症状性非急性期大脑中动脉闭塞血管内再通治疗效果分析

Analysis of therapeutic effects on endovascular recanalization of symptomatic non-acute middle cerebral artery occlusion

目的探讨症状性非急性期大脑中动脉闭塞血管内再通治疗术前评估、手术安全性及临床效果。方法采用回顾性分析方法,选择2018年1月至2021年6月收治的26例症状性非急性大脑中动脉闭塞患者临床资料,评估其临床症状、脑灌注、闭塞部位、闭塞长度、侧支循环、远端毛细血管床等,17例符合血管内再通治疗。采用配对t检验对17例患者血管内再通手术前后脑血流量、脑血容量、平均通过时间、达峰时间及各项评分进行比较。结果17例给予血管内再通治疗,9例行颅内外动脉搭桥治疗。17例患者中,对侧肢体偏瘫7例,反复脑梗死6例,发作性对侧肢体麻木或无力4例,认知功能障碍3例,头痛3例。17例大脑中动脉闭塞侧脑灌注和健侧相比均明显降低。17例中1例微量导丝不能闭塞处,反复尝试后放弃手术;16例闭塞血管成功再通(脑梗死溶栓分级=2b-3),其中单纯球囊扩张9例,支架置入7例。17例患者术后3个月美国国立卫生研究院卒中量表(National Institute of Health stroke scale,NIHSS)评分由术前的(9.57±2.32)分降至(3.75±1.42)分,脑血流量、脑血容量、平均通过时间、达峰时间也较术前均明显改善(t值分别为9.08、5.54、4.26、8.56、6.00,均P<0.001),认知功能蒙特利尔国际认知评估量表(Montreal Gognitive Assessment,MoCA)评分术前(22.70±1.70)分,术后3个月(26.30±2.30)分有统计学意义(t=6.66,P<0.001)。术后CT脑血管动脉造影或全脑血管造影,16例再通患者1例闭塞,15例血管再通良好,围手术期没有颅内出血事件,6个月随访期内没有新发卒中事件。结论对于症状性非急性大脑中动脉闭塞患者,进行多维评估后选择可能获益的患者进行血管内再通治疗,并发症少,再通率高,近期随访临床效果较好,但长期疗效有待于进一步观察。

Objective To investigate the preoperative evaluation,safety and clinical efficacy of intravascular recanalization for patients with symptomatic non-acute middle cerebral artery occlusion.Methods Twenty-six patients with symptomatic non-acute middle cerebral artery occlusion admitted between January 2018 to June 2021 were retrospectively analyzed.The clinical symptoms,cerebral perfusion,occlusive site,occlusive length,collateral circulation and distal capillary were evaluated.There were 17 cases accorded with intravascular recanalization.The cerebral blood flow,cerebral blood volume,MTT,peak time and scores of 17 patients before and after revascularization were compared by paired t test.Results Endovascular recanalization was performed in 17 patients and extracranial-intracranial artery bypass grafting was performed in 9 patients.Among the 17 cases,there were 7 cases of hemiplegia of contralateral limbs,6 cases of recurrent cerebral infarction,4 cases of paroxysmal contralateral limb numbness or weakness,3 cases of cognitive dysfunction and 3 cases of headache.The cerebral perfusion of the occluded side of the middle cerebral artery in 17 cases was significantly lower than that of the healthy side.One patient failed to pass through the occlusion with micro guide wire,and gave up the operation after repeated attempts.The occluded vessels were successfully recanalized in 16 cases(thrombolytic grade of cerebral infarction=2b-3),and recanalized in 16 cases,including 9 cases of simple balloon dilatation and 7 cases of stent implantation.Three months after the operation,the National Institute of Health Stroke Scale(NIHSS)score of 17 patients decreased from(9.57±2.32)to(3.75±1.42).The cerebral blood flow,cerebral blood volume,mean transit time and peak time were also significantly improved compared with those before the operation(t value was 9.08,5.54,4.26,8.56,6.00,respectively,all P<0.001).The Montreal Cognitive Assessment(MoCA)score of cognitive function was(22.70±1.70)before the operation,and there months after operation(26.30±2.30)points(t=6.66,P<0.001)were statistically significant.After operation,CT cerebral angiography or whole cerebral angiography showed that 1 case was occluded,15 cases had good recanalization,no intracranial hemorrhage occurred during the perioperative period,and no new stroke occurred during the 6-month follow-up period.Conclusion For patients with symptomatic non acute middle cerebral artery occlusion,the patients who may benefit from multi-dimensional evaluation are selected for intravascular recanalization treatment.There are few complications and high recanalization rate.The short-term follow-up clinical effect is good,but the long-term effect needs to be further observed.