缺血后处理技术在中动脉急性闭塞脑梗死患者血管介入中的应用

目的探讨缺血后处理技术在中动脉急性闭塞脑梗死患者血管介入中的应用效果。方法选择2017年5月至2019年6月在本院就诊的90例中动脉急性闭塞脑梗死患者,根据治疗方法不同将其分为观察组(血管内介入+缺血后处理治疗)和对照组(血管内介入治疗),两组各45例。比较两组患者治疗前后的脑梗死体积变化、美国国立卫生研究院卒中量表(NIHSS)评分、90天mRS评分、死亡率、血管再通率以及症状性颅内出血情况。结果两组患者发病1天后脑梗死体积明显大于术前,且观察组脑梗死体积显著小于对照组(P0.05)。两组患者术前和术后即刻的NIHSS评分差异无统计学意义(P0.05),但患者术后1天、术后7天和术后14天的NIHSS评分均下降,且观察组患者NIHSS评分显著低于对照组患者(P0.05)。观察组患者术后90天良好预后率和血管再通率均显著高于对照组,死亡率显著低于对照组(P0.05)。两组患者症状性颅内出血比较差异无统计学意义(P0.05)。结论缺血后处理技术在中动脉急性闭塞脑梗死患者血管介入中可以改善脑梗死体积和神经功能,提高血管再通率,降低死亡率,具有更好的预后效果。     

不同静脉溶栓时间窗对脑梗死患者的疗效及预后影响

目的比较不同静脉溶栓时间窗对脑梗死患者的疗效及预后的影响。方法选择2013-04—2015-04间收治的81例脑梗死患者作为研究对象,随机分为观察组(n=41)与对照组(n=40)。2组均应用尿激酶继续溶栓,观察组发病至溶栓时间6 h内,对照组6~9 h内,比较2组治疗效果。结果观察组治疗有效率、预后良好率均高于对照组,差异有统计学意义(P0.05)。结论不同静脉溶栓时间窗对脑梗死患者疗效及预后有一定影响,6 h内溶栓可缩小脑梗死面积,提高闭塞血管的再通率,有效缓解脑梗死症状。     

经大隐静脉入路行导管溶栓治疗急性下肢深静脉血栓的可行性

目的评估经大隐静脉入路行急性下肢深静脉血栓置管溶栓治疗的可行性。方法收集70例急性下肢深静脉血栓患者,随机分为A、B两组,A组为实验组(n=35),采用大隐静脉入路置管溶栓,B组为对照组(n=35),采用传统腘静脉入路置管溶栓。评估A、B两组患肢的消肿率、溶栓率、并发症发生率、手术时间。结果 70例均为单侧下肢急性深静脉血栓,A、B两组的患肢消肿率分别为(80.11±4.02)%、(81.70±6.13)%,差异无统计学意义(F=0.723,P=0.89);溶栓率分别为(84.91±3.40)%、(87.72±4.73)%,差异无统计学意义(F=0.685,P=0.71);手术时间分别为(3.91±0.74)min、(4.31±1.13)min,并发症发生率分别为2.86%(1/35)、5.71%(2/35),差异均无统计学意义(P均0.05),A组1例出现隐神经损伤,B组2例并发腘窝血肿。结论经大隐静脉入路置管溶栓治疗急性下肢深静脉血栓可行,可作为常规腘静脉入路的有益补充。     

支架植入术后导管接触性溶栓治疗髂静脉重度狭窄伴急性深静脉血栓形成

目的观察支架植入术后导管接触性溶栓(CDT)治疗髂静脉重度狭窄伴急性深静脉血栓形成(DVT)的效果。方法对42例髂静脉重度狭窄伴急性DVT行支架植入术联合CDT治疗,对其中22例(观察组)于植入支架后行CDT治疗,20例(对照组)于CDT治疗后植入支架。对比2组尿激酶用量、导管溶栓时间、静脉系统评分、患肢消肿率、并发症及随访情况。结果 2组技术成功率均为100%。观察组尿激酶用量和导管溶栓时间均低于对照组(P均0.05)。术后2组静脉系统评分均较术前降低(P均0.05),但组间术前及术后评分差异均无统计学意义(P均0.05)。术后2组患肢(大腿及小腿)消肿率差异均无统计学意义(P均0.05)。术后4例(观察组、对照组各2例)导管留置部位轻微出血,未见肺栓塞、颅内出血等严重并发症。随访3个月时观察组1例出现左侧小腿肌间静脉血栓,增加利伐沙班剂量至15 mg/d抗凝后复查深静脉超声显示静脉血流通畅;随访6个月时2组髂静脉支架通畅率均为100%。结论支架植入术后CDT治疗髂静脉重度狭窄伴急性DVT安全有效,且相比先溶栓后植入支架可缩短溶栓时间、减少尿激酶用量。     

注射用尿激酶治疗急性脑梗死的疗效观察

目的:观察注射用尿激酶静脉溶栓治疗急性脑梗死的临床效果和安全性分析。方法:36例急性脑梗死患者随机分为2组,治疗组16例给予注射用尿激酶(100万U),加入生理盐水100ml,30mi n内快速静脉滴注完毕;对照组20例给予肠溶阿司匹林/低分子肝素、注射用血栓通、脑细胞活化剂、钙通道阻滞剂及甘露醇等常规治疗;两组疗程为14天。比较两组临床疗效、不良反应和治疗前及治疗后1天、7天、14天的神经功能缺损评分。结果:治疗组总有效率93.71%,对照组80.02%,差异有统计学意义(P<0.05);治疗前及治疗后1天、7天、14天的神经功能缺损评分两组间比较有统计学意义(P<0.01)。治疗组未见出血并发症,溶栓后再闭塞4例,死亡1例,对照组症状性出血2例,再闭塞5例,死亡3例。不良反应两组比较差异无统计学意义(P>0.05)。结论:急性脑梗死发病3～6h内给予注射用尿激酶静脉溶栓治疗安全有效。     

急性缺血性脑卒中行静脉溶栓联合支架机械取栓治疗的流程管理

目的探讨急性缺血性脑卒中行静脉溶栓联合支架机械取栓患者治疗的临床流程管理效果。方法选取本院60例急性缺血性脑卒中患者按照随机数字表法分组为对照组和观察组,每组各30例。对照组给予静脉溶栓联合支架机械取栓治疗,并实施常规治疗;观察组于对照组基础上实施临床流程管理。分别于治疗前、治疗后2、4、6、8周神经功能缺损及临床疗效;记录两组患者入院到治疗的时间(DNT)、住院时间、住院费用及并发症。结果观察组患者DNT、住院时间明显短于对照组,住院费用明显少于对照组,P0.05;并发症率0.0%明显低于对照组13.33%,χ~2=4.29,P=0.03。观察组治疗后2、4、6、8周时NIHSS评分明显低于对照组,两组治疗后NIHSS评分较治疗前下降,P0.05。观察组总有效率为93.33%较对照组73.33%具有明显优势。结论急性缺血性脑卒中行静脉溶栓联合支架机械取栓治疗期间实施临床流程管理可提高疗效,减少并发症,促进患者神经功能恢复,缩短其住院时间,节约治疗费用。     

动脉内机械取栓治疗急性后循环缺血性脑卒中临床效果及预后影响因素

目的探讨机械取栓治疗急性后循环缺血性脑卒中患者的临床效果及预后影响因素。方法对15例急性后循环缺血性脑卒中患者行动脉内机械取栓治疗,统计血管成功再通率,并观察术后24 h内脑出血、脑梗死等不良反应发生情况。术后3个月随访,以改良Rankin量表(mRS)评估患者预后;对比预后良好(mRS评分0～2分)与不良(mRS评分3～6分)患者间基线资料及治疗相关指标的差异。结果对15例患者均成功开通闭塞血管,血管成功再通率100%(15/15)。术后24 h内1例发生脑出血,5例发生大面积脑梗死。术后3个月9例患者预后良好,5例预后不良,1例死亡。与预后不良患者比较,预后良好患者发病至入院时间更短(t=-2.435,P=0.030),入院时后循环Alberta卒中项目早期CT评分(pc-ASPECTS)更高(t=5.925,P0.001),术前美国国立卫生研究院卒中量表(NIHSS)评分更低(t=3.053,P=0.009)。结论动脉内机械取栓治疗急性后循环缺血性脑卒中效果好且安全性高;发病至入院时间、术前NIHSS评分及pc-ASPECTS是影响患者预后的因素。     

急性混合型下肢深静脉血栓取栓与溶栓远期疗效分析

目的 比较手术取栓与系统溶栓对急性混合型下肢深静脉血栓形成(DVT)的远期疗效.方法 回顾分析1991年9月至2005年6月的142例急性混合型DVT病例的临床资料.手术取栓77例,其中合并髂总静脉狭窄或闭塞49例,对于髂总静脉严重狭窄或闭塞者采取不同方法处理.手术后辅以区域性尿激酶溶栓、肝素抗凝治疗.系统溶栓65例,均系统性应用尿激酶、肝素.结果 治疗后2周,手术取栓组双下肢周径差由(4.3±2.2)cm降为(0.6±0.5)cm,系统溶栓组由(3.9±2.5)cm降为(1.6±0.9)cm,差异有统计学意义(t=-8.346,P=0.00).平均随访(49±42)个月,手术取栓组周径差降为(0.5±0.4)cm,系统溶栓组降为(1.4±1.3)cm(t=-5.764,P=0.00);手术取栓组水肿、色素沉着、溃疡等后遗症发生率分别为29.9%、15.6%、0%,低于系统溶栓组的50.8%、84.6%、6.2%(P＜0.05).彩超发现,手术取栓组静脉通畅率(89.6%)和瓣膜功能正常率(72.7%),均高于系统溶栓组(分别为30.8%、9.2%)(Z=-8.502,P=0.00).手术取栓组治愈率70.1%,高于系统溶栓组治愈率30.8%(Z=-4.740,P=0.00).手术组死亡率为3.9%,溶栓组无住院死亡率.结论 本组资料显示手术取栓对急性混合型DVT的疗效好于系统溶栓,尤其在保护静脉瓣膜功能方面明显优于系统溶栓;但手术创伤较大、有一定的死亡率.     

重组组织型纤溶酶原激活物早期静脉溶栓治疗急性脑梗死的临床研究

目的探讨重组组织型纤溶酶原激活剂早期静溶栓治疗急性脑梗死的疗效及安全性。方法回顾性分析笔者所在医院80例急性脑梗死患者的临床资料,发病时间〈6h的患者给予rt-PA50mg静脉溶栓治疗,溶栓前及溶栓后30min、24h、14d及3个月分别采用美国国立卫生院卒中量表（NIHSS）评分,溶栓后3个月给予修订的Rankin评分和日常生活能力Barthal指数评分,评价其疗效及安全性。结果溶栓后各时间点NIHSS评分均有明显改善,组间比较无显著性差异（均P〉0.05）;≤6h治疗其1h、3h、24h再通率效果显著,明显优于另两组（均P〈0.05）;≤6h治疗再出血的发生情况明显低于另两组（均P〈0.05）。结论 ACI发病6h内给予rt-PA静脉溶栓治疗相对安全有效。     

直接抽吸取栓术治疗大脑中动脉M2段闭塞

目的观察直接抽吸取栓术治疗大脑中动脉M2段闭塞的效果。方法回顾性分析8例接受直接抽吸取栓术治疗的大脑中动脉M2段闭塞患者,统计血管再通率及术后24 h颅内出血情况;于术前及术后24 h、14天对患者进行美国国立卫生研究院卒中量表(NIHSS)评分,术后90天统计改良Rankin量表(mRS)评分,以评价预后。结果 8例(100%)血管均成功再通,无需其他取栓器材和技术补救;术后均未发生症状性颅内出血,3例出现无症状性颅内出血。患者术后24 h、术后14天NIHSS评分逐渐下降。术后90天,8例均达到mRS评分≤2分的良好结局,其中7例达到mRS评分≤1分的优良结局。结论直接抽吸取栓术治疗大脑中动脉M2段闭塞可早期改善患者神经功能,有效性和安全性均良好。     

Endovascular interventions for patients with serious symptoms caused by embolic carotid T occlusion

The efficacy of endovascular interventions based on magnetic resonance (MR) imaging for acute ischemic stroke caused by embolic carotid T occlusion was assessed. Endovascular intervention was performed in 10 of 751 consecutive acute ischemic stroke patients admitted to our institution between April 2001 and July 2003. Indications were: presentation within 6 hours of onset of cardioembolic stroke; National Institute of Health Stroke Scale (NIHSS) score ≥ 10 on admission; absence of extensive signal hyperintensity on diffusion-weighted imaging; and carotid T occlusion on angiography. Localized intra-arterial thrombolysis using urokinase and/or mechanical clot disruption using micro-balloon catheter were performed. Radiographic findings, ΔNIHSS defined as NIHSS on day 7 - NIHSS on admission, 3-month modified Rankin scale (mRS), 3-month mortality, and symptomatic intracranial hemorrhage (ICH) were evaluated. Partial recanalization was achieved in 5 of 10 patients, but no recanalization was obtained in 5 patients. No significant differences in 3-month mRS (0-2) or symptomatic ICH were identified between these groups. However, the partial recanalization group showed significantly better clinical outcomes (median 3-month mRS 3 vs. 6, p = 0.009) and lower mortality rate at 90 days (0% vs. 80%, p = 0.047) with significantly greater ΔNIHSS (-8 vs. +6, p = 0.009). Endovascular intervention based on MR imaging resulting in partial recanalization may reduce poor outcomes and mortality in patients with embolic carotid T occlusion. Improvement of the outcomes of such patients requires more efficient methods such as clot retrieval therapy.     

Hyperbaric oxygen combined with intravenous edaravone for treatment of acute embolic stroke: a pilot clinical trial

The efficacy of hyperbaric oxygen (HBO) therapy combined with intravenous edaravone (free radical scavenger) administration was prospectively investigated in patients with acute embolic stroke involving the anterior cerebral circulation. Patients with acute embolic stroke in the anterior cerebral circulation admitted within 48 hours of onset from August 2001 to March 2002 with National Institutes of Health Stroke Scale (NIHSS) scores on admission of 5 or more were assigned randomly to HBO and control groups. The HBO group underwent HBO therapy combined with intravenous edaravone administration for 7 days, whereas the control group received only conventional treatment. The primary endpoint was the modified Rankin Scale score at 90 days (favorable outcome, score 0 or 1). The secondary endpoint was the NIHSS score at 7 days. Analysis was carried out by intention to treat. Six of the 19 patients in the HBO group, but only one of the 19 patients in the control group, had favorable outcomes at 90 days (p < 0.05), although NIHSS score at 7 days did not differ significantly between the two groups. HBO therapy combined with intravenous edaravone administration appears to be effective for the treatment of patients with acute embolic stroke in the anterior cerebral circulation.     

Bivalirudin for endovascular intervention in acute ischemic stroke: case report

OBJECTIVE AND IMPORTANCE: Intra-arterial thrombolysis has been demonstrated to improve recanalization and outcomes among patients with acute ischemic stroke. However, thrombolytic agents have limited effectiveness and are associated with a significant risk of bleeding. Bivalirudin is a direct thrombin inhibitor that has been demonstrated in the cardiology literature to have a more favorable efficacy and bleeding profile than other antithrombotic medications. We report the use of bivalirudin during endovascular treatment of acute stroke, when hemorrhagic complications are not uncommon. CLINICAL PRESENTATION: A 71-year-old woman with atrial fibrillation presented with right hemiparesis and aphasia and was found to have a National Institutes of Health Stroke Scale score of 10. Computed tomographic scans revealed no evidence of intracranial hemorrhage, aneurysm, or ischemic stroke. Cerebral angiography revealed thromboembolic occlusion of the superior division of the left middle cerebral artery. INTERVENTION: For anticoagulation, a loading dose of bivalirudin was intravenously administered before the interventional procedure, followed by continuous infusion. Attempts to remove the clot with an endovascular snare failed to induce recanalization of the vessel. Bivalirudin was then administered intra-arterially. Immediate postprocedural angiography demonstrated restoration of flow in the left middle cerebral artery. Repeat computed tomographic scans demonstrated no intracranial hemorrhage. The patient's hemiparesis and aphasia were nearly resolved and her National Institutes of Health Stroke Scale score was 2 at the time of her discharge 5 days later. CONCLUSION: To our knowledge, this is the first report of the use of bivalirudin for treatment of acute ischemic stroke. Bivalirudin may be a useful agent for intravenous anticoagulation and intra-arterial thrombolysis in this setting.     

Endovascular treatment of acute stroke

Opinion statement An obvious treatment goal in patients suffering an acute stroke due to an occlusion of a cerebral vessel is restoring blood flow to ischemic tissue. Studies have shown that recanalization of blood vessels can be achieved through endovascular therapy using either thrombolytics or mechanical clot removal. Because the clinical response to intravenous thrombolysis is exquisitely time-dependent, patients should be treated as soon as possible. Intravenous thrombolysis is the initial therapy in patients who present within 3 hours of stroke onset. Endovascular therapy should be considered for patients with large-vessel occlusions who are not candidates for intravenous thrombolysis or who do not recanalize after intravenous thrombolysis.     

Mechanical embolectomy

Mechanical embolectomy in acute ischemic stroke employs the use of novel endovascular devices to revascularize occluded intracerebral arteries. Devices like the Merci Retiever and other endovascular snares, laser thrombectomy and rheolytic/obliterative microcatheters, intracranial balloon angioplasty and stenting, and intra-arterial and transcranial ultrasound-enhanced chemical thrombolysis are intended to improve tissue rescue and diminish reperfusion hemorrhage while broadening the population eligible for therapy. Patient selection with MRI- and CT-based stroke protocols can detect tissue at risk and may obviate the classic limitations of the stroke therapeutic time window. These devices are being developed and modified at a rapid pace, requiring mounting endovascular expertise, and are being used successfully alone or in conjunction with chemical thrombolysis with relative safety.     

Endovascular treatment in patients with acute ischemic stroke: Technical aspects and results

Ischemic stroke is the primary cause of acquired disability in the world and its treatment is still a challenge. Intravenous (IV) thrombolysis with recombinant tissue plasminogen activator (rt-PA) administered within 4½ hours of the onset of the symptoms is the only approved medical treatment in the acute phase of cerebral infarction. However, its efficacy is limited where there is proximal intracranial arterial occlusion, and there are many contraindications. The endovascular approach, combined or not with IV thrombolysis, allows high rates of recanalization to be achieved within a short period of time, with a low rate of procedural complications when thrombolysis is less effective (internal carotid artery, M1 segment of the middle cerebral artery). In these situations, endovascular techniques are playing an increasing role in the treatment of these patients even though there is still no indisputable scientific proof of their efficacy. The priority at present is to finish the French THRACE study, but it is already time to think about the next one.     

Recanalization therapy for acute ischemic stroke,part 2: mechanical intra-arterial technologies

Stroke therapy has been revolutionized in the past two decades with the widespread implementation of chemical thrombolysis for acute stroke. However, chemical thrombolysis continues to be limited in its efficacy secondary to relatively short time windows and a high associated risk of hemorrhage. In an attempt to minimize hemorrhagic complications and extend the available therapeutic window, mechanical devices designed specifically for thrombus removal, clot obliteration, and arterial revascularization have experienced a recent surge in development and utilization. As such, chemical thrombolytics now represent only one of many options in acute stroke therapy. These new mechanical devices have extended the potential treatment window and now provide alternatives to patients who do not respond to conventional intravenous thrombolysis. This review will discuss the development of these devices, supporting literature, and the individual strengths that each engenders towards a life-saving therapy for stroke.     

Intra-arterial thrombolysis and thrombectomy for acute ischemic stroke: technique and results

Endovascular intraarterial (IA) strategies have emerged as important treatment options for patients with acute ischemic stroke who are ineligible for intravenous (IV) tissue plasminogen activator (tPA) or in whom such therapy has failed. The goal of this article is to provide a comprehensive review of percutaneous IA endovascular techniques aimed at revascularization in the setting of acute ischemic stroke from IA thrombolysis, mechanical thrombectomy, and primary intracranial stenting to retrievable-stent technology. For each modality, we focus on the existing clinical data, including our institutional experience and techniques.     

Acute management of stroke – I: ischaemic stroke

The adage that ‘Time is Brain’ remains a cornerstone of acute stroke treatment, and reflects the importance of timely diagnosis and treatment in order to minimise long-term consequences. The greatest advance in the management of ischaemic stroke has come in the form of reperfusion strategies, the success of which relies upon appropriate patient selection and the prompt initiation of therapy. The benefits of intravenous thrombolysis up to 4.5 hours are now firmly established, with trials underway to determine whether certain subgroups may benefit from thrombolysis beyond this timeframe. Intra-arterial thrombolysis has been used for decades but data on its efficacy and safety are limited. Novel methods of reperfusion, such as mechanical clot retrieval and stenting, have high recanalisation rates with acceptable safety and should be considered in patients with mid- to large-sized artery occlusion. Multi-modal reperfusion therapies, which use a combination of pharmacological and endovascular techniques, are showing encouraging results.     

Thrombolysis for acute ischemic stroke

Thrombolysis with intravenous alteplase is the primary therapy for acute ischemic stroke, and is approved in most countries. Early administration improves functional outcome though benefit and risk depend on the time elapsed between stroke onset and initiation of treatment. Randomized controlled trials demonstrated benefit from intravenous thrombolysis when initiated up to 4.5 hours after symptom onset, and pooled analysis of all trials indicates that the sooner that alteplase is given, the greater is the benefit. Treatment carries a risk of bleeding, with symptomatic intracranial hemorrhage (SICH) of around 3%. Initiating treatment after 4.5 hours increases mortality and reverses the risk-benefit balance. Baseline stroke severity, age, diabetes and concomitant stroke are associated with poorer outcome from acute stroke; but secondary analyses and controlled registry data suggest that intravenous alteplase remains effective in most subgroups. Intra-arterial thrombolysis has a less extensive evidence base and is mostly unapproved for acute stroke. Access to thrombolysis remains patchy and involves unacceptable delays: greater awareness of the benefits and time dependency are crucial.