椎动脉开口闭塞合并椎基底动脉急性闭塞的血管内治疗策略

doi:10.3877/cma.j.issn.2095-5782.2018.01.003

目的：

探讨椎动脉开口闭塞合并椎基底动脉急性闭塞的血管内治疗策略、临床疗效及安全性。

方法：

选取2014年6月—2017年7月我院收治的8例合并椎动脉开口闭塞的急性后循环大血管闭塞患者。采取经股动脉常规途径、经股动脉及肱动脉途径、结合椎动脉内膜剥脱途径联合Solitaire支架取栓开通血管。分析血管开通前后的改良TIMI灌注分级、入院与出院NIHSS评分、90 d后的mRS评分。

结果：

血管内治疗策略及血管开通情况：经股动脉常规途径行血管内治疗5例，经股动脉及肱动脉途径2例，结合椎动脉内膜剥脱开通血管1例。2例患者闭塞椎动脉开口未能开通，手术失败；6例患者椎动脉以及基底动脉获得良好开通；出院时NIHSS评分（11.88±7.06）明显低于入院NIHSS评分（30.75±8.21），差异有统计学意义（t=3.297，P=0.013）。死亡2例，步行出院4例。90 d随访临床结果显示优良5例（mRS为0~2分），1例患者中度残障，mRS评分3分。

结论：

多种血管内治疗途径能使合并椎动脉开口闭塞的急性后循环闭塞大血管获得较好的再通率，显著改善后循环急性缺血性脑卒中患者的预后。

关键词: 血管内治疗, 急性卒中, 后循环, 椎动脉开口闭塞

Objective:

To investigate the endovascular therapeutic strategies for acute posterior cerebral large artery occlusion due to occlusion of vertebral artery (VA) origin, and disscuss the clinical effect and safety.

Methods:

This study retrospectively analyzed eight patients with acute posterior ischemic stroke due to occlusion of VA origin who underwent endovascular therapy from June 2014 to July 2017. Using the common path through femoral artery, femoral artery and brachial artery, the intervertebral artery endarterectomy combined with the Solitaire stent was performed to open the blood vessel. The evaluation contents included endovascular therapeutic strategies, TIMI grade to confirm the reconstruction of blood flow, the early neurologic improvement of National Institutes of Health Stroke Scale (NIHSS) on admission and discharge and the functional score on the modified Rankin scale (mRS) at 90 d.

Results:

All patients had different levels of consciousness disorder (sleepiness to lethargy of 3 cases and light coma to deep coma of 5 cases) . The proximal basilar artery (BA) was occluded in 1 patient, middle BA in 4 cases, tip of BA in 3 cases and occlusion of VA origin was found at left (3 cases) and right (5 cases) . Six patients were recanalized successfully. The endovascular therapeutic strategies included transfemoral artery pathway (5 cases) , transfemoral and transbrachial artery pathway (2 cases) and combined endarterectomy of vertebral artery (1 case) . The scores of the NIHSS were decreased (30.75±8.21 on admission, vs. 11.88±7.6 at discharge; t=3.297, P=0.013) . Two patients died, however, 4 patients walked at discharge. Five patients had good functional independence (90 d modified Rankin score of 0 to 2) .

Conclusions:

Multimode endovascular methods in treatment of patients with acute posterior cerebral infarction due to occlusion of VA origin can improve arterial reperfusion, early neurologic recovery, and functional outcome.

Key words: Endovascular therapy, Acute stroke, Posterior circulation, Occlusion of vertebral artery origin

表1 8例患者的临床资料

患者编号	年龄（岁）	性别	BA闭塞	VA	球囊(mm)	取栓支架(mm)	Apollo扩张支架(mm)	入院NIHSS评分	出院NIHSS评分	90 dmRS评分
1	75	男	中段	右侧	3×15	4×20	4×15	28	4	2
2	66	男	尖端	右侧	3×22	4×20	4×15	38	2	1
3	73	男	中段	右侧	3×15	4×20	4×9	32	0	0
4	64	男	近段	左侧	3×15	6×30	3.5×15	38	1	0
5	59	男	中段	左侧	-	-	-	38	40	-
6	58	男	中段	左侧	2.5×22	4×20	3.5×18	16	0	0
7	53	男	尖端	右侧	3×12	4×20	4×15	22	10	3
8	86	女	尖端	右侧	-	-	-	34	38	-

表1 8例患者的临床资料

患者编号	年龄（岁）	性别	BA闭塞	VA	球囊(mm)	取栓支架(mm)	Apollo扩张支架(mm)	入院NIHSS评分	出院NIHSS评分	90 dmRS评分
1	75	男	中段	右侧	3×15	4×20	4×15	28	4	2
2	66	男	尖端	右侧	3×22	4×20	4×15	38	2	1
3	73	男	中段	右侧	3×15	4×20	4×9	32	0	0
4	64	男	近段	左侧	3×15	6×30	3.5×15	38	1	0
5	59	男	中段	左侧	-	-	-	38	40	-
6	58	男	中段	左侧	2.5×22	4×20	3.5×18	16	0	0
7	53	男	尖端	右侧	3×12	4×20	4×15	22	10	3
8	86	女	尖端	右侧	-	-	-	34	38	-

图1 典型病例（男，75岁，基底动脉动脉闭塞）行椎动脉内膜剥脱联合Solitaire支架取栓治疗前后

[1]	Savitz SI, Caplan LR. Vertebrobasilar disease[J]. N Engl J Med, 2005, 352(25):2618-2626.
[2]	Ecker RD, Tsujiura CA, Baker CB, et al. Endovascular reconstruction of vertebral artery occlusion prior to basilar thrombectomy in a series of six patients presenting with acute symptomatic basilar thrombosis[J]. J Neurointerv Surg, 2014, 6(5):379-383.
[3]	Abe A, Okubo S, Onozawa S, et al. Acute vertebral artery origin occlusion leading to basilar artery thrombosis successfully treated by angioplasty with stenting and thrombectomy[J]. Interv Neuroradiol, 2014, 20(3):325-328.
[4]	Matsubara N, Miyachi S, Kojima T, et al. Acute vertebral artery origin occlusion leading to basilar artery thrombosis successfully treated by angioplasty with stenting and intracranial fibrinolysis[J]. Neurointervention, 2013, 8(1):41.
[5]	Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke[J]. N Engl J Med, 2015, 372(1):11-20.
[6]	Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection[J]. N Engl J Med, 2015, 372(11):1009-1018.
[7]	Yoon W, Kim SK, Heo TW, et al. Predictors of good outcome after stent-retriever thrombectomy in acute basilar artery occlusion[J]. Stroke, 2015, 46(10):2972-2975.
[8]	Singer OC, Berkefeld J, Nolte CH, et al. Mechanical recanalization in basilar artery occlusion：the ENDOSTROKE study[J]. Ann Neurol, 2015, 77(3):415-424.
[9]	Brekenfeld C, Schroth G, Mattle HP, et al. Stent placement in acute cerebral artery occlusion：use of a self-expandable intracranial stent for acute stroke treatment[J]. Stroke, 2009, 40(3):847-852.
[10]	Behme D, Weber W, Mpotsaris A. Acute basilar artery occlusion with underlying high-grade basilar artery stenosis：multimodal endovascular therapy in a series of seven patients[J]. Clin Neuroradiol, 2015, 25(3):267-274.
[11]	Desai JA, Almekhlafi MA, Hill MD, et al. Ultrasound guided V3 segment vertebral artery direct percutaneous puncture for basilar artery mechanical thrombectomy in acute stroke：a technical report[J]. J Neurointerv Surg, 2014, 6(3):e18.
[12]	Hann S, Chalouhi N, Starke R, et al. Comparison of neurologic and radiographic outcomes with Solitaire versus Merci/Penumbra systems for acute stroke intervention[J]. Biomed Res Int, 2013, 2013:715170.

[1]	凌海平, 那世杰, 刘涛, 庄宗, 张玉华, 张庆荣, 杭春华. 支架辅助弹簧圈栓塞治疗血泡样动脉瘤的临床疗效分析[J]. 中华脑科疾病与康复杂志(电子版), 2021, 11(05): 263-267.
[2]	徐志嘉, 贾振宇, 赵林波, 刘圣, 施海彬, 曹月洲. 高敏肌钙蛋白T动态变化在晚时间窗内进行血管内治疗的急性缺血性脑卒中患者中的预测价值[J]. 中华介入放射学电子杂志, 2023, 11(01): 42-47.
[3]	赖和泰, 刘羽, 程光森, 刘永康, 李忠亮, 陆骊工. 39例Surpass Streamline治疗未破裂动脉瘤患者诊疗分析：单中心临床经验[J]. 中华介入放射学电子杂志, 2023, 11(01): 19-24.
[4]	陈正文, 李沛城, 陈珑, 刘一之, 李波, 袁晨, 侯凯文. 后循环急性缺血性脑卒中患者经机械取栓完全复流后不良预后的影响因素分析[J]. 中华介入放射学电子杂志, 2022, 10(01): 22-26.
[5]	孙世蒙, 李天晓, 李立, 邵秋季, 常凯涛, 吴桥伟. 国产Tubridge血流导向装置治疗椎动脉夹层动脉瘤的初步应用[J]. 中华介入放射学电子杂志, 2021, 09(02): 160-164.
[6]	王俊杰, 尹晓亮, 刘二腾, 陆军, 祁鹏, 胡深, 杨希孟, 陈鲲鹏, 张东, 王大明. 机器学习对预测颈内动脉非急性闭塞患者血管内再通术成功的潜在价值[J]. 中华脑血管病杂志(电子版), 2023, 17(05): 464-470.
[7]	孙洪扬, 刘基, 龚字翔, 王广英, 宁召腾, 赵璇, 朱其义, 王贤军. 急性前循环大血管闭塞性轻型卒中血管内治疗的临床预后及手术时机选择[J]. 中华脑血管病杂志(电子版), 2023, 17(05): 445-451.
[8]	袁兴运, 陈万红, 鱼丽萍, 姚力. 以Wallenberg综合征起病的椎动脉颅外段闭塞介入治疗探讨[J]. 中华脑血管病杂志(电子版), 2023, 17(04): 394-399.
[9]	杜小林, 陈鄂, 康俊龙, 肖庆, 丰伟, 田新华. 椎-基底动脉夹层动脉瘤介入治疗的疗效分析[J]. 中华脑血管病杂志(电子版), 2023, 17(04): 350-358.
[10]	黎丹丹, 程峙娟, 刘旭, 陈未平, 殷敏, 郭华, 涂江龙. 急性后循环进展性缺血性卒中患者血管内治疗的效果[J]. 中华脑血管病杂志(电子版), 2023, 17(02): 112-123.
[11]	张文胜, 幸伟芳, 谢颖, 何锦照. 急性前循环大血管闭塞血管内治疗头颅CT高密度影的研究进展[J]. 中华脑血管病杂志(电子版), 2023, 17(02): 159-162.
[12]	钱锦宏, 吴建东, 丁志良, 董晓峰, 唐晓宇, 马冕, 邓朋. 慢性症状性颈内动脉闭塞开通的初步探索[J]. 中华脑血管病杂志(电子版), 2022, 16(06): 416-421.
[13]	李伟, 乜全民, 王增武, 郭晖, 秦时强. 后循环血管形态改变对急性椎基底动脉闭塞患者机械取栓临床预后的影响[J]. 中华脑血管病杂志(电子版), 2022, 16(05): 320-325.
[14]	陈东升, 张萌, 张彩兰, 孙支唐. 急性基底动脉闭塞血管内治疗的研究进展[J]. 中华脑血管病杂志(电子版), 2022, 16(05): 360-365.
[15]	彭涛, 张紫霓, 朱碧峰, 但毕堂. 前循环串联病变血管内治疗预后的影响因素分析[J]. 中华脑血管病杂志(电子版), 2021, 15(05): 319-322.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Endovascular therapeutic strategies for acute posterior cerebral large artery occlusion due to occlusion of vertebral artery origin

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Endovascular therapeutic strategies for acute posterior cerebral large artery occlusion due to occlusion of vertebral artery origin