一侧颈动脉狭窄伴对侧颈动脉闭塞患者颈动脉支架置入术的脑保护措施

目的 探讨一侧颈动脉狭窄伴有对侧颈动脉闭塞的高危患者实施支架置入术前及术中的脑保护措施对降低围手术期缺血事件发生的有效性. 方法 12例患者术前均进行血流阻断耐受试验,对2例重度不能耐受缺血负荷的患者术前进行颅内外血管吻合术,对2例相对不耐受缺血负荷的患者选择在全身麻醉下进行支架置入术.术中采取减少脑血流阻断时间、降低血栓形成等各种有效脑保护措施,防止缺血事件的发生.术后通过弥散加权MRI(DWI)检查及缺血性神经症状的临床表现,评估脑保护措施的有效性. 结果 术后出现短暂性脑缺血发作3例,出现一过性失明1例,出现永久性缺血神经症状1例.术后24 h DWI阳性率为50.0%,多为小于1～2 mm小病灶散在分布.术后颈动脉血管扩张达90%以上8例,70%-90%4例. 结论 术前正确评估缺血耐受程度及血流特征,术中有效缩短血流阻断时间及防止血栓形成或栓子脱落等脑保护措施可有效降低一侧颈动脉狭窄伴有对侧颈动脉闭塞的高危患者在围手术期发生永久性缺血事件发生.

Measures for brain protection in carotid angioplasty and stenting in patients with carotid artery stenosis and contralateral occlusion

Objective To assess the value of brain protection measures in carotid angioplasty and stenting(CAS)for carotid stenosis and contralateral occlusion in reducing the perioperative cerebral isehemic events.Methods Twelve patients undergoing CAS in our department were included in this analysis.All the patients received balloon occlusion test(BOT)of the carotid artery preoperatively.Two patients who were intolerant to BOT received extracranial-intracranial vascular anastomosis,and another 2 patients relatively intolerant to BOT received CAS under general anesthesia.The brain protection measures including reduction of the cerebral blood flow occlusion time and prophylactic management of thrombosis were administered to prevent the ischemic events.The efficacy of the brain protection measures was evaluated by diffusion-weighted imaging(DWI)and observation of the clinical ischemic neurological symptoms.Results Three patients suffered transient ischemic attacks(TIAs),1 patient had temporary vision loss,and 1 had permanent ischemic neurological deficits after the operation.DWI yielded positive results in 50% of the patients after the operation,characterized mostly by small local lesions of 1-2 ram.Eight patients presented with carotid artery dilation by over 90%,and 4 by 70% to 90% after the operation.Conclusion The brain protection measures including precise preoperative evaluation of the ischemic tolerance and blood flow and reduction of cerebral blood flow occlusion time and prevention of thrombosis during the operation can effectively reduce the incidence of perioperative ischemic events in high-risk patients with carotid stenosis and contralateral occlusion.