抽吸取栓和支架取栓治疗急性缺血性脑卒中的疗效对比分析

目的比较抽吸取栓和支架取栓治疗急性缺血性前循环大血管闭塞的临床效果。 方法回顾性分析普宁市人民医院神经外科自2017年1月至2019年12月采用血管内介入取栓术治疗的97例急性缺血性前循环大血管闭塞患者的临床资料。根据术中采取的取栓技术将患者分为抽吸组和支架组。比较2组患者的基线资料、手术开通效果及预后情况,采用单因素和多因素Logistic回归分析影响出院时预后的独立影响因素。 结果本组纳入的97例急性缺血性前循环大血管闭塞患者中,抽吸组39例,支架组58例,2组患者的血管再通率比较,差异有统计学意义（P>0.05）;出院时,19例（48.7%）抽吸组患者恢复良好,15例（25.9%）支架组患者恢复良好,差异有统计学意义（P<0.05）。多因素分析结果显示高ASPECT评分和抽吸技术是出院时良好预后的独立影响因素。出院后90 d随访,结果显示抽吸组和支架组的预后良好率分别是60.0%和45.8%,差异无统计学意义（P>0.05）。 结论高ASPECT评分和抽吸技术是良好临床结果的独立预测因素。相比支架取栓,抽吸取栓能获得更好的影像学和远期临床结果。     

逆向半回收——改良的solumbra取栓技术

血管内治疗急性缺血性卒中已经成为一项标准的治疗技术。多重神经血管装置的结合 使用可为技术的改良提供更多的可能性。我们描述了一种改良的取栓技术--使用远端颅内导管 （distal intracranial catheter,DIC）在取栓之前半回收取栓装置。这项技术的成功运用包括回拉DIC使支 架完全释放,前推DIC部分地回收支架,从而使支架在取栓之前形成锥形,更好地嵌合和固定血栓、 缩短取栓行程,同时减少血管内皮损伤。该项技术可作为血栓切除术的一个良好选择,并可提高取 栓效率。     

急性缺血性卒中机械取栓的研究进展

机械取栓是急性缺血性卒中(AIS)患者进行血管内治疗的重要方法,通过血管内操作把血管内血栓取出体外,恢复大脑血运重建,减少致残率,甚至挽救更多生命。大量随机对照试验证明前循环急性缺血性卒中机械取栓治疗效果是显著的,根据影像学证实脑组织存在缺血半暗带而超时间窗的患者进行机械取栓仍然合理的[1]。在本文中,我们将对AIS机械取栓的循证学证据、机械取栓手术形式的选择及存在的问题进行综述,便于神经科医生了解取栓研究进展,选择最佳的血管内治疗策略。     

单中心急性缺血性卒中行机械取栓的疗效分析（附58例报告）

目的分析对急性缺血性卒中患者行急诊机械取栓的疗效。方法回顾性纳入同济大学附属第十人民医院神经外科2016年1月至12月收治的58例急性缺血性卒中患者,对所有患者建立稳定的血管通路,采用取栓支架结合手动抽吸的方式行急诊机械取栓治疗。术中采用脑梗死溶栓（TICI）分级评估血管再通情况,术后24 h行头颅CT复查,支架置入患者术后3 d内行CT血管成像（CTA）检查评估支架内有无再狭窄或闭塞。出院前采用美国国立卫生研究院卒中量表（NIHSS）对患者进行评分。术后90 d对存活患者根据改良Rankin量表评分（mRS）行门诊或电话随访。结果58例患者自入院至穿刺开始平均时间为（98.2±21.6）min,穿刺至血管开通平均时间为（45.4±21.3）min。共86.2%（50/58）的患者术中实现成功再通（TICI 2b、3级）,13.8%（8/58）未能有效再通。术后24 h头颅CT复查显示,并发大面积半球脑梗死4例,颅内出血7例,其中症状性颅内出血2例。12例患者（12枚支架）术中支架释放,术后3 d内行CTA检查显示,有2例支架内发生闭塞,其余通畅无再狭窄。出院前5例患者死亡,其余53例NIHSS评分平均为（5.9±4.7）分,较术前显著降低[（13.7±5.3）分,P〈0.05]。存活的53例患者术后90 d均获随访,mRS平均为（2.8±2.0）分,其中0～2分40例,预后良好率为68.9%（40/58）。结论通过建立稳定的血管通路,采用取栓支架结合手动抽吸的方式行急诊机械取栓是治疗急性缺血性卒中的有效手段。     

急性缺血性卒中动脉溶栓和取栓治疗的研究进展

发病时间窗内采用静脉溶栓是治疗急性缺血性卒中的首选方法。然而对于大血管闭塞性 脑梗死,静脉溶栓血管再通率偏低,血管内治疗可提高血管再通率。本文主要对动脉溶栓及机械取 栓的研究进展进行综述,旨在指导未来的临床工作。     

急性大血管闭塞性缺血性卒中患者机械取栓术后预后影响因素分析

目的筛查急性大血管闭塞性缺血性卒中血管内机械取栓术后预后相关影响因素。方法 2018年1月至2019年7月共117例急性大血管闭塞性缺血性卒中患者行血管内机械取栓术(包括支架取栓术、抽吸取栓术、支架取栓术联合抽吸取栓术),单因素和多因素Logistic回归分析筛查术后预后不良危险因素。结果 Logistic回归分析显示,高龄(OR=1.062,95%CI:1.013～1.113;P=0.012)、既往糖尿病(OR=3.074,95%CI:1.023～9.240;P=0.045)、入院时高NIHSS评分(OR=1.143,95%CI:1.043～1.252;P=0.004)、责任血管为椎-基底动脉(OR=11.151,95%CI:2.877～43.079;P=0.000)是急性大血管闭塞性缺血性卒中血管内机械取栓术后预后不良的危险因素。结论高龄,既往糖尿病、入院时高NIHSS评分、后循环缺血性卒中的急性大血管闭塞性缺血性卒中患者血管内机械取栓术后预后不良。     

直接抽吸取栓术与机械支架取栓术在急性颅内血管闭塞中的疗效对比

目的 比较直接抽吸取栓术（a direct aspiration first-pass technique,ADAPT）与机械支架取栓术治 疗急性颅内血管闭塞的有效性和安全性。 方法 回顾性纳入2019年3-12月于四川大学华西医院连续收治的急性颅内血管闭塞患者,根据采 用手术方法不同将患者分为ADAPT组和支架组。血管成功再通定义为血流mTICI≥2b级,治疗技术相关 指标为穿刺-血管再通时间、一次完全再通比例、一次完全再通手术时间、全部闭塞血管再通比例;主 要疗效评价指标为90 d预后良好（mRS≤2分）比例;主要安全性评价指标为术中血栓逃逸与术后症 状性颅内出血发生率。 结果 本研究最终纳入106例患者,年龄24～90岁,平均69.6±13.5岁,男性51例（48.1%）;其中 ADAPT组46例,支架组60例。ADAPT组中43例（93.5%）患者实现全部闭塞血管再通;支架组中52例 （86.7%）患者实现全部闭塞血管再通。ADAPT组穿刺-血管再通时间短于支架组[52.5（31.5～87.7）min vs 64.0（51.0～98.7）min,P =0.036];一次完全再通时间短于支架组（37.2±12.4 min vs 59.5±21.4 mi n, P＜0.001）;两组一次完全再通、全部闭塞血管再通比例差异无统计学意义。ADAPT组90 d预后良好患 者比例高于支架组（63.0% vs 36.7%,P =0.007）;两组术中血栓逃逸及症状性颅内出血发生率差异无 统计学意义。 结论 与支架组比较,采用ADAPT技术较支架取栓治疗急性颅内血管闭塞患者,手术时间更短,患 者临床预后更佳。     

Solitaire支架机械取栓治疗急性缺血性卒中疗效分析

目的探讨Solitaire支架机械取栓术治疗急性缺血性卒中的疗效。方法回顾分析使用Solitaire支架取栓或静脉溶栓的急性缺血性卒中患者临床资料,分析患者治疗后再通情况,比较治疗前后NIHSS评分差异及随访3个月时mRS情况。结果 18例机械取栓患者均获得再通,17例完全再通,其中1例患者取栓术后局部狭窄行支架成形术;1例取栓后大脑前动脉A2段不显影。术后复查头颅CT平扫,1例为术区少量出血;1例患者出现大面积脑出血,出血后死亡;1例患者出现大面积脑梗死伴出血后死亡。患者术前NIHSS评分18.0(10.8,20.2)分,术后1周NIHSS评分9.0(5.0,14.2);3个月后随访mRS评分2分9例。16例静脉溶栓患者术前NIHSS评分16.0(10.0,20.0),术后1周NIHSS评分10.0(8.0,14.0),3个月后随访mRS评分2分5例。术前(Z=-0.434,P=0.664)和术后(Z=-0.313,P=0.754)的NIHSS评分在两组之间差异无统计学意义,但机械取栓组的NIHSS评分降低值大于静脉溶栓组(6.5 vs 6.0),差异有统计学意义(Z=-2.090,P=0.037);机械取栓组患者治疗后出院3个月mRS评分1.5(1.0,2.3)低于静脉溶栓组mRS评分4.5(1.0,4.8),并差异有统计学意义(Z=-2.015,P=0.044)。结论 Solitaire支架取栓治疗急性缺血性卒中再通率高,可以改善预后,是急性缺血性卒中的可选治疗方式。     

急性缺血性卒中大血管闭塞性质的判断与取栓方式和材料的选择

血管内机械取栓是治疗大血管闭塞性急性缺血性卒中的有效治疗方法。应结合病史、发 病形式及影像学检查等综合判断病变性质；依据病变性质并参考手术路径，个性化选择支架取栓、 抽吸取栓、球囊/支架血管成形术、动脉溶栓任一种或多种方法联合取栓；并依据手术方式选择手 术材料，以快速高效地完成手术。     

支架取栓技术与接触抽吸技术治疗急性颅内大血管闭塞的Meta分析

目的 系统评价接触抽吸技术与支架取栓技术治疗发病6 h内颅内大血管闭塞的有效性和安全性。方法 计算机检索Pubmed、Embase、ClinicalTrials.gov以及Cochrane数据库,收集支架取栓术与接触抽吸术治疗大血管闭塞的随机对照研究,应用Review Manager 5.3软件进行Meta分析。结果 共纳入9项研究,共2 851例病人。Meta分析结果显示:两组术后血管再灌注成功率（OR=1.17;95% CI:0.57~2.41;P=0.66）、术后24 h内脑出血发生率（OR=0.97;95% CI:0.68~1.39;P=0.89）、术后90 d预后良好率（OR=7.59;95% CI:1.94~29.72;P=0.82）均无统计学差异,但是支架取栓组病死率明显高于接触抽吸组（OR=7.59;95% CI:1.94~29.72;P=0.004）。结论 对于急性颅内大血管闭塞,接触抽吸技术在血管再灌注成功率、术后脑出血风险、预后良好率方面与支架取栓技术相近,但接触抽吸相比较支架取栓的病死率更低。     

Catastrophic Multiple Microbleeds Caused by Infective Endocarditis Following Intravenous Thrombolysis and Endovascular Thrombectomy

Ischemic stroke is one of the most common complications of infective endocarditis (IE). IE must be considered as one of the causes of acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO), but early diagnosis of IE is difficult. AIS with ELVO must be treated using endovascular thrombectomy (EVT), with or without intravenous thrombolysis (IVT). IVT for AIS due to IE is not well established and remains controversial because of the risk of intracranial hemorrhage. A 42-year-old man suffered from right hemiparesis and disorientation, and AIS with ELVO was diagnosed. EVT with IVT was successfully performed and recanalization was achieved, but catastrophic multiple cerebral microbleeds appeared after treatment. EVT without IVT could be chosen for AIS caused by IE to avoid hemorrhagic complications. Hypointense signal spots on T2*-weighted magnetic resonance imaging (MRI) and susceptibility-weighted MRI could facilitate early diagnosis of IE.     

急性缺血性卒中血管内治疗的术式转换和补救

急性缺血性卒中血管内治疗取得良好预后的基础是及时恢复缺血区脑组织的有效灌注，
即达到前向血流mTICI 2b/3级。当使用取栓支架取栓、抽吸导管取栓、球囊/支架成形术等方法开通
闭塞血管过程中，未能达到缺血区有效灌注时，应仔细分析原因，再度审视手术路径、病变性质、闭
塞血管特点、血栓性状及负荷量等因素，避免不必要的重复操作，减少手术延误，适时转换手术方
式，更换手术材料，或辅以药物等可行的补救措施，尽快恢复缺血区有效灌注。     

急性缺血性卒中大血管闭塞性质的判断与取栓方式和材料的选择

血管内机械取栓是治疗大血管闭塞性急性缺血性卒中的有效治疗方法。应结合病史、发
病形式及影像学检查等综合判断病变性质；依据病变性质并参考手术路径，个性化选择支架取栓、
抽吸取栓、球囊/支架血管成形术、动脉溶栓任一种或多种方法联合取栓；并依据手术方式选择手
术材料，以快速高效地完成手术。     

抗血小板治疗在血管内治疗缺血性脑血管病中的应用

血管内治疗能显著降低缺血性脑血管病的致残、病死及卒中复发率。随着神经介入技术 和材料以及患者筛选策略的进步，缺血性卒中患者应用血管内治疗也日益增加。抗血小板治疗作为 缺血性卒中预防和治疗的重要手段，是血管内治疗中的重要一环，阿司匹林、氯吡格雷等是基石性 抗血小板药物，但具体的用药方案尚不统一。本文回顾和总结了国内外指南针对缺血性脑血管病行 血管内治疗患者的抗血小板策略建议，以及重要血管内治疗研究中采用的抗血小板治疗方案，以期 为神经介入医师行血管内治疗时抗血小板药物的应用提供参考。     

Mechanical Thrombectomy in Pediatric Stroke: Report of Three New Cases

BackgroundMechanical thrombectomy for treatment of arterial ischemic stroke (AIS) and cerebral venous thrombosis (CVT) is well-studied in adult populations, but not in children.MethodsWe report 3 new cases of pediatric stroke treated using mechanical thrombectomy. Two cases of AIS and 1 case of CVT were identified from 2018 pediatric stroke clinic records.ResultsThrombectomy was successful in 1 of the 2 AIS cases and in the CVT case. None of the children were asymptomatic after thrombectomy. One AIS case had good recovery than developed dystonia which responded to treatment; the second AIS case had residual hemiplegia; and the child with CVT had mild school problems.ConclusionsMechanical thrombectomy is being increasingly used for pediatric stroke treatment. This study and recent literature reviews suggest thrombectomy holds promise as a treatment for selected pediatric stroke patients. Questions remain about the safety and efficacy of thrombectomy in children with stroke since large randomized controlled studies are not yet feasible.     

院前通知对急性颅内大动脉闭塞患者取栓流程及疗效的影响

目的 探讨院前通知对取栓患者入院-再灌注时间（door-to-reperfusion time,DRT）和临床预后的影响。 方法 回顾性分析2015年1月-2016年12月在浙江省人民医院神经内科接受取栓患者的临床和影像 学资料。将院前通知定义为当地医院在患者转运之前向本中心卒中小组进行短信告知。对院前通知 和非院前通知组的基线特点,以及两组DRT和预后进行比较。预后良好定义为3个月改良Rankin量表 评分≤3分。 结果 共纳入123例接受取栓治疗的缺血性卒中患者,57例（46.3%）患者在转运到达前进行了院前 通知。在术后达到再灌注的人群中（100例）,与非院前通知组患者相比,院前通知组患者的DRT明显 较短（P＜0.001）。术前静脉溶栓[优势比（odds ratio,OR）=2.774,P =0.023]是预后良好的独立影响因 素,院前通知不是影响预后的独立因素（OR =2.586,P =0.058）。但院前通知联合术前静脉溶栓是预 后良好的独立影响因素（OR =7.662,P =0.006）。 结论 院前通知可以缩短DRT。在取栓后达到再灌注的人群中,术前进行静脉溶栓能够使患者获益, 而术前静脉溶栓联合院前通知将使获益概率增加2.7倍。     

Thrombectomy in Acute Ischemic Stroke in the Extended Time Window: Real-Life Experience in a High-Volume Center

ObjectivesSelected patients with acute ischemic stroke (AIS) caused by proximal middle cerebral artery (MCA) or internal carotid artery occlusion benefit from endovascular thrombectomy (EVT) in extended time window (6–24 h from last seen well) based on two landmark randomized controlled trials (RCTs) DAWN and DEFUSE-3. We evaluated patients’ outcome in the real-life with the focus on adherence to protocol of the two RCTs.Materials and methodsWe included consecutive patients with AIS (excluding basilar artery occlusions) referred to EVT in our stroke center in the extended time window between January 2018 and December 2019 and compared the outcome of patients who fulfilled criteria of the RCTs with those who did not.ResultsOf the total of 100 patients, 23 complied with RCT's criteria and 18 presented with minor non-adherence (lower NIHSS score or longer treatment delay), whereas 22 patients had large baseline ischemia (>1/3 MCA), 28 presented with M2 and more distal occlusions, and 9 patients did not undergo perfusion imaging prior to EVT. Good 3-month outcome (modified Rankin Scale 0-2) was observed in 54% of those who either met the RCT criteria or presented with lower NIHSS score or longer treatment delay, but only in 30% of M2 occlusions, and in none of the patients with large baseline ischemia.ConclusionsOur findings highlight the impact of mostly large baseline ischemia but also vessel status when selecting patients for EVT in the extended time window and emphasize the need for further data in these patient subgroups.     

Prediction of mTICI 3 recanalization and clinical outcomes in endovascular thrombectomy for acute ischemic stroke: a retrospective study in the Taiwan registry

Neurological Sciences - Early recanalization for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) by endovascular thrombectomy (EVT) is strongly related to improved functional...     

直接取栓与桥接治疗对急性大血管闭塞性缺血性卒中疗效比较的荟萃分析

目的     比较急性大血管闭塞性缺血性卒中（acute ischemic stroke with large vessel occlusion，AIS-LVO）患者直接取栓治疗（direct endovascular thrombectomy，DEVT）和桥接治疗（bridging therapy，BT）的疗效和安全性。     

Acute Ischemic Stroke Therapy in Infective Endocarditis: Case Series and Systematic Review

Objectives: To evaluate the safety of acute ischemic stroke (AIS) therapy in patients with infective endocarditis (IE) with intravenous thrombolysis (IVT) or endovascular therapy (EVT) such as mechanical thrombectomy. Methods: We conducted a retrospective study of patients who underwent AIS therapy with IVT or EVT at a tertiary referral center from 2013 to 2017, that were later diagnosed with acute IE as the causative mechanism. We then performed a systematic review of reports of acute ischemic reperfusion therapy in IE since 1995 for their success rates in terms of neurological outcome, and mortality, and their risk of hemorrhagic complication. Results: In the retrospective portion, 8 participants met criteria, of whom 4 received IVT and 4 received EVT. Through systematic review, 24 publications of 32 participants met criteria. Combined, a total of 40 participants were analyzed: 18 received IVT alone, 1 received combined IVT plus EVT, and 21 received EVT alone. IVT compared to EVT were similar in rates of good neurologic outcomes (58% versus 76%, P= .22) and mortality (21% versus 19%, P= .87), but had higher post-therapy intracranial hemorrhage (63% versus 18% [P= .006]). Conclusion: IV thrombolysis has a higher rate of post-therapy intracranial hemorrhage compared to EVT. EVT should be considered as first-line AIS therapy for patients with known, or suspected, IE who present with a large vessel occlusion.