急性颅内大动脉梗死静脉溶栓禁忌患者多模式血管再通术分析

Multimodal vascular recanalization for acute intracranial large artery infarction in patients with contraindications of venous thrombolysis

目的探讨Solitaire支架结合Gateway球囊导管多模式血管再通术治疗急性颅内大动脉梗死静脉溶栓禁忌患者的效果,并与桥接治疗作比较。方法回顾性分析2015年1月至2017年12月采用Solitaire AB支架取栓治疗的22例急性颅内大动脉梗死患者临床资料。其中男13例,女9例,年龄42～81岁;均有静脉溶栓禁忌证,13例超过溶栓时间窗(6例为醒后卒中)。CT或MR检查后予直接取栓或多模式血管再通治疗。比较患者术前和出院时美国国立卫生研究院卒中量表(NIHSS)评分,采用改良Rankin量表(mRS)评分评估预后。结果 22例患者中20例闭塞血管成功开通,再通率90.9%。术后开通血管患者改良脑梗死溶栓(mTICI)治疗后血流分级均≥Ⅱb级,穿刺至开通时间30～125 min(3例>120 min),平均(1.64±0.73) h。NIHSS评分由术前平均(17.06±9.18)分改善至出院时平均(6.35±4.37)分,疗效确定(P<0.01)。90 d随访显示14例mRS评分≤2,预后良好率为63.6%,死亡1例。结论严格掌握适应证情况下,多模式血管再通术治疗急性颅内大动脉梗死安全有效,与桥接治疗相比有更低的术后脑出血率(9.1%)和死亡率(4.5%)。Gateway球囊导管既可作为微导管用于接触性动脉溶栓,又可用于碎栓、血管扩张,可有效提高再通率。

Objective To investigate the curative efficacy of multimodal vascular recanalization by using Solitaire stent combined with Gateway balloon catheter in treating acute ischemic stroke(AIS) in patients with contraindications of intravenous thrombolysis, and to compare the efficacy with that of bridging treatment. Methods The clinical data of 22 patients with AIS, who received thrombectomy with Solitaire AB stents during the period from January 2015 to December 2017 in No.85 Hospital of People’s Liberation Army of China, were retrospectively analyzed. The patients included 13 males and 9 females, with the age of 42-81 years old. All the 22 patients had contraindications of intravenous thrombolysis. In 13 patients, the interval between the onset of AIS and the initial medical visit was beyond thrombolytic time window(6 patients had wake-up stroke). After CT or MRI examinations, direct thrombectomy or multimodal vascular recanalization was carried out. National Institutes of Health Stroke Scale(NIHSS) score was used to assess the scores, and modified Rankin Scale(mRS) was adopted to evaluate the prognosis. Results Of the 22 patients, successful vascular recanalization was achieved in 20, the recanalization rate was 90.9%. In all 20 patients who got vascular recanalization after treatment, the mTICI vascularization grade was ≥Ⅱb. The time from puncturing to vascular recanalization ranged from 30 to 125 minutes(>120 minutes in 3 patients), with a mean of(1.64±0.73) hours. NIHSS score was improved from preoperative(17.06±9.18) points to(6.35±4.37) points at the time of discharge from hospital, and the curative effect was reliable(P<0.01). Follow-up examinations 90 days after the treatment showed that mRS≤2 was seen in 14 patients, the good prognosis rate was 63.64%,and death o ccurred in one patient. Conclusion Under the condition when the indications are strictly observed, multimodal vascular recanalization is safe and effective for the treatment of acute intracranial large artery infarction. Compared with bridging treatment, multimodal vascular recanalization carries lower rate of postoperative intracerebral hemorrhage(9.1%) and lower rate of mortality(4.5%). Gateway balloon catheter can be used not only for microcatheter-directed arterial thrombolysis but also for thrombectomy and blood vessel dilatation, which can effectively improve the recanalization rate.