目的 观察对症状性前循环颅内动脉重度狭窄患者急性期实施血管内治疗的可行性。方法 回顾性纳入2019年6月至2023年6月广东省中医院脑血管病科连续收治的30例症状性前循环颅内动脉重度狭窄患者的临床资料，应用危险分层评分对其进行评估，并探讨实施急性期(≤72。0h)血管内治疗的安全性及有效性。血管内治疗包括球囊扩张+自膨式支架置入、球囊扩张式支架置入、球囊扩张治疗。危险分层评分为本研究根据临床经验，在短暂性脑缺血发作(TIA)ABCD3-I评分基础上增加对分水岭梗死的评分内容，用于症状性颅内动脉中重度狭窄急性期卒中进展或复发风险的筛选，其中危险分层评分0～3分定义为低危，4～7分定义为中危，8～13分定义为高危。以术后残留狭窄率≤50％且血流拓展脑梗死溶栓(eTICI)分级＞2c级判定为血运重建成功。记录接受血管内治疗患者的人口学信息及临床资料，包括年龄、性别、脑血管病危险因素(高血压病、糖尿病、高脂血症、高同型半胱氨酸血症、饮酒史、吸烟史)、起病资料(发病至血管内治疗时间、症状、进展情况)、病变血管、危险分层评分、术前及术后90 d美国国立卫生研究院卒中量表(NIHSS)评分、术后90d改良Rankin量表(mRS)评分、术中脑血管事件(颅内出血、责任血管闭塞)及术后90d内脑血管事件(颅内出血、脑梗死、TIA、支架内再狭窄)、死亡事件。结果 30例症状性前循环颅内动脉重度狭窄患者中，排除发病至血管内治疗的时间＞72。0h患者3例、因其他疾病需长期服用抗凝药物1例、失访1例、并存其他心源性脑栓塞疾病3例、非动脉粥样硬化导致动脉狭窄4例、拒绝急性期血管内治疗7例，最终纳入符合纳入与排除标准患者11例。(1)11例患者均成功实施血管内治疗，其中男7例;年龄52～76岁，中位数年龄64岁;高血压病9例，糖尿病3例，高脂血症7例，高同型半胱氨酸血症2例(仅9例完善了该项检查)，吸烟史2例，饮酒史1例;发病至血管内治疗4。0～72。0 h，中位数时间12。0h;左、右侧大脑半球梗死分别为3、8例，伴前后分水岭、内分水岭、前内后分水岭梗死分别为4、3、2例，伴内后、前内分水岭梗死各1例。(2)11例患者中，危险分层评分10～13分，中位数评分11分;术前NIHSS评分0～11分，中位数评分7分。(3)11例患者中，10例病变血管位于大脑中动脉，I例位于颈内动脉C7段;术前狭窄率70％～99％，中位数狭窄率86％;术前eTICI分级2a级7例，2b50级4例(存在远端血流缓慢);9例接受球囊扩张+自膨式支架置入，1例接受球囊扩张式支架置入，1例行球囊扩张治疗;术后狭窄率10％～20％，中位数狭窄率15％;术后eTICI分级2c级3例，3级8例。(4)11例患者中，术后第1天发生颅内出血1例，术后第3天新发脑梗死1例。完成术后90 d影像学随访患者8例，其中支架内再狭窄2例;术后90 d NIHSS评分0～20分，中位数评分2分;术后90 d mRS评分0～4分，中位数评分1分。mRS评分≤2分患者8例，未发生死亡事件。结论 初步分析表明，症状性前循环颅内动脉重度狭窄实施急性期血管内治具有一定的有效性，但安全性有待继续观察。危险分层评分对高危患者的筛选仍需大样本、多中心研究进一步探讨。
Efficacy analysis of the acute endovascular treatment in patients with symptomatic severe anterior intracranial atherosclerotic stenosis
Objective Observing the feasibility of acute endovascular treatment for patients with symptomatic anterior intracranial atherosclerotic severe stenosis.Method From Jun 2019 to Jun 2023,30 symptomatic anterior intracranial atherosclerotic severe stenosis cases were retrospectively collected in the Guangdong Hospital of Traditional Chinese Medicine to evaluate the risk stratification score and explore the safety and effectiveness of acute(≤72.0h)endovascular treatment.Endovascular treatment includes balloon dilation+self-expanding stent placement,balloon-mounted stent placement,and balloon dilation.From the clinical experience,the risk stratification score was based on the ABCD3-I score for transient ischemic attacks(TIA)and additional evaluation of cerebral watershed infarction to identify the risk of stroke progression or recurrence in acute stage of symptomatic intracranial artery stenosis.The score of 0-3 was defined as low-risk,4-7 as medium risk,and 8-13 as high-risk.The successful revascularization of blood flow is determined based on the residual stenosis≤50％and the extended thrombolysis in cerebral infarction(eTICI)＞2c.The information of patient receiving endovascular treatment was recorded,including age,sex,risk factors of cerebrovascular disease(hypertension,diabetes,hyperlipidemia,hyperhomocysteinemia,drinking history,smoking history),onset data(time from onset to endovascular treatment,symptoms,progression),diseased vessels,risk stratification score,National Institutes of Health Stroke Scale(NIHSS)score before and 90 days after surgery,modified Rankin scale(mRS)score 90 days after surgery,intraoperative cerebrovascular events(intracranial hemorrhage,occlusion of responsible vessels),and postoperative cerebrovascular events 90 days after surgery(intracranial hemorrhage,cerebral infarction,TIA and in-stent restenosis)and deaths.Results Among 30 patients with symptomatic anterior intracranial atherosclerotic severe stenosis,3 patients were excluded from the time interval between onset and endovascular treatment＞72.0 hours,1 patient needed long-term anticoagulant drugs due to other diseases,1 patient lost follow-up,3 patients coexisted with other cardiogenic cerebral embolism diseases,4 patients with non-atherosclerotic arterial stenosis,and 7 patients refused emergency endovascular treatment.11 patients were finally included.(1)All 11 patients were successfully treated with endovascular treatment,and 7 were males;age ranged from 52 to 76 years old,with a median age of 64 years old;there were 9 cases with hypertension,3 cases diabetes,7 cases hyperlipidemia,2 cases hyperhomocysteinemia(only 9cases performed the examination),2cases smoking history,1 case drinking history;time from onset to endovascular treatment is 4.0-72.0 h,with a median time of 12.0 h;there were 3 and 8 cases of infarction in the left and right hemispheres,respectively,with 4,3,and 2 cases accompanied with anterior-posterior watershed,medial watershed,and anlerior-medial-posterior watershed infarctions,and 1 case accompanied by posterior-medial,anterior-medial watershed infarctions.(2)Among the 1 1 patients,the risk stratification score was 10-13 points,with a median score of 11 points;preoperative NIHSS score ranged 0-11 points,with a median score of 7 points.(3)Among the 1 1 patients,10 lesions located in the middle cerebral artery and 1 in the C7 segment of the internal carotid artery;the preoperative stenosis rate was 70％to 99％,with a median stenosis rate of 86％;preoperative eTICI grading was 2a in 7 cases and 2b50 in 4 cases(with slow distal blood flow);9 cases received balloon dilation and self-expanding stent placement,1 case received balloon-mounted stent placement,and 1 case received balloon dilation treatment;the postoperative stenosis rate is 10％to 20％,with a median stenosis rate of 15％;there were 3 cases with postoperative eTICI grade 2c and 8 cases with grade 3.(4)Among the 11 patients,one experienced intracranial hemorrhage on the first day after surgery and one had a new cerebral infarction on the third day after surgery.Eight patients were followed up by imaging 90days after surgery,demonstrating 2 cases of in-stent restenosis;90 days post-surgery,NIHSS score was 0-20 points,with a median score of 2 points;after 90 days of surgery,the mRS score was 0-4 points,with a median score of 1 point.There were 8 patients with mRS score ≤ 2 and no death events occurred.Conclusions Preliminary analysis shows that acute endovascular treatment for symptomatic anterior intracranial atherosclerotic severe stenosis has certain effectiveness,but the safety needs to be further validated.The screening of high-risk patients using risk stratification scores still requires further exploration through large sample and multicenter studies.
Symptomatic intracranial atherosclerotic severe stenosisEndovascular treatmentProgressive strokeRisk stratification
万方数据
维普
