颅内动脉瘤介入治疗相关症状性缺血并发症分析

Intervention-related symptomatic ischemic complications due to endovascular treatment for intracranial aneurysms

目的探讨颅内动脉瘤介入治疗相关症状性缺血并发症原因和处理措施。方法回顾性分析2011年1月至2019年4月上海华山医院连续介入治疗的942例患者(1 055枚动脉瘤)中确诊的37例(3.9%,37/942)症状性缺血并发症的原因和处理措施。结果 37例患者中术中症状性缺血并发症25例(2.6%,25/942),包括载瘤动脉内血栓形成16例(瘤颈部反复操作10例、过度栓塞4例、支架贴壁欠佳2例),瘤颈部分支闭塞3例(弹簧圈表面血栓形成或瘤颈部反复操作),远端分支栓塞或血栓形成6例(导引导管内附壁血栓脱落5例、分支血管痉挛1例);术后症状性缺血并发症12例(1.3%,12/942),包括载瘤动脉内血栓形成7例(替罗非班应用不足3例、支架贴壁欠佳1例、支架串联重叠部位血栓形成1例、弹簧圈致栓1例、重度贫血1例),瘤颈部分支闭塞1例(弹簧圈表面血栓形成),远端分支栓塞或血栓形成4例(均为球囊闭塞试验假阴性)。37例患者均经及时抗凝、抗血小板、抗血管痉挛或术中机械碎栓等介入治疗,术后6个月改良Rankin量表(mRS)评分仅2例≥2分,其余患者预后良好(mRS评分均<2分)。结论颅内动脉瘤介入治疗相关症状性缺血并发症病因复杂,通过及时识别并联合应用抗凝、抗血小板、抗血管痉挛和机械碎栓等介入治疗,多数患者可获得良好预后。

Objective To discuss the causes and managements of intervention-related symptomatic ischemic complications due to endovascular treatment for intracranial aneurysms. Methods Between January 2011 and April 2019, a total of 942 consecutive patients with intracranial aneurysm(1 055 aneurysms in total)received interventional treatment at Shanghai Huashan Hospital of China. Among the 942 patients,37(3.9%,37/942) developed symptomatic ischemic complications, their causes were analyzed and the managements were discussed. Results Of the 37 patients, intraoperative symptomatic ischemic complication occurred in 25(2.6%,25/942), including thrombosis in the parent artery(n=16), which was caused by repeated manipulation over aneurysm neck(n=10), excessive embolization(n=4) and poor adhesion of stent on the vascular wall(n=2);occlusion of aneurysm neck branch(n=3), which was caused by thrombosis on coil surface or repeated manipulation over aneurysm neck;and distal branch embolism or thrombosis(n=6), which was caused by thrombus escaping from guiding-catheter(n=5) or branch vasospasm(n=1). Postoperative symptomatic ischemic comp-lications occurred in 12 patients(1.3%, 12/942), including thrombosis in the parent artery(n=7), which was caused by insufficient use of tirofiban(n=3), poor adhesion of stent on the vascular wall(n=1), thrombosis at the stent-overlapped site(n=1), coil-induced occlusion(n=1), and severe anemia(n=1);occlusion of aneurysm neck branch(n=1), which was caused by thrombosis on coil surface;and distal branch embolism or thrombosis(n=4),which was due to false negative of balloon occlusion testing. All 37 patients were promptly treated with anticoagulation,antiplatelet, anti-vasospasm, intraoperative mechanical thrombectomy and other interventional treatments. Six months after treatment, modified Rankin scale(mRS) scoring showed that mRS score ≥2 points was seen in only 2 patients, all the remaining patients had a favorable prognosis(mRS score<2 points).Conclusion The causes of intervention-related symptomatic ischemic complications due to endovascular treatment for intracranial aneurysms are complex. Timely identification of this complication and combination use of anticoagulation, antiplatelet, anti-vasospasm, intraoperative mechanical thrombectomy and other interventional treatments can achieve excellent prognosis in most patients.