卒中患者颅内前循环远端分支血管闭塞支架机械取栓的安全性及有效性。方法回顾2017年1月至2018年11月于江苏省人民医院卒中中心接受血管内治疗的急性缺血性脑卒中患者,将具有颅内前循环远端分支动脉(A2、M2)闭塞病例纳入分析。根据患者是否静脉溶栓,分为桥接治疗组与直接取栓组。主要观察指标为机械取栓后90 d的良好预后率[改良Rankin量表(mRS)评分≤2分)]。次要观察指标为血管再通率(改良脑梗死溶栓分级2b或3)、症状性颅内出血和术后90 d病死率。结果在接受血管内治疗的311例病例中,19例患者被诊断为颅内前循环远端血管闭塞,其中大脑中动脉M2段闭塞14例、大脑前动脉A2段闭塞2例、大脑中动脉M2段+大脑前动脉A2段闭塞3例。桥接治疗组患者6例,直接取栓组13例。支架机械取栓术后闭塞血管整体再通率为18/19,症状性颅内出血发生率为1/19,90 d预后良好率为8/19,90 d病死率为5/19。两组患者血管成功再通率(桥接治疗组与直接取栓组分别为6/6、12/13)、症状性出血转化率(0/6、1/13)、术后90 d预后良好率(2/6、6/13)及病死率(1/6、4/13)差异均无统计学意义(均P>0.05)。结论颅内前循环远端分支血管闭塞4.5 h内的桥接治疗及24 h之内经影像学筛选后的机械取栓治疗可能都是安全有效的。

To evaluate the safety and efficacy of mechanical thrombectomy with stent-retriver for anterior circulation small vessel occlusion in patients with acute ischemic stroke (AIS).Methods From a prospectively collected thrombectomy database of consecutive patients with AIS between January 2017 and November 2018, 311 angiographic images were analyzed to assess small vessel occlusions (A2 and M2 segments). Patients were categorized into alteplase with thrombectomy group and thrombectomy alone group. The primary outcome was a favorable outcome (modified Rankin Scale scores 0-2) at 90 days. Secondary outcomes were successful recanalization (modified thrombolysis in cerebral infarction 2b or 3), symptomatic intracranial hemorrhage, and 90-day mortality.Results Small vessel occlusions were identified in 19 patients, including 14 M2 occlusions, two A2 occlusions, and three M2+A2 occlusions. Six patients were in the alteplase with thrombectomy group and 13 patients in the thrombectomy alone group. Favorable outcome was achieved in eight of 19 patients at 90 days. Successful recanalization was achieved in 18 patients (18/19), symptomatic intracranial hemorrhage was observed in one patient (1/19), and death was recorded in five patients (5/19). No statistically significant difference was detected between the two groups with regard to successful recanalization (6/6 in the alteplase with thrombectomy group vs 12/13 in the thrombectomy alone group), symptomatic intracranial hemorrhage (0/6 vs 1/13), favorable outcome (2/6 vs 6/13) and death (1/6 vs 4/13;all P>0.05).Conclusion As to anterior circulation small vessel occlusions, the combination-therapy within 4.5 hours or mechanical thrombectomy alone in extended time window with perfusion evaluation may be both safe and effective.