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

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

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