动脉灌注替罗非班在处理颅内动脉瘤栓塞术中急性血栓栓塞的研究

目的 探讨动脉灌注盐酸替罗非班在处理颅内动脉瘤栓塞术中急性血栓栓塞的有效性及安全性.方法 收集2010年1月至2012年4月10例行颅内动脉瘤栓塞术中发生血栓栓塞患者,其中9例采用盐酸替罗非班动脉内靶向灌注处理,作为研究对象,另1例采用尿激酶动脉溶栓处理.9例均在完成动脉瘤腔致密填塞后,经微导管行盐酸替罗非班0.5 ～ 1.0 mg靶向灌注,并配合使用微导管、微导丝机械碎栓.术后进行DSA或CT追踪随访,观察有无脑梗死或脑出血发生.结果 9例术中造影血管均完全再通,且术中CT均未发现颅内新增出血征象;术后3～7d复查CT发现不同程度脑梗死4例;术后1个月后复查,遗留不同程度神经功能缺损2例,余均恢复良好.结论 颅内动脉瘤栓塞术中处理急性血栓栓塞并发症时,经动脉靶向灌注盐酸替罗非班是一种安全、有效的方法.     

动、静脉结合r-tPA溶栓治疗早期脑梗死

目的 评价动、静脉结合r-tPA溶栓治疗急性脑梗死的方法和临床疗效.方法 共15例急性脑梗死患者,术前均行CT、MR 和DSA检查证实颅内动脉闭塞部位：M1段4例,M2段2例,M3、4段2例,A1、2段1例,颈内动脉2例, P1段1例,豆纹动脉1例,其他穿支2例.其中术前经DSA证实12例.溶栓治疗时间在发病后3～7 h,采用动脉内药物灌注和机械疏通相结合方法溶栓,另外经静脉术前和术后持续滴注r-tPA辅助.术后观察临床症状和影像表现.结果 15例患者溶栓治疗中微导管和溶栓导管均到位满意,DSA所示闭塞段血管均有效再通.术后CT检查发现片状渗血2例,异位脑梗死1例.术后肢体功能即刻明显改善6例.临床观察3个月,症状基本完全恢复6例,较好改善7例,2例无明显改善;生活能力完全自理13例,有效率达87%（13/15）,生活能部分自理者1例,失去生活自理能力 1例,无患者死亡.结论 动、静脉结合溶栓治疗急性颅内动脉栓塞是一种有效、安全的治疗方法;局部动脉内灌注和机械疏通有效结合以及术前各项影像学检查的综合分析,将有利于动脉溶栓治疗的进行.     

脑梗死的超早期动脉接触性溶栓不同时间窗的疗效对比

脑梗死有较高的致死率和致残率,其治疗的关键是早期溶栓治疗,因此超早期经动脉接触性溶栓已被大力提倡。本文收集2000-04—2004-07共收治的18例急性脑梗死病人,均采取超早期经动脉接触性溶栓,获得了满意疗效,现报道如下。1材料与方法18例超早期(从发病到溶栓<6 h)脑梗死患者,男12例,女6例,年龄53~68岁,均有肢体偏瘫,舌面瘫,失语及意识障碍。采用Seld inger法股动脉穿刺插管,先行全脑血管造影,发现梗塞血管后用微导管做超选择性插管,经微导管推注尿激酶进行溶栓,尿激酶用法和用量:50万u溶于150 m l生理盐水15 m in推完,20 m in后造影复查,若…     

肠系膜上动脉栓塞的导管取栓溶栓治疗

目的 评价导管取栓溶栓治疗肠系膜上动脉栓塞的疗效.资料与方法 急性肠系膜上动脉栓塞11例患者(男7例,女4例,年龄61～81岁,风湿性心脏病并房颤7例,心肌梗死4例,合并小脑梗死1例,下肢动脉栓塞2例)采用6 F导引导管、5 F导管、颈动脉保护伞取栓导管溶栓术.结果 11例患者均成功取出血栓,取栓溶栓后血管复通,2例患者开腹探查,1例切除坏死肠管,1例未见肠管坏死,无治疗相关并发症.结论 导管取栓溶栓治疗肠系膜上动脉栓塞操作简便,能迅速恢复肠管血运,提高了临床治愈率.     

肝移植术后急性肝动脉血栓形成的介入治疗

目的评价用血管内介入放射学技术治疗原位肝移植后急性肝动脉血栓形成(HAT)的安全性和疗效。方法对10例肝移植后早期发生急性HAT患者进行了介入治疗。10例均表现为术后转氨酶、胆红素进行性增高。HAT发生于移植术后16h～10d(平均4.5d),Doppler超声波检查提示HAT,经血管造影证实。血管内介入技术有肝动脉内留置导管持续低剂量溶栓和肝动脉内支架置入术,同时经静脉给予低剂量肝素。肝动脉内溶栓期间间隔6～12h复查超声波。结果10例均表现为肝固有动脉完全阻塞。溶栓治疗成功8例。复查血管造影显示肝固有动脉有血流通过,肝内动脉分支显影,肝功能明显改善。肝动脉内留置导管时间为12h～9d(平均4.8d)。8例溶栓成功的患者均存在肝固有动脉吻合口处狭窄,其中7例狭窄程度>90%,进行肝动脉血管内支架置入术。溶栓治疗失败2例,1例于溶栓开始后12h发生腹腔内出血,行急诊开腹探查,发现肝动脉吻合口出血,随即再次吻合;1例留置导管溶栓7d后未能开通肝动脉阻塞,但向肝脏供血的侧支建立、肝功能有所改善,未作进一步治疗。8例治疗成功者术后随访4～20个月(中位值12个月),一般情况良好,复查超声波显示肝动脉血流通畅。结论血管内介入放射学技术是治疗肝移植后早期急性HAT的有效方法,有较高的安全性。     

动脉内接触性溶栓治疗急性脑梗死时间窗选择与疗效分析

目的 探讨动脉内接触性溶栓治疗急性脑梗死的时间窗选择与疗效的关系.资料与方法 245例脑梗死均在CT检查及血管造影基础上接受选择性动脉内接触性溶栓治疗,其中在发病后6 h以内溶栓者56例,6～24 h溶栓者189例.分析两组患者的血管再通率和90天预后.结果 脑血管造影发现颈内动脉(ICA)系统闭塞173例,椎基底动脉(VBA)系统闭塞72例;溶栓后ICA系统再通113例,VBA系统再通37例.治疗后90天预后好者180例,预后差者65例.溶栓后颅内出血12例.6 h内组和6～24 h组患者血管内溶栓治疗后90天预后良好率分别为80.35 %(45/56)和71.43 %(135/189),血管再通率分别为66.07%(37/56)和59.79%(113/189),血管再通中位时间分别为67 min和73 min.结论 动脉内接触性溶栓可以明显改善脑梗死患者的预后,仅以发病时间不超过6 h作为动脉内溶栓治疗标准不够全面,应当根据病情适当放宽动脉内溶栓的时间窗.     

肾透析患者桡动脉-头静脉人工造瘘通道阻塞的溶栓再通术

目的：探讨血液透析患者自体血管瘘道(桡动脉与头静脉侧端吻合)阻塞后用SP微导管的同轴导管技术微创的处理方法。方法：总结5例内瘘闭塞的肾透析患者，行血管造影诊断及介入溶栓治疗。其中4例右侧、1例左侧桡动脉-头静脉人工造瘘堵塞，经皮右股动脉或肱动脉穿刺插管，送入headbunt经左或右锁骨下动脉至人工造瘘的桡动脉阻塞端，再送入SP微导管进行血栓溶栓术及导丝穿刺血栓松解术。全过程2～4h，实际溶栓时间50min～2h。结果：4例患者再通术成功，1例因狭窄而未通，无严重并发症发生。结论：采用SP微导管的同轴导管技术行肾透析惠者的桡动脉-肘正中静脉人工内瘘阻塞的溶栓及血栓松解术简便、安全、有效而且微创。     

颅内动脉溶栓联合机械碎栓治疗急性脑梗死

目的探讨动脉溶栓联合机械碎栓治疗急性脑梗死的可行性和安全性。方法通过对9例急性脑梗死患者实施动脉内尿激酶溶栓联合机械性碎栓介入治疗(其中大脑前动脉A1段栓塞1例、大脑中动脉M1段栓塞6例、颈内动脉C1段狭窄1例、颈内动脉主干栓塞1例;起病距介入治疗时间3 h内2例,3～6 h 5例,>24 h 2例。结果7例6 h以内急性脑梗死患者主要栓塞血管得到100%开通,2例大于24 h患者症状得到改善(颈内动脉C1段狭窄1例、颈内动脉主干栓塞1例)。结论超选择局域性动脉内尿激酶溶栓联合机械碎栓治疗6 h以内急性脑梗死,能使闭塞的血管尽快开通,是一种安全有效的介入治疗术式。     

前交通动脉瘤的栓塞治疗

目的　总结 2 62例前交通动脉瘤栓塞治疗的经验。方法　均采用电解可脱卸弹簧圈(guglielmidetachablecoil,GDC)作动脉瘤内栓塞治疗。对双侧A1正常者应用双侧颈动脉置管技术监测栓塞术中载瘤动脉通畅情况 ,对瘤颈累及双侧A2者采用微导管微导丝辅助技术保持载瘤动脉通畅。发生术中出血者予弹簧圈继续栓塞 ,发生术中血栓形成者予尿激酶溶栓。 3 4例颅内多发动脉瘤均同次手术治愈。结果　动脉瘤完全闭塞 160例 ,>90 %闭塞 5 6例 ,<90 %闭塞 4 6例。术中因过度栓塞造成载瘤动脉闭塞 10例 ,术后脑梗死 16例。术中发生血栓形成 3例 ,经溶栓后恢复通畅。术后死于肺部并发症 1例 ,植物生存 1例。随访 190例 ,3～ 6个月行DSA/MRA复查 ,动脉瘤复发行 2次栓塞 8例 ,复发经手术治愈 1例 ,其余治疗结果稳定。结论　GDC栓塞治疗前交通动脉瘤效果好。采用微导管 /微导丝辅助技术可提高致密栓塞率和减少脑梗死并发症发生     

急性脑梗死溶栓治疗的时间窗及其影响因素分析

目的 分析急性脑梗死患者不同时间的动脉内溶栓治疗效果,探讨影响治疗时间窗的因素.方法 54例脑梗死患者均在CT检查及血管造影基础上接受选择性动脉溶栓治疗其中在6 h以内溶栓者42例,6～24 h溶检者12例.统计两组患者术后血管再通率和神经功能缺失积分差值.结果 两组患者治疗有效率分别为88.1%和75.0%,显效率分别为71.4%和50.0%, 管再通率分别为69.0%和50.0%,血管再通中位时间分别为68和73min.结论 动脉内溶检时间窗是与多种因素密切相关的,仅以发病时间不超过6 h作为治疗标准是不够全面的,应当根据病情合理放宽溶栓的时间窗,最大限度降低患者的病残率,提高了患者的生活质量.     

大脑中动脉闭塞的超选择性动脉内溶栓治疗

目的 :探讨超选择性动脉内溶栓治疗急性大脑中动脉闭塞的价值。方法 :经股动脉穿刺 ,将微导管超选择插至闭塞血管远端或置于血块内注入尿激酶 (UK)进行溶栓治疗。 12名急性大脑中动脉闭塞患者接受了溶栓治疗。结果 :8例获得大脑中动脉完全再通 ,3例获得部分再通 ,1例没有发生再通。随访 5个月 ,6人生活能完全自理 ,2人生活部分自理 ,3人无法生活自理 ,1人死亡。结论 :超选择性动脉内溶栓治疗可作为急性大脑中动脉闭塞可供选择的治疗方法之一。     

Snare retrieval of intracranial thrombus in patients with acute stroke

Intravenous or intraarterial thrombolysis of intracranial emboli is becoming an accepted clinical treatment modality for acute ischemic stroke, but not all emboli respond to the lytic drug regimens available today. If drug therapy fails, mechanical retrieval seems warranted. Four patients whose condition was resistant to intravenous and intraarterial thrombolytic drug treatment underwent at least partial clot removal with use of a snare, and almost immediate clinical improvement was noted. A fifth patient's clot was removed before lytic drugs were administered. All five patients, who presented with a sudden onset of stroke, were evaluated by arterial angiography; then, after a failed trial of intraarterial fibrinolytic drugs, they were treated by passing a 2- or 4-mm snare through a microcatheter. The snare wire was guided around the thrombus, gently brought back toward the microcatheter-but not into it-and the entire microcatheter and snare assembly was then removed. In four of the five cases, follow-up angiography performed immediately after the retrieval showed wider distal branches than normal. Follow-up computed tomography results were abnormal in all cases, showing hyperdense material in the territory that was previously ischemic. This hyperdensity subsided within 48 hours in all but one patient who developed small parenchymal hemorrhages; however, he remained asymptomatic. The snare device offers an additional or alternative therapy until completely effective thrombolytic agents become available. Although use of a snare is not ideal, device improvements should make the retrieval less technically challenging and more effective. There is a need for improved mechanical extraction devices, especially in light of the patient improvement that occurred. This experience also suggests that immediate removal of a mature clot could reduce the total time of brain ischemia more quickly than administration of thrombolytic drugs.     

Combined stent placement and thrombolysis in acute vertebrobasilar ischemic stroke

BACKGROUND AND PURPOSE: Acute vertebrobasilar ischemic stroke is often associated with high morbidity and mortality with limited therapeutic options. Endovascular treatment with thrombolysis has offered some hope for affected patients; however, overall outcomes have been less than satisfactory. In this report, we present the results of our approach in six consecutive cases of acute vertebrobasilar ischemic stroke by combined proximal vessel stent placement and thrombolysis. METHODS: Six consecutive cases were retrospectively reviewed for the clinical outcome of patients presenting to our institution with acute posterior circulation stroke who underwent cerebral revascularization including proximal arterial stent placement by using balloon-expandable coronary stents and intraarterial thrombolysis. All of these patients were initially evaluated by stroke team neurologists and imaged with MR, including diffusion-weighted imaging documenting acute posterior circulation stroke. MR angiography of the circle of Willis was also obtained. Short-term follow-up was conducted to assess National Institutes of Health stroke scores (NIHSS) and modified Rankin scores. RESULTS: In these six cases, a combined approach of proximal arterial stent placement (five cases of vertebral artery origin and one case of carotid and subclavian stent placement plus vertebral artery revascularization) and thrombolysis was performed at variable times after stroke onset (range, 30 hours to 5 days). Four of the six patients had good basilar artery recanalization (Thrombolysis in Myocardial Infarction [TIMI] grade 0-1 before tissue plasminogen activator thrombolysis and TIMI grade 2 after procedure). Four of six patients had excellent immediate recovery and were discharged to an acute rehabilitation unit or their homes with improved neurologic symptoms and functional status. Two patients died: one patient presented with coma at outset with an NIHSS of 38, and the other patient probably had reocclusion of the basilar artery within 24 hours despite initial postprocedural improvement. CONCLUSION: We demonstrate that, in the setting of acute stroke, stent placement in combination with revascularization and thrombolysis is practical and allows quick access to a clot and simultaneously increases perfusion through collaterals during the thrombolytic process. In particular, basilar thrombolysis may be facilitated by proximal vertebral stent placement as concomitant atheromatous vertebrobasilar stenosis is common.     

Can catheter-directed thrombolysis be applied to acute lower extremity artery embolism after recent cerebral embolism from atrial fibrillation?

PURPOSE: To assess the feasibility and efficacy of catheter-directed thrombolysis with recombinant tissue plasminogen activator (rt-PA) for acute limb embolism in patients with recent cerebral embolism due to atrial fibrillation. MATERIALS AND METHODS: Eight patients (six men, two women; mean age 63.5 years) with acute embolic occlusion of two left common iliac arteries, four femoral arteries (three left; one right), and two right popliteal arteries were treated. All patients had a history of recent cerebral embolism (mean 6 days, range 5-15 days) and all had a history of atrial fibrillation (duration 5-10 years). Catheter-directed thrombolysis started a few hours (mean 6.2h; range 3-10h) after the onset of arterial embolism. Two 5mg boluses of rt-PA were injected into the proximal clot through a 5 F end-hole catheter and, subsequently, two additional boluses of 5mg rt-PA were injected into the emboli. In patients with residual emboli, infusion with rt-PA (1mg/h) was continued. Percutaneous transluminal angioplasty was performed in three patients, and a stent was deployed in one patient. RESULTS: Technical success was achieved in all patients. Clinical success rate was 87.5% (7/8). The one clinical failure was secondary to chronic occlusion of outflow runoff vessels. The mean duration of continuous rt-PA infusion was 3.6h, the mean total dose of rt-PA administered was 23.6mg (range 20-28mg). There was no significant change in stroke scale scores during thrombolysis and no intracerebral haemorrhage was found at computed tomography (CT) after thrombolysis. Minor complications included haematomata at puncture sites (6/8), bleeding around the vascular sheath (2/8), and haematuria (1/8). During the follow-up period of 3-6 months, one patient suffered from recurrent cerebral embolism and died. CONCLUSIONS: Catheter-directed thrombolysis with rt-PA is an option for acute lower extremity arterial embolism in patients with recent cerebral embolism and a history of atrial fibrillation. Further studies should be undertaken to determine the risk of intracerebral haemorrhage caused by catheter-directed thrombolysis in individual stroke patients.     

Combined intraarterial/intravenous thrombolysis for acute ischemic stroke

BACKGROUND AND PURPOSE: The intravenous use of recombinant tissue-type plasminogen activator (rTPA) in acute ischemic stroke has been investigated in three large trials. Limited series have reflected outcome after local intraarterial thrombolysis (LIT) in the cerebral territory. The purpose of this study was to evaluate the safety and efficacy of combined intraarterial/intravenous thrombolysis using rTPA (actilyse) for acute ischemic stroke. METHODS: Forty-five patients with acute onset of severe hemispheric stroke and without signs of major cerebral infarction on early CT scans were randomized by order of admission. Twelve patients were treated with 50 mg actilyse (maximal dose, 0.7 mg/kg); three had occlusion of the internal carotid artery and nine had occlusion of the middle cerebral artery. Thrombolysis was started by LIT and continued intravenously within 6 hours of stroke onset. Outcome, assessed after 1 and 12 months according to the modified Rankin scale (MRS), was considered good (MRS score, 0-3) for patients who were functionally independent and poor (MRS score, 4-5) for those who were dependent or had died. RESULTS: In the thrombolysis group, outcome was good in eight patients at 1 month and in 10 patients at 12 months; in the control group, outcome was good in seven (21%) and 11 (33%) patients, respectively. Of the eight patients with a good outcome after thrombolysis, four had complete and one had partial recanalization. In the control group, the rate of intracerebral hemorrhage was 6%. Mortality at 1 month in the thrombolysis and control groups was 17% and 48%, respectively. CONCLUSIONS: Combined intraarterial/intravenous thrombolysis with low-dose rTPA may be a safe and effective treatment for acute ischemic stroke within 6 hours in carefully selected patients.     

经导管动脉内灌注尿激酶治疗急性脑动脉阻塞

目的 :探讨动脉血管内溶栓治疗急性脑动脉阻塞的疗效和价值。方法 :在DSA机下采用超选择性动脉插管灌注尿激酶治疗 48例急性脑动脉闭塞疾患。平均发病时间 2 9.6h ,尿激酶用量 80 0 0 0～ 3 0 0 0 0 0IU ,灌注时间持续 45～48min。结果 :6例患者即刻完全再通 ,3 8例部分再通 ,4例未通 ,临床有效率为 91.6%。结论 :超选择性动脉内灌注尿激酶是治疗急性脑动脉闭塞性疾病的优先选择方法。     

急性脑血栓的动脉内溶栓治疗

急性缺血性脑卒中主要由脑血管血栓形成所致,占急性脑血管病的50%～60%,是中枢神经系统最常见的致死和致残性疾病.缺血“半暗带”理论的提出,为脑梗死溶栓治疗提供了理论依据.随着医学影像学的发展及神经介入技术的进步,动脉内溶栓技术已经成为急性颅内动脉血栓形成的主要治疗方法之一,现介绍如下.     

急性缺血性脑梗死动脉内溶栓临床疗效评价

目的评价尿激酶动脉内溶栓治疗急性缺血性脑梗死的临床疗效。方法对162例急性缺血性脑梗死患者应用尿激酶进行局部动脉内溶栓治疗,分析不同阻塞血管部位血管再通率和3个月后格拉斯哥预后评分(GOS)之间的关系。结果脑血管造影发现血管闭塞162例,其中颈内动脉系统闭塞119例(73.5%):颈内动脉(ICA)主干闭塞27例(16.7%),大脑中动脉(MCA)闭塞63例(38.9%),大脑前动脉(ACA)闭塞29例(17.9%);椎基底动脉(VBA)闭塞43例(26.5%)。溶栓后再通分别为11例,40.7%;49例,77.8%;20例,68.9%和23例53.5%。治疗后3个月恢复良好者90例(55.6%),预后差72例(44.4%)。颅内出血8例(4.9%);再灌注损伤73例(45.1%);再栓塞6例(3.1%)。分析后认为ICA主干、VBA动脉再通率较低,预后差;MCA、ACA再通率高,预后好;开始治疗时间血管再通率和临床疗效相关(相关系数r=0.86)。结论局部动脉溶栓可以明显改善脑梗死患者的预后;预后和开始治疗的时间、血管再通有相关性,大脑中、前动脉血管再通率高,预后较好;颈内动脉主干血管阻塞很难再通;椎基底动脉血管再通后症状有所改善;血管不能再通或并发脑出血预后较差。     

MRI of ischemic stroke in canines: applications for monitoring intraarterial thrombolysis

PURPOSE: To describe a canine embolic stroke model that is appropriate for endovascular procedure evaluations and develop local cerebral blood flow (CBF) maps to monitor the progression of stroke and thrombolysis. In the future, MR may displace X-ray imaging in some endovascular procedures, such as intraarterial (IA) thrombolysis for stroke therapy, due to increased monitoring capabilities. For MR to attain its full potential in endovascular therapy, the development of appropriate disease models and monitoring techniques is essential. MATERIALS AND METHODS: The canine stroke model uses an injection of autologous clot to produce ischemic and infarcted tissue and produces a range of stroke severities within the anterior cerebral circulation. Local CBF maps were formed by using the catheter that would be in place to deliver the thrombolytic agent for treatment to deliver the gadolinium-based contrast agent for perfusion imaging. RESULTS: After the injection of clot, changes on imaging were consistent with the progression of ischemic stroke. Local CBF maps showed perfusion changes with stroke progression and treatment. CONCLUSION: We successfully demonstrate the progression of ischemic stroke in the canine to mimic the progression of human stroke. CBF maps to show local perfusion characteristics show great potential in the evaluation of stroke therapy.