阶梯式血管内治疗策略应用于急性前循环颅内动脉粥样硬化性和心源性栓塞性大血管闭塞的比较研究

A comparative study of step-by-step endovascular treatment strategy in acute anterior circulation intracranial atherosclerosis and cardiogenic embolic large vessel occlusion

目的比较阶梯式血管内治疗策略应用于急性前循环颅内动脉粥样硬化性(Intracranial atherosclerosis,ICAS)和心源性栓塞性大血管闭塞的安全性和有效性。方法选取2021年4月-2023年2月在阜阳市人民医院接受阶梯式血管内治疗的急性前循环颅内大血管闭塞性缺血性脑卒中患者;依据病因分为ICAS组和栓塞组,比较2组患者的基线资料、手术相关资料和发病90 d后预后良好[改良Rankin量表(Modified Rankin scale,mRS)0~2分]率。结果本研究共筛选150例接受机械取栓治疗的急性前循环大血管闭塞患者,最终入组69例,其中ICAS组28例,栓塞组41例;与栓塞组比较,ICAS组年龄较轻[(61.96±11.56)岁vs(71.12±9.92)岁,P<0.001]、NIHSS评分低[(16.65±6.14)分vs(19.88±5.56)分,P=0.022]、心房颤动比例低(7.14%vs 68.29%,P<0.001)、侧支循环良好(39.29%vs 17.07%,P=0.027)、发病至入院时间更长[(353.75±187.54)min vs(261.32±185.88)min,P=0.047];2组性别、高血压病、糖尿病、静脉溶栓、闭塞部位比较均无明显差异(P>0.05);与栓塞组比较,ICAS组穿刺至血管再通时间更长[(83.57±21.47)min vs(64.51±31.00)min,P=0.006],首次血管再通效应(率)低(10.71%vs 31.71%,P=0.042),Solumbra技术次数较多[(1,2)次vs(0,2.5)次,P=0.011],桥接Solumbra技术例数较多(78.57%vs 51.22%,P=0.021),补救性血管成形术(78.57%vs 2.44%,P<0.001)以及围手术期抗栓(89.28%vs 7.32%,P<0.001)比例更高;2组最终血管再通率、出血性转化(Hemorrhagic transformation,HT)率、症状性颅内出血(Symptomatic intracranial hemorrhage,SICH)率、恶性脑水肿、发病90 d后预后良好(mRS 0~2分)的比例和病死率比较均无明显差异(P>0.05)。结论阶梯式血管内治疗策略应用于急性前循环ICAS和心源性栓塞性大血管闭塞的安全性和有效性相当,但前者手术时间较长,首次血管再通率较低、桥接Solumbra技术例数以及次数较多,因此可能更适合首选Solumbra技术,而心源性栓塞性病变先行ADAPT技术更合理。

Objective To compare the safety and effectiveness of step-by-step endovascular treatment strategy in acute anterior circulation intracranial Atherosclerosis and embolic large vessels occlusion.Methods The patients with acute anterior circulation intracranial large vessels occlusive ischemic stroke who received step-by-step endovascular treatment strategy in Fuyang People's Hospital from April 2021 to February 2023 were selected and divided into ICAS group and embolic group according to the etiology.Compare the baseline data,surgical related data,and clinical prognosis[(modified rankin scale,mRS)0~2 points]rate between the patients of the two groups.Results In this study,150 patients with acute anterior circulation large vessels occlusion who received mechanical embolectomy were screened,and 69 patients were finally enrolled,with 28 patients in the ICAS group and 41 patients in the embolic group.Compared with the embolic group,the ICAS group was younger[(61.96±11.56)years vs(71.12±9.92)years,P<0.001],the NIHSS score was lower[(16.65±6.14)points vs(19.88±5.56)points,P=0.022],the proportion of Atrial fibrillation was lower(7.14%vs 68.29%,P<0.001),the collateral circulation was good(39.29%vs 17.07%,P=0.027),and the time from onset to admission was longer[(353.75±187.54)min vs(261.32±185.88)min,P=0.047];There was no significant difference between the two groups in gender,hypertension,diabetes,intravenous thrombolysis,and occlusive site(P>0.05).Compared with the embolic group,the ICAS group had a longer time from puncture to vascular recanalization[(83.57±21.47)min vs(64.51±31.00)min,P=0.006],lower rate of primary vascular recanalization(10.71%vs 31.71%,P=0.042),more times of Solumbra technique[(1,2)vs(0,2.5),P=0.011],more cases of bridging Solumbra technique(78.57%vs 51.22%,P=0.021),and a higher proportion of remedial angioplasty(78.57%vs 2.44%,P<0.001),as well as perioperative thrombolysis(89.28%vs 7.32%,P<0.001);There was no significant difference between the two in terms of final vessel recanalization rate,HT,SICH,malignant brain edema,3 months mRS(0~2 points)rate,and mortality rate(P>0.05).Conclusion The safety and effectiveness of the step-by-step endovascular treatment strategy in the treatment of acute anterior circulation ICAS and cardiac embolic large vessel occlusion is comparable to embolic group,but the former's operation time is longer,the primary vessel recanalization rate is lower,the case numbers and times of bridging Solumbra technique times are more.Therefore,ICAS may be better suited to Solumbra technology,while the ADAPT technique is more reasonable for embolic lesions.