不同发病时间窗的急性基底动脉闭塞患者行血管内治疗的预后分析

Analysis of endovascular therapy on prognosis of patients with acute basilar artery occlusion at different onset time windows

目的探讨地区级医院对不同发病时间窗急性基底动脉闭塞(ABAO)患者行血管内治疗的临床疗效、安全性以及可能影响其预后的相关因素.方法回顾分析台州市中心医院2017年5月至2020年10月采用Solitaire或Trevo支架取栓治疗的17例ABAO患者的临床疗效.所有患者均采用取栓支架结合手动抽吸的方式行机械取栓,部分患者予以球囊扩张等补救措施.以术前和术后7 d美国国立卫生研究院卒中量表(NIHSS)评分、术中改良脑梗死溶栓分级(mTICI)、术后90 d改良Rankin量表(mRS)评分评估治疗的有效性;以症状性颅内出血率、术后90 d病死率、围手术期并发症评估安全性.结果17例ABAO患者中,13例成功再通(mTICI 2b~3级),再通率为76.5%,总体术后7 d NIHSS评分中位数较术前有所下降.有6例发病至股动脉穿刺时间(OPT)>6 h,OPT>6 h和≤6 h患者的预后良好率分别为33.3%(2/6)、54.5%(6/11),病死率分别为33.3%(2/6)、27.3%(3/11),差异均无统计学意义;未成功再通的4例患者术后3个月均死亡.全部17例患者均未发生症状性颅内出血,围手术期并发症发生率为11.8%(2/17).术后90 d mRS评分>3分的患者术前NIHSS评分、术前格拉斯哥昏迷评分(GCS)以及大动脉粥样硬化(LAA)和心源性栓塞(CE)患者比例与mRS评分≤3分患者比较差异均有统计学意义〔术前NIHSS评分(分):27(23,31)比17(13,22),术前GCS评分(分):5(4,8)比11(9,12),LAA:66.7%(6/9)比0%(0/8),CE:33.3%(3/9)比100.0%(8/8),均P<0.05〕.结论在地区级医院对符合手术适应证的ABAO患者开展血管内治疗安全有效,且OPT>6 h(但<24 h)的基底动脉闭塞患者仍能在血管内治疗中获益,若不能成功再通则病死率极高.术前NIHSS评分高、GCS评分低及大动脉粥样硬化狭窄引起闭塞的患者预后较差.

Objective To explore the clinical efficacy and safety of endovascular treatment for patients with acute basilar artery occlusion(ABAO)with different onset time windows in regional hospitals and the related factors that may affect their prognosis.Methods A retrospective analysis of the clinical efficacy of 17 patients with ABAO treated with Solitaire or Trevo stents for embolectomy in Taizhou Central Hospital from May 2017 to October 2020 was carried out.All patients underwent stent embolectomy combined with manual aspiration for mechanical embolization,and some patients were given remedial measures such as balloon expansion.The effectiveness of treatment was evaluated by American National Institute of Health Stroke Scale(NIHSS)score before and 7 days after surgery,intra-operative modified thrombolysis in cerebral infarction(mTICI),and modified Rankin scale(mRS)score 90 days after surgery.The symptomatic intracranial hemorrhage rate,postoperative 90-day mortality and peri-operative complications were used to assess the safety of the operation.Results Of the 17 patients,13 cases were successfully re-canalized(mTICI 2b-3),with the recanalization rate being 76.5%,and the overall median NIHSS score 7 days after operation was lower than that before operation.Six out of 17 cases had the time from onset to puncture time(OPT)more than 6 hours,the good prognosis rate in patients with OPT more than 6 hours compared with those less than 6 hours was 33.3%(2/6)vs.54.5%(6/11),and the mortality rates were 33.3%(2/6)and 27.3%(3/11),the differences were not statistically significant;four patients whose operation was failed without recanalization died 3 months after operation.No symptomatic intracranial hemorrhage occurred in all 17 patients.The incidence of perioperative complications was 11.8%(2/17).There were statistical significant differences in preoperative NIHSS score,Glasgow coma scale(GCS)score and the proportion of Large atherosclerosis(LAA)and cardiogenic embolism(CE)between the patients with mRS score>3 and patients with mRS score≤390 days after operation[preoperative NIHSS score:27(23,31)vs.17(13,22),preoperative GCS score:5(4,8)vs.11(9,12),LAA:66.7%(6/9)vs.0%(0/8),CE:33.3%(3/9)vs.100.0%(8/8),all P<0.05].Conclusions It is safe and effective to carry out endovascular treatment in regional hospitals for ABAO patients who meet the surgical indications,and the patients with basilar artery occlusion with OPT more than 6 hours(but less than 24 hours)can still obtain benefit from endovascular treatment.If the patients'artery with thrombosis cannot be successfully re-canalized after operation,the mortality rate is extremely high.In an ABAO patient with preoperative high NIHSS score,low GCS score and occlusion caused by large atherosclerotic stenosis,his or her prognosis is relatively poor.