椎动脉颅内段急性闭塞临床影像特征及血管内治疗效果观察

Acute intracranial vertebral artery occlusion: clinical and imaging features, and observation on the effect of endovascular treatment

目的 探讨椎动脉颅内段急性闭塞(AIVAO)患者的临床影像特征、血管内治疗(EVT)的有效性和安全性。方法 前瞻性收集并分析2017年2月至2022年3月河南省人民医院国家高级卒中中心脑血管病科连续收治的发病24 h内接受急诊EVT的AIVAO患者的临床、影像、EVT及随访资料,包括起病形式(进展型、急进型、缓解-加重型)、术前美国国立卫生研究院卒中量表(NIHSS)评分、基底动脉CT血管成像评分、基于扩散加权成像的后循环Albert卒中项目早期CT评分、桥脑中脑指数、急性梗死部位、责任血管与对侧椎动脉优势情况比较、病因分型(颅内动脉粥样硬化性疾病、心源性栓塞、夹层)、术中采用的开通技术(支架取栓、导管抽吸取栓、支架置入、球囊扩张)、首发开通技术、补救措施[球囊扩张和(或)支架置入]、血管再通分级(以改良脑梗死溶栓分级评估,2b~3级为成功再灌注)、发病至血管首次再通时间、穿刺至血管首次再通时间,以及围手术期并发症如术中栓子逃逸、术中夹层、术后7 d内症状性颅内出血,术后90 d改良Rankin量表评分(评分≤3分为预后良好)等,并根据术后90 d随访结果,将所有入选患者分为预后良好组与预后不良组,分析两组间患者临床、影像、EVT及随访资料的差异。结果 共纳入42例患者,其中90.5%(38/42)为男性;起病形式以进展型居多(57.1%,24/42);梗死部位集中在小脑半球(81.0%,34/42);95.2%(40/42)患者病因为颅内动脉粥样硬化性疾病,4.8%(2/42)病因为夹层;73.8%(31/42)的AIVAO发生在优势椎动脉侧;首发开通技术以支架取栓居多(50.0%,21/42),85.7%(36/42)采用多模式开通技术;直接血管成形率为38.1%(16/42),补救血管成形率为59.5%(25/42);95.2%(40/42)实现了成功再灌注;围手术期并发症发生率为35.7%(15/42),以术中栓子逃逸发生率(26.2%,11/42)最高,6例(14.3%)术后7 d内发生症状性颅内出血;术后90 d良好预后率为45.2%(19/42),术后90 d病死率为21.4%(9/42)。与预后良好组比较,预后不良组基线NIHSS评分更高[中位数评分:23.0(15.0,30.0)分比16.0(11.0,23.0)分,P=0.032]、后交通动脉开放患者比例更低(8/23比14/19,P=0.012)。结论 AIVAO患者颅内动脉粥样硬化性疾病病因占比较高,进展型卒中发生率高,责任血管多为优势椎动脉,多需行多模式再通技术,成功再灌注率高,栓子逃逸并发症发生率高,高基线NIHSS评分、低后交通动脉开放率可能与不良预后相关。

Objective To investigate the clinical and imaging features, efficacy and safety of endovascular treatment(EVT) in patients with acute intracranial vertebral artery occlusion(AIVAO). Methods From February 2017 to March 2022, the clinical, imaging, EVT and follow-up data of AIVAO patients enrolled in Department of Cerebrovascular Diseases, National Advanece Stroke Center, Henan Provincial People′s Hospital, who received emergency EVT within 24 hours from onset were continuously collected and analyzed prospectively. The data we collected mainly included the mode of stroke onset(progressive, acute, relieved-aggravative), preoperative National Institutes of Health Stroke scale(NIHSS), the basilar artery on computed tomography angiography score, the posterior circulation Albert stroke program early computed tomography score based on diffusion-weighted imaging, pons midbrain index, acute infarction site, comparison of the dominant vessel in the responsible vessel and the contralateral vertebral artery, etiological classification(intracranial atherosclerotic disease, cardiogenic embolism, dissection), recanalization technique(stent thrombectomy, aspiration, stenting, balloon angioplasty), the first-line EVT technology, rescue therapy(balloon angioplasty and [or] stenting), classification of vascular reperfusion(evaluated by modified thrombolysis in cerebral infarction score, grade 2b-3 as successful reperfusion), onset to first recanalization time, puncture to first recanalization time, and perioperative complications such as intraoperative thrombus migration, intraoperative dissection, and symptomatic intracranial hemorrhage within 7 days after operation, modified Rankin scale score(≤3 as good outcome) at 90-day after operation. According to the 90-day follow-up results, all enrolled patients were divided into the good outcome group and the poor outcome group. The differences in clinical, imaging, EVT and follow-up data between the two groups were analyzed. Results Forty-two eligible patients were included, with 90.5%(38/42) were males. The most common mode of stroke onset was progressive type(57.1%,24/42). The acute infarction was concentrated in the cerebellar hemisphere(81.0%, 34/42). Intracranial atherosclerotic disease was the etiology of 40 patients(95.2%, 40/42), and dissection was the etiology of 2 patients(4.8%,2/42). 73.8%(31/42) of AIVAO occurred in the dominant vertebral artery. Most of the first-line EVT technologies are stent thrombectomy(50.0%, 21/42), and 85.7%(36/42) underwent multimodal recanalization technique. The direct angioplasty rate was 38.1%(16/42), and the rescue angioplasty rate was 59.5%(25/42). 95.2%(40/42) achieved successful reperfusion. The perioperative complication rate was 35.7%(15/42), among which the incidence of intraoperative thrombus migration was the highest(26.2%, 11/42). Symptomatic intracranial hemorrhage within 7 days after operation occurred in 6 patients(14.3%). The 90-day good outcome rate was 45.2%(19/42), and the 90-day mortality rate was 21.4%(9/42). Compared with the good outcome group, the poor outcome group had a higher baseline NIHSS score(median: 23.0[15.0, 30.0] vs. 16.0[11.0, 23.0], P=0.032) and lower posterior communicating artery patency ratio(8/23 vs.14/19,P=0.012). Conclusions The rate of intracranial atherosclerotic disease in AIVAO patients is very high. AIVAO patients have a high incidence of progressive stroke. Most of the responsible vessels are the dominant intracranial vertebral arteries, and multimodal recanalization techniques are often used. The reperfusion success rate and the thrombus migration rate is high. A high baseline NIHSS score and a low posterior communicating artery patency ratio may be associated with the poor outcome.