大脑中动脉M2段闭塞血管再通研究进展

与颈内动脉和大脑中动脉M1段相比，大脑中动脉M2段更加纤细、迂曲，其急性闭塞后血 管再通治疗包括静脉溶栓、动脉溶栓及机械取栓，但血管内治疗的安全性和有效性仍有争议。目前 的研究显示，动脉溶栓和机械取栓的血管再通率高于单纯的静脉溶栓，但这3种治疗方法对90 d预 后的影响差异不大。另外，因研究相对较少，目前治疗方法对出血转化的影响尚无定论。     

选择性动脉溶栓治疗急性大脑中动脉闭塞的体会

目的探讨选择性动脉溶栓治疗急性大脑中动脉闭塞的效果。方法对临床初诊急性大脑中动脉闭塞的患者,经全脑血管造影证实大脑中动脉闭塞并系责任血管后,取尿激酶50万IU稀释在50 ml生理盐水中,先在1 min内推注10万IU,再按1万IU/min泵入,每10 min造影一次。50 min泵完尿激酶,对再通者,停止溶栓;不全开通者再追加20万IU尿激酶;若血管还未开通或开通不理想,改用微导丝对血栓或栓子进行机械碎栓。结果采用选择性动脉溶栓与机械碎栓相结合的治疗方法,12例完全再通,8例部分再通,1例溶栓后再闭塞。2例血管完全开通后合并出血。16例患者临床症状得到改善,2例出现新的脑梗死灶。结论对于基层医院,采取选择性动脉溶栓和机械碎栓结合的方法救治急性大脑中动脉闭塞,疗效满意。     

支架机械取栓治疗急性基底动脉闭塞的疗效观察

目的观察急性基底动脉闭塞行支架机械取栓治疗的可行性和疗效。方法回顾性纳入2013年9月至2016年12月海军军医大学附属长海医院神经外科收治的30例急性基底动脉闭塞的患者。其中采用Solumbra技术取栓17例,采用单纯支架取栓13例。评价基底动脉闭塞行支架机械取栓治疗的技术可行性、血管再通率、90 d时的预后良好率及手术并发症等。分析术后24 h的神经功能变化、不同技术手段对血管再通率的影响及卒中分型与预后的关系。结果30例急性基底动脉闭塞患者中,50%（15例）的患者为心源性栓塞型。支架机械取栓术后有87%（26/30）的闭塞血管成功再通[改良脑梗死溶栓（mTICI）分级为2b/3级];术后90 d的预后良好率[改良Rankin量表评分（mRS）≤3分]为67%（20/30）。支架取栓术后24 h美国国立卫生研究院卒中量表（NIHSS）评分的中位数较术前明显降低（分别为3分、25分,P＝0.003）。单因素分析结果表明,Solumbra技术组一次取栓血管再通达到mTICI 2b/3级的比率明显高于单纯支架取栓组（分别为69%、30%,P＝0.033）;心源性栓塞型患者的预后良好率明显高于大动脉粥样硬化型患者（分别为87%、45%,P＝0.038）。常见的手术并发症或不良事件包括异位栓塞、出血转化、无效再灌注、再闭塞等。术后90 d随访的病死率为10%（3/30）。结论急性基底动脉闭塞行支架机械取栓治疗安全可行;选择适宜的支架取拴技术有利于提高血管再通率。心源性栓塞型可能是预测基底动脉闭塞机械取栓术后预后良好的重要因素。     

微创方案治疗急性椎基底动脉闭塞性脑梗死临床研究

目的探讨静脉溶栓、动脉溶栓及机械取栓方案对急性椎基底动脉闭塞性脑梗死患者近远期疗效及安全性的影响。方法选取焦作煤业集团中央医院2016-01-2018-01收治急性椎基底动脉闭塞性脑梗死患者共135例,以随机数字表法分为A组(45例)、B组(45例)及C组(45例),分别采用静脉溶栓、动脉溶栓及机械取栓方案治疗,比较3组血管再通率、NIHSS评分改善良好率、随访预后改善率、随访病死率及颅内症状性出血发生率。结果 C组血管再通率和NIHSS评分改善良好率均显著高于A组、B组(P0.05);B组血管再通率和NIHSS评分改善良好率均显著高于A组(P0.05);C组随访预后改善率显著高于A组、B组(P0.05);3组随访病死率比较差异无显著性(P0.05);同时C组术后颅内症状性出血发生率显著低于A组、B组(P0.05)。结论机械取栓方案治疗急性椎基底动脉闭塞性脑梗死在近远期疗效和安全性方面均显著优于静脉溶栓、动脉溶栓,更具临床应用价值。     

急性缺血性脑卒中血管再通方法的比较性研究

急性缺血性脑卒中(AIS)的预后与急性期的血管再通密切相关。评价血管再通效率的标准有3条,即血管再通率、临床转归率和不良反应。AIS血管再通的方法有静脉溶栓、动脉溶栓、动静脉溶栓、机械再通术,机械再通术又分为支架再通术和机械碎栓/取栓术再通术。从血管再通效率的评价标准而言,机械再通术虽血管再通率高,但不良反应较多,且临床转归率并未提高多少;而静脉溶栓虽血管再通率不及机械再通术,但临床转归率也不低,不良反应明显减少,是首选之血管再通治疗方法。     

机械取栓与动脉溶栓治疗急性脑动脉闭塞单中心回顾性对照研究

目的对比分析机械取栓与动脉溶栓血管再通方法对于治疗急性脑动脉闭塞的有效性及安全性。方法回顾比较分析2005年5月至2014年5月期间行动脉溶栓及机械取栓患者,比较其发病到入院时间、入院到穿刺时间以及穿刺到获得再通时间、血管再通率TICI评分、患者术前及出院时NIHSS评分变化、90d时MRS评分、颅内出血发生率、死亡率。结果机械取栓组102例,动脉溶栓组50例,两组在发病入院时间(300 min vs.120 min,Z=-5.704,P=0.000),穿刺到再通时间(30 min vs.65 min,Z=-5.011,P=0.001)存在统计学差异,机械取栓组明显优于动脉溶栓组。两组在血管再通率(91.2%vs.60.0%,P=0.01)、总出血率(21.7%vs.36.0%,P=0.046)、死亡率(16.6%vs.26.0%,P=0.043)比较存在统计学差异,机械取栓组明显优于动脉溶栓组。两组90d时症状性出血率(12%vs.16%,P=0.055)、NIHSS评分变化(3 vs.4,Z=-0.236,P=0.823)、90d时良好预后率(48.2%vs.46.0%,P=0.823)比较无统计学差异。机械取栓组的支架放置率高于动脉溶栓组(22.5%vs.8.0%,P=0.018)。两组责任血管分层比较:机械取栓组颈内动脉(81.8%vs.55.6%,P=0.048)、基底动脉(93.1%vs.55.6%,P=0.032)、大脑中动脉(97.5%vs.60%,P=0.026)的血管再通率明显高于动脉溶栓组,机械取栓组颈内动脉(13.8%vs.33.3%,P=0.001)、基底动脉(13.8%vs.22.2%,P=0.011)的症状性出血率明显低于动脉溶栓组。机械取栓组大脑中动脉死亡率显著低于动脉溶栓组(2.5%vs.20.0%,P=0.000)。机械取栓组基底动脉良好预后率明显高于动脉溶栓组(41.3%vs.22.2%,P﹤0.01)。结论对于急性脑动脉闭塞患者的血管内治疗,机械取栓相比动脉溶栓有更宽的时间窗,更高的再通率和更好的预后。     

急性基底动脉闭塞血管内治疗及临床预后预测因素研究进展

急性基底动脉闭塞是卒中患者死亡率最高的疾病之一，新一代血管内机械取栓装置能降 低死亡率及改善临床预后。然而急性基底动脉闭塞经血管内机械取栓治疗患者临床结局受到多种因 素的影响，包括患者年龄、治疗前卒中的严重程度、发病至血管开通治疗的时间、治疗前梗死体积的 大小、血栓负荷及侧支循环状态等。本文就急性基底动脉闭塞血管内再通治疗进展及临床预后的影 响因素做一综述。     

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。     

支架取栓治疗急性椎基底动脉闭塞7例报道

目的观察急性椎基底动脉闭塞支架取栓治疗的安全性与可行性。方法分析2014年6月至2016年11月收治的支架取栓数据库中所有急性椎基底动脉闭塞患者的临床资料。结果共计7例患者中,4例为基底动脉闭塞,2例为椎基底动脉交界处闭塞,1例为椎动脉颅内段闭塞。治疗后6/7例(85.7%)实现血管再通。5/7例(71.4%)患者30 d m RS≤4,表明对神经功能恢复有意义。2/7例(28.6%)患者死亡,出血转化情况不明,余5例未发生出血转化。结论支架取栓是治疗急性椎基底动脉闭塞安全可行的方法;但需要随机对照研究进行证实。     

超选择性动脉溶栓联合支架取栓治疗急性大脑中动脉闭塞

目的探讨超选择性动脉溶栓联合支架取栓治疗急性大脑中动脉(middle cerebral artery,MCA)闭塞的有效性和安全性。方法回顾性分析20例初诊并进入绿色通道的急性MCA闭塞病例资料。行急诊头颅CTA或MRA检查,证实MCA闭塞后,经DSA评估,将微导管超选至闭塞部位,以尿激酶溶栓后血管未开通,立即在全身肝素化后行Solitaire AB型支架取栓。比较入院时,治疗后1、7、14 d,以及出院时NIHSS评分。结果 MCA闭塞完全再通10例,部分再通8例;合并出血3例。病人临床症状改善18例,死亡2例。入院时与出院时NIHSS评分分别为10.79±5.84和7.26±5.61,两者差异具有统计学意义(P0.01)。结论采取超选择性动脉溶栓联合支架取栓救治急性MCA闭塞,能明显提高血管再通率,改善预后,方法安全且有效。     

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.     

Outcomes of mechanical thrombectomy with pre-intravenous thrombolysis: a systematic review and meta-analysis

Journal of Neurology - Whether pre-intravenous thrombolysis (IVT) provides any extra benefits to mechanical thrombectomy (MT) remains controversial. We conducted a systematic review and...     

Safety of Mechanical Thrombectomy with Combined Intravenous Thrombolysis in Stroke Treatment 4.5 to 9 Hours from Symptom Onset

BackgroundAn extended time window for intravenous thrombolysis (IVT) for acute stroke patients up to 9 hours from symptom onset has been established in recent trials, excluding patients who received mechanical thrombectomy (MT). We therefore investigated whether combined therapy with IVT and MT (IVT+MT) is safe in patients with ischemic stroke and large vessel occlusion (LVO) in an extended time window.MethodsWe retrospectively analyzed patients with anterior circulation ischemic stroke and LVO who were treated within 4.5 to 9 hours after symptom onset using MT with or without IVT. Primary endpoint was the occurrence of any intracranial hemorrhage (ICH). Multivariable logistic regression was used to adjust for potential confounders.ResultsIn total, 168 patients were included in the study, 44 (26%) were treated with IVT+ MT. 133 (79%) patients had a M1-/distal carotid artery occlusion. Median ASPECT-Score was 8 (IQR 7-10) and complete reperfusion (mTICI 2b-3) was achieved in 132 (79%) patients. 18 (41%) of the patients in the IVT+MT group developed any ICH vs. 45 (36%) patients in the direct MT group (p=0.587). Symptomatic ICH occurred in 5 (11%) patients with IVT+MT vs. 8 (6%) patients receiving direct MT (p=0.295). In multivariable analysis, IVT+MT was not an independent predictor of ICH (adjusted for NIHSS, degree of reperfusion, symptom-onset-to-treatment time and therapy with tirofiban; OR 0.95 [95% CI 0.43-2.08], p=0.896).ConclusionMechanical thrombectomy in stroke patients seems to be safe with combined intravenous thrombolysis within 4.5 to 9 hours after onset as it did not significantly increase the risk for intracranial hemorrhage.     

Effect of mechanical thrombectomy alone or in combination with intravenous thrombolysis for acute ischemic stroke

Objective and design

Whether combining intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) is superior to mechanical thrombectomy alone for large vessel occlusion acute ischemic stroke is still uncertain. Our aim was to compare the safety and the efficacy of these two therapeutic strategies.

Materials

Patients with acute ischemic stroke secondary to anterior circulation large vessel occlusion.

Methods

A retrospective analysis was conducted. IVT was performed with full dose recombinant tissue plasminogen activator. MT alone was performed only if intravenous thrombolysis was contraindicated. Primary outcomes were successful reperfusion, 3-month functional independence, symptomatic intracranial hemorrhage (sICH), and 3-month mortality.

Results

325 patients were analyzed: 193 treated with combined IVT and MT, 132 with MT alone. The combined treatment group showed higher systolic blood pressure (140 [80–230] vs 150 [90–220]; p?=?0.036), rate of good collaterals (55.9% vs 67%; p?=?0.03), use of aspiration devices (68.2% vs 79.3%; p?=?0.003) and shorter onset-to-reperfusion time (300 [90–845] vs 288 [141–435]; p?=?0.008). No differences were found in the efficacy and safety outcomes except for mortality which was lower in the combined treatment group (36.4% vs 25.4%; p?=?0.02). However, after multivariable analysis combined treatment was not associated with lower mortality (OR 1.47; 95% CI 0.73–2.96; p?=?0.3).

Conclusions

Our study suggests that mechanical thrombectomy alone is effective and safe in patients with contraindications to intravenous thrombolysis. Preceding use of IVT in eligible patients was not associated with increased harm or benefit. Randomized controlled trials are needed to clarify whether intravenous thrombolysis before mechanical thrombectomy is associated with additional benefit.

     

颈内动脉系统脑梗死3～6 h静脉溶栓与动脉溶栓的比较

目的 观察颈内动脉系统梗死患者3～6 h时间窗内静脉溶栓和动脉溶栓治疗的疗效.方法 对34例发病3～4.5 h和18例发病4.5～6 h颈内动脉系统梗死患者,根据头颅磁共振灌注加权成像(PWI)/弥散加权成像(DWI)≥20%,分别行静脉和动脉内超选择性重组组织型纤溶酶原激活剂(rt-PA)溶栓治疗.治疗前后进行卒中量表(NIHSS)评分,并观察血管再通率、出血率,治疗后90 d用修正Raikin量表(MRS)评价临床预后.结果 溶栓后2组患者NIHSS评分较治疗前明显改善(P＜0.05),2组间NIHSS的改善程度差异无统计学意义(P＞0.05).治疗后90 d预后良好率:静脉溶栓组55.9%,动脉溶栓组61.1%,2组间比较差异无统计学意义(P＞0.05).血管再通率:静脉溶栓组47.1%、动脉溶栓组77.8%,2组间比较差异有统计学意义(P＜0.05).出血率:静脉溶栓组17.6%,动脉溶栓组33.3%,2组比较差异无统计学意义(P＞0.05).结论 在头颅MR PWI/DWI不匹配时,颈内动脉系统脑梗死发生3~4.5 h内静脉溶栓与4.5~6 h内动脉溶栓治疗安全有效,两者的效果相当.     

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.     

The effect of intravenous thrombolysis on patients with successful thrombectomy depends on final reperfusion grade: A retrospective study

Aims

Although intravenous thrombolysis (IVT) has not shown confirmative effects on the outcomes of patients receiving successful thrombectomy, it might influence the outcomes of a subset of these patients. This study aims to evaluate whether the effects of IVT depend on final reperfusion grade in patients with successful thrombectomy.

Methods

This is a single-center, retrospective analysis of patients with an acute anterior circulation large-vessel occlusion and a successful thrombectomy between January 2020 and June 2022. Final reperfusion grade was evaluated by the modified Thrombolysis in Cerebral Infarction (mTICI) score, which was dichotomized into incomplete (mTICI 2b) and complete (mTICI 3) reperfusion. The primary outcome was functional independence (90-day modified Rankin Scale score 0–2). Safety outcomes were 24-h symptomatic intracranial hemorrhage and 90-day all-cause mortality. Multivariable logistic regression analyses were used to assess the interactions between IVT treatment and final reperfusion grade on outcomes.

Results

When comparing all 167 patients enrolled in the study, IVT did not influence the extent of functional independence (adjusted OR: 1.38; 95% CI: 0.65–2.95; p = 0.397). The effect of IVT on functional independence depended on final reperfusion grade (p = 0.016). IVT benefited patients with incomplete reperfusion (adjusted OR: 3.70; 95% CI 1.21–11.30; p = 0.022), but not those with complete reperfusion (adjusted OR: 0.48, 95% CI: 0.14–1.59; p = 0.229). IVT was not associated with 24-h symptomatic intracerebral hemorrhage (p = 0.190) or 90-day all-cause mortality (p = 0.545).

Conclusions

The effect of IVT on functional independence depended on final reperfusion grade in patients with successful thrombectomy. IVT appeared to benefit patients with incomplete reperfusion, but not those with complete reperfusion. Because reperfusion grade cannot be determined prior to endovascular treatment, this study argues against withholding IVT in IVT-eligible patients.     

Endovascular thrombectomy for basilar artery occlusion stroke: Analysis of the German Stroke Registry-Endovascular Treatment

Background and purpose

Acute ischemic stroke due to basilar artery occlusion (BAO) causes the most severe strokes and has a poor prognosis. Data regarding efficacy of endovascular thrombectomy in BAO are sparse. Therefore, in this study, we performed an analysis of the therapy of patients with BAO in routine clinical practice.

Methods

Patients enrolled between June 2015 and December 2019 in the German Stroke Registry-Endovascular Treatment (GSR-ET) were analyzed. Primary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3), substantial neurological improvement (≥8-point National Institute of Health Stroke Scale [NIHSS] score reduction from admission to discharge or NIHSS score at discharge ≤1), and good functional outcome at 3 months (modified Rankin Scale [mRS] score of 0–2).

Results

Out of 6635 GSR-ET patients, 640 (9.6%) patients (age 72.2 ± 13.3, 43.3% female) experienced BAO (median [interquartile range] NIHSS score 17 [8, 27]). Successful reperfusion was achieved in 88.4%. Substantial neurological improvement at discharge was reached by 45.5%. At 3-month follow-up, good clinical outcome was observed in 31.1% of patients and the mortality rate was 39.2%. Analysis of mTICI3 versus mTICI2b groups showed considerable better outcome in those with mTICI3 (38.9% vs. 24.4%; p = 0.005). The strongest predictors of good functional outcome were intravenous thrombolysis (IVT) treatment (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.76–5.23) and successful reperfusion (OR 4.92, 95% CI 1.15–21.11), while the effect of time between symptom onset and reperfusion seemed to be small.

Conclusions

Acute reperfusion strategies in BAO are common in daily practice and can achieve good rates of successful reperfusion, neurological improvement and good functional outcome. Our data suggest that, in addition to IVT treatment, successful and, in particular, complete reperfusion (mTICI3) strongly predicts good outcome, while time from symptom onset seemed to have a lower impact.     

Basilar artery occlusion

The clinical presentation of basilar artery occlusion (BAO) ranges from mild transient symptoms to devastating strokes with high fatality and morbidity. Often, non-specific prodromal symptoms such as vertigo or headaches are indicative of BAO, and are followed by the hallmarks of BAO, including decreased consciousness, quadriparesis, pupillary and oculomotor abnormalities, dysarthria, and dysphagia. When clinical findings suggest an acute brainstem disorder, BAO has to be confirmed or ruled out as a matter of urgency. If BAO is recognised early and confirmed with multimodal CT or MRI, intravenous thrombolysis or endovascular treatment can be undertaken. The goal of thrombolysis is to restore blood flow in the occluded artery and salvage brain tissue; however, the best treatment approach to improve clinical outcome still needs to be ascertained.     

Endovascular thrombectomy with or without intravenous thrombolysis in acute basilar artery occlusion ischemic stroke: A meta-analysis

IntroductionIt is poorly understood if endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) better facilitates clinical outcomes in patients with acute basilar artery occlusion (BAO) ischemic stroke.MethodsA systematic literature review and meta-analysis was completed to investigate the outcomes of EVT with IVT versus direct EVT alone in acute BAO. Data was collected from the literature and pooled with the authors’ institutional experience. The primary outcome measure was 90-day modified Rankin sale (mRS) of 0-2. Secondary measures were successful post-thrombectomy recanalization defined as mTICI ≥2b, 90-day mortality, and rate of symptomatic ICH.ResultsOur institutional experience combined with three multicenter studies resulted in a total of 1,127 patients included in the meta-analysis. 756 patients underwent EVT alone, while 371 were treated with EVT+IVT. Patients receiving EVT+IVT had a higher odds of achieving a 90-day mRS of ≤ 2 compared to EVT alone (OR: 1.50, 95% CI 1.15 to 1.95, P =0.002, I² =0%). EVT+IVT also had a lower odds of 90-day mortality (OR: 0.57, 95% CI 0.37 to 0.89, P=0.01, I²=24%). There was no difference in sICH between the two groups (OR: 1.0, 95% CI: 0.56 to 1.79, P=0.99, I²=0%). There was also no difference in post-thrombectomy recanalization rates defined as mTICI ≥2b (OR: 1.11, 95% CI 0.70 to 1.75, P = 0.65, I²=37%).ConclusionsOn meta-analysis, EVT with bridging IVT results in superior 90-day functional outcomes and lower 90-day mortality without increase in symptomatic ICH. These findings likely deserve further validation in a randomized controlled setting.