双路图技术在症状性颅内动脉慢性闭塞血管再通术中的应用

Double roadmap technique application in endovascular recanalization of symptomatic chronic total occlusion of intracranial cerebral artery

目的探讨双路图技术在症状性颅内动脉慢性闭塞血管再通术中的应用效果。方法回顾性连续纳入2015年10月至2023年5月常州市第一人民医院神经外科收治的采用双路图技术行症状性颅内动脉慢性闭塞血管再通术患者9例。收集患者的人口学资料及临床资料。人口学资料包括性别、年龄;临床资料包括既往史(包括高血压病、糖尿病、高脂血症、吸烟史)、末次脑梗死发作至手术时间、术前美国国立卫生研究院卒中量表(NIHSS)评分、闭塞部位、闭塞远端血管代偿方式、双路图方式、手术方式、术后即刻血管再通情况[采用改良脑梗死溶栓(mTICI)分级评估血流再通情况,<2b级为血管再通不良,2b~3级为血管成功再通)、围手术期并发症(包括术中血管穿孔、远端栓塞、术后1周内新发脑梗死)、出院时NIHSS评分等。术后24 h复查头部CT确认颅内有无出血及脑梗死,术后1周内复查MRI或扩散加权成像或MR血管成像或CT血管成像(CTA)评估有无新发脑梗死及血管再闭塞。术后90 d门诊随访,采用改良Rankin量表(mRS)评分评估患者神经功能恢复情况(mRS评分0~2分为临床预后良好,>2分为临床预后不良,其中6分为死亡)。术后3~12个月门诊随访,记录mRS评分,并行CTA检查评估血管通畅情况。结果9例采用双路图技术行症状性颅内动脉慢性闭塞血管再通术患者均存在与闭塞血管相关的脑梗死,其中椎动脉V4段闭塞3例,基底动脉下段闭塞1例,颈内动脉颅内段闭塞5例。术前NIHSS评分1~10分,中位评分3(2,7)分,末次脑梗死发作至手术时间为15~60 d,平均(25±14)d。9例患者的闭塞血管远端血管床均可通过Willis环由对侧或前后循环显示,其中4例采用双侧颈内动脉双路图技术,3例采取双侧椎动脉双路图技术,2例采用前后循环双路图技术;8例术后即刻脑血管造影示闭塞段血管成功再通(mTICI分级3级),1例术中通过双路图技术发现微导丝穿越时明显偏离血管走向,DSA证实为血管穿孔,终止手术,但未造成严重并发症。9例患者出院时NIHSS评分1~6分,中位评分2(2,3)分,术后随访6~12月无缺血症状复发,术后90 d随访,mRS评分≤2分8例,3分1例。8例血管成功再通的患者术后3~6个月均完成CTA随访,均显示血流通畅。结论在Willis环代偿显示闭塞段远端血管床的症状性颅内动脉慢性闭塞血管再通术中应用双路图技术可行,但仍需大样本数据及长期随访研究进一步证实其安全性和有效性。

Objective To investigate the effect of double roadmap technique in recanalization of symptomatic intracranial artery chronic occlusion.Methods Nine consecutive patients with symptomatic chronic intracranial artery occlusion who underwent recanalization using double roadmap technique at Department of Neurosurgery,the First People′s Hospital of Changzhou from October 2015 to May 2023 were retrospectively enrolled into this study.The demographic and clinical data of the patients were collected.Demographic data included gender and age.The clinical data included past history(including hypertension,diabetes,hyperlipidemia,smoking history),time from the last stroke attack to operation,preoperative National Institutes of Health stroke scale(NIHSS)score,occlusion site,compensation method of distal vessel occlusion,double roadmap method,operation method,immediate vascular recanalization after operation using modified thrombolysis in cerebral infarction(mTICI)grading was used to evaluate blood flow recanalization,with grade<2b as poor recanalization and grade 2b-3 as successful recanalization,perioperative complications(including intraoperative vascular perforation,distal embolism,and new cerebral infarction within 1 week after operation),and NIHSS score at discharge.Head CT was reexamined 24 hours after operation to confirm whether there was intracranial hemorrhage and new cerebral infarction,and MRI or diffusion weighted imaging or MR angiography or CT angiography(CTA)was reexamined within 1 week after operation to assess whether there was new cerebral infarction and vascular reocclusion.The modified Rankin scale(mRS)score was used to evaluate the recovery of neurological function(mRS score 0-2 was defined as good clinical outcome,>2 was defined as poor clinical outcome,of which 6 was defined as death).All patients were followed up for 3-12 months.The mRS score was recorded,and CTA was performed to evaluate the vascular patency.Results All the 9 patients who underwent recanalization of symptomatic chronic occlusion of intracranial artery by double roadmap technique had cerebral infarction related to the occluded vessels,including 3 cases of occlusion of the V4 segment of vertebral artery,1 case of occlusion of the lower segment of basilar artery,and 5 cases of occlusion of the intracranial segment of internal carotid artery.The preoperative NIHSS score was 1-10,with a median of 3(2,7).The time from the last cerebral infarction to operation was 15-60 days,with an average of(25±14)days.The distal vascular bed of the occluded vessels in 9 patients could be visualized by contralateral or anterior and posterior circulation through the circle of Willis,including 4 cases with bilateral internal carotid artery double roadmap technique,3 cases with bilateral vertebral artery double roadmap technique,and 2 cases with anterior and posterior circulation double roadmap technique.Immediate postoperative cerebral angiography showed successful recanalization of the occluded vessel(mTICI grade 3)in 8 cases,and 1 case was found to deviate significantly from the direction of the vessel when the micro-guide wire was crossed by the double roadmap technique during the operation,which was confirmed by DSA as vascular perforation and the operation was terminated,but no serious complications were caused.All 9 patients had NIHSS scores of 1 to 6 at discharge,The median NIHSS score was 2(2,3).The mRS score was≤2 in 8 cases and 3 in 1 case at 90 days after operation.There was no recurrence of ischemic symptoms during the follow-up of 6 to 12 months after operation.Eight patients with successful recanalization completed CTA follow-up 3 to 6 months after the operation,and the blood flow was unobstructed.Conclusions It is feasible to use double roadmap technique in recanalization of symptomatic intracranial chronic occlusion with compensated distal vascular bed of the circle of Willis.Large sample data and long-term follow-up studies are needed to confirm its safety and efficacy.