补救性颈动脉穿刺机械取栓治疗急性前循环大血管闭塞性脑卒中的临床分析(附8例报道)

Mechanical thrombectomy via carotid artery salvage puncture for acute anterior circulation large vessel occlusive stroke: a clinical analysis of 8 cases

目的探讨补救性颈动脉穿刺机械取栓治疗急性前循环大血管闭塞性脑卒中的可行性及效果。方法回顾性收集自2021年6月至2023年9月于咸阳市第一人民医院、西安市第九医院、西安大兴医院、西电集团医院神经内科行补救性颈动脉穿刺机械取栓的8例急性前循环大血管闭塞性脑卒中患者, 分析患者的血管闭塞部位、发病至股动脉穿刺时间、补救性颈动脉穿刺原因、股动脉穿刺至补救性颈动脉穿刺时间、颈动脉穿刺成功至血管再通时间、术后即刻改良脑梗死溶栓(mTICI)分级、术后24 h美国国立卫生研究院卒中量表(NIHSS)评分、术后90 d改良Rankin量表(mRS)评分等资料。结果 8例患者中7例大脑中动脉M1段闭塞、1例大脑中动脉M2段闭塞;3例因Ⅲ型主动脉弓、1例因主动脉弓置换术后、1例因右侧颈总动脉成折角迂曲、2例因左侧颈总动脉起始处成折角迂曲、1例因双侧股动脉闭塞而无法建立经股动脉穿刺路径。8例患者均在局麻下穿刺颈动脉成功, 其中7例术后即刻为mTICI分级3级、1例为mTICI分级2b级;颈动脉穿刺至血管再通时间平均约35 min, 最短者为10 min, 最长者为90 min。所有患者术后24 h NIHSS评分均较术前下降, 均未发生颈动脉穿刺部位血肿、气道受压等并发症。6例患者术后90 d mRS评分为0~2分, 2例患者的mRS评分为6分(死亡原因均为肺部感染)。结论对于伴Ⅲ型主动脉弓、颈总动脉成折角迂曲、腹主动脉闭塞等致经股动脉穿刺建立机械取栓路径困难的急性前循环大血管闭塞性脑卒中患者, 快速改行补救性颈动脉穿刺机械取栓是一种可行且有效的方法。

ObjectiveTo investigate the efficacy and feasibility of mechanical thrombectomy(MT)via carotid artery salvage puncture in patients with acute anterior circulation large vessel occlusive stroke.MethodsA retrospective analysis was performed.Eight patients with acute anterior circulation large vessel occlusive stroke underwent MT via carotid artery salvage puncture in Departments of Neurology,First People's Hospital of Xianyang,Xi'an Ninth Hospital,Xi'an Daxing Hospital and XD Group Hospital from June 2021 to September 2023 were enrolled.Occlusion location,time from onset to femoral artery puncture,causes of carotid artery salvage puncture,time from femoral artery puncture to carotid artery salvage puncture,time from successful carotid artery puncture to vascular recanalization,modified thrombolysis in cerebral infarction(mTICI)score immediately after MT,and scores of National Institutes of Health Stroke Scale(NIHSS)24 h after MT and modified Rankin Scale(mRS)90 d after MT were analyzed.ResultsOf the 8 patients,7 had M1 segment occlusion and 1 patient had M2 segment occlusion.Direct thrombectomy was not possible resulting from type III aortic arch in 3 patients,aortic arch replacement in 1 patient,right common carotid artery twisting angle in 1 patient,left common carotid artery twisting angle in 2 patients,and bilateral femoral artery occlusion in 1 patient.All 8 patients had successful carotid artery puncture under local anesthesia,including 7 with mTICI 3 and 1 patient with mTICI 2b.Average time from successful carotid artery puncture to vascular recanalization was about 35 min,ranged 10-90 min.All patients had decreased NIHSS score 24 h after MT compared with before MT,and no complications such as hematoma or airway compression occurred in carotid artery puncture site.Six patients had mRS scores of 0-2 and 2 had scores of 6(death cause:pulmonary infection)90 d after surgery.ConclusionFor patients with patients with acute anterior circulation large vessel occlusive stroke,MT via carotid artery salvage puncture is a safe and feasible method in cases of difficulty in establishing thrombectomy route via femoral artery such as type III aortic arch,common carotid artery twisting angle,abdominal aorta occlusion.