急性缺血性卒中血运重建后无复流:神经介入医师的阿喀琉斯之踵?

No-reflow phenomenon after revascularization in acute ischemic stroke:Achilles’heel of the neurointerventionalist?

2015年,多项临床试验证明了血管内再灌注疗法(endovascular reperfusion therapies,EVT)对大血管闭塞的卒中患者的疗效,改变了世界范围内的卒中治疗指南和临床实践。然而,尽管实现了较高比例脑大血管再通,但是其中约有一半的患者在3个月时显示出较差的神经功能结局。高的脑大血管再通率与低的良好神经功能恢复率之间的差异成为了神经介入医师的痛。艾伯塔卒中研究早期CT评分(Alberta stroke program early CT score,ASPECTS)、直接到达、先前的溶栓、起病到再通时间<6 h、再通状况等固然是导致这种差异的原因,但是,我们可能忽视了血管再通不等于组织再灌注这一重要问题。大血管再通后,组织的仍然不良灌注现象被称为无复流现象(no reflow phenomenon,NRP)。冠脉NRP成为了急性冠脉闭塞经皮冠状动脉介入术(percutaneous coronary intervention,PCI)后临床预后的重要预测指标,在过去的近半个世纪,冠脉疾病研究领域就NRP的发病机制、诊断及处理做了大量的探索,切实改善了冠脉PCI的临床疗效。神经科医师在积极进行急性缺血性卒中血管内治疗的同时,是否应该积极关注脑的NRP呢?

In 2015,several clinical trials demonstrated the efficacy of endovascular reperfusion therapies(EVT)in stroke patients with large vessel occlusion,which had changed stroke treatment guidelines and clinical practice all over the world.However,despite substantial recanalization,about half of the patients obtain a poor functional outcome at 3 months after endovascular treatment.The difference between the high recanalization rate of cerebral vessels and the low recovery rate of good clinical function has become a pain for neurointerventionalists!Alberta stroke program early CT score(ASPECTS),direct arrival,previous thrombolysis,time from onset to recanalization<6 h,and recanalization status,etc.are certainly the reasons for this outcome.But we may have overlooked an important issue,that recanalization of blood vessels does not mean reperfusion of tissues.The phenomenon of poor tissue perfusion after recanalization is called no-reflow phenomenon(NRP).Coronary NRP has become an important predictor of clinical prognosis for acute coronary occlusion after percutaneous coronary intervention(PCI).In the past nearly half century,interventional cardiologists have done a lot of researches on the pathogenesis,diagnosis and treatment of NRP,which effectively improve the clinical efficacy of coronary PCI.When neurointerventionalists are actively carrying out endovascular treatment for acute ischemic stroke,should they actively pay more attention to NRP?