脑静脉窦血栓的综合血管内治疗

目的评价综合应用颈动脉溶栓、静脉窦置管溶栓及静脉窦支架置入术治疗脑静脉窦血栓的疗效。方法对我科1997年7月～2005年6月收治的99例脑静脉窦血栓患者进行综合血管内治疗,其中5例患者接受静脉窦置管溶栓合并静脉窦支架置入术(方案1),38例患者接受颈动脉溶栓合并静脉窦置管溶栓(方案2),56例患者接受单纯颈动脉溶栓(方案3),观察3组患者的临床疗效。结果经治疗,99例患者中有94例颅内压降至300 mm H_2O, 75例患者静脉窦实现再通,93例患者循环时间降至11 s以下。结论综合应用颈动脉溶栓、静脉窦置管溶栓及静脉窦支架置入术等方法治疗脑静脉窦血栓是一种安全、有效的手段。     

脑静脉血栓的治疗方法探讨

目的 探讨脑静脉血栓的治疗方法。方法对133例脑静脉血栓单独或联合采用经颈动脉溶栓、静脉窦内留置微导管连续溶栓、静脉窦成形（支架置入或球囊扩张）等方法进行治疗，同时辅以全身抗凝治疗。结果治疗后颅内压均明显下降，除１例ICP降至350mmH2O者失明，1例行静脉窦球囊扩张成形者（拒绝接受静脉窦支架置入）由术前760mmH2O降至450mmH2O外．其余病人ICP基本稳定在200-260mmH2O。颅内出血严重致脑疝死亡2例。溶栓后发生脑出血3例．均经手术治愈。结论同时应用血管内溶栓和全身抗凝是治疗脑静脉血栓较为可靠和安全的方法；血栓部位不同者治疗方案应个性化。     

经颈动脉溶栓治疗脑静脉窦血栓的影像学及组织病理学研究

目的观察经颈动脉溶栓治疗兔脑静脉窦血栓的影像学及组织病理学变化,以为临床应用提供依据。方法39只新西兰兔随机分为对照组(15只)、抗凝组(12只)和溶栓组(12只),建立兔脑静脉窦血栓模型,施行经颈动脉溶栓治疗。脑血管造影检查计算脑循环时间,免疫组织化学检测和血管分析方法检测CD31表达水平,并计数微血管密度。结果经颈动脉溶栓治疗后,溶栓组动物脑循环时间[(4.78±0.54)s]低于抗凝组[(6.75±0.46)s]和对照组[(7.00±0.50)s](均P<0.05);溶栓组动物微血管密度[(4.55±0.20)%]明显高于抗凝组[(3.55±0.23)%]和对照组[(2.28±0.70)%](均P<0.01)。结论经颈动脉溶栓治疗脑静脉窦血栓的临床疗效肯定,即使治疗后静脉窦仍呈闭塞状态,仍可使患者脑循环时间明显下降、微血管密度明显增加。     

脑静脉窦内支架植入术中球囊扩张状态下行脑血管造影术的临床意义

目的探讨脑静脉窦内支架植入术中于球囊扩张状态下行脑血管造影术以预测术后穿支静脉回流情况的临床价值。方法共93例脑静脉窦内支架植入术患者(包括51例脑静脉窦狭窄合并颅内高压和42例源于脑静脉窦狭窄的搏动性耳鸣),63例直接行脑血管造影术测量横窦和乙状窦直径并根据测量结果选择支架,30例于球囊扩张状态下行狭窄侧颈动脉或椎动脉造影术以明确穿支静脉回流情况,回流缓慢者选择较脑静脉窦直径小1~2 mm的支架。结果脑静脉窦内支架植入术成功率达100%(93/93)。63例根据脑血管造影术测量的横窦和乙状窦直径而选择支架患者中45例选择9 mm×40 mm支架、15例选择8 mm×40 mm支架、3例选择7 mm×40 mm支架,支架平均直径(8.67±0.68)mm;术后11例(17.46%)出现穿支静脉回流缓慢。余30例于球囊扩张状态下行颈动脉或椎动脉造影术而选择支架的患者中3例选择8 mm×40 mm支架、11例选择7 mm×40 mm支架、16例选择6 mm×40 mm支架,支架平均直径(7.57±0.67)mm;术后仅1例(3.33%)出现穿支静脉回流缓慢。两组患者选择的支架直径(t=15.632,P=0.001)和术后穿支静脉闭塞发生率(校正χ2=60.065,P=0.001)差异均有统计学意义。结论脑静脉窦内支架植入术后穿支静脉闭塞是较为常见的并发症,术中于球囊扩张状态下行脑血管造影术可以有效预测穿支静脉闭塞的可能性,并为选择适宜直径的支架提供依据。     

血管内局部溶栓治疗颅内静脉窦血栓

目的评价局部溶栓与机械碎栓治疗静脉窦血栓的影像学资料与治疗效果。方法对7例静脉窦血栓病人经股静脉穿刺,将微导管选择性插入已闭塞的静脉窦内。6例行静脉窦局部灌注尿激酶或基因重组组织型纤溶酶原激活剂,1例采用球囊机械碎栓术;3例伴脑皮质或深部静脉血栓者同时经颈动脉给予溶栓药。结果造影示6例已闭塞的静脉窦部分再通,1例无明显再通;3例侧支静脉回流增多。1例溶栓后原有脑内血肿增大,导致偏瘫加重;1例术后发生无症状出血性静脉梗死。随访10个月~3年,6例mRankin评分0~1分,1例mRankin评分2分。结论血管内局部溶栓治疗静脉窦血栓,静脉窦完全再通率低,但血管部分再通及侧支静脉回流增多,可改善病人的临床预后。     

脑静脉窦血栓形成17例临床分析

目的总结颅内静脉窦血栓形成的治疗经验。方法回顾性分析17例颅内静脉窦血栓形成病人的临床资料,其中包括行单纯抗凝、经颈动脉溶栓和经静脉接触性溶栓治疗。术后继续抗凝治疗12～18个月。术后随访2～29个月,平均18个月。结果2例行单纯抗凝治疗,3例行以抗凝治疗及颈动脉穿刺尿激酶注射,4例行动脉内溶栓,8例在动脉内溶栓同时行静脉窦内超选插管溶栓治疗。出院时,所有病人临床症状改善和颅内压恢复,未出现与血管内治疗相关的并发症。结论血管内治疗是颅内静脉窦血栓安全、有效的治疗手段。     

重症颅内静脉窦血栓形成的血管内治疗

目的探讨重症颅内静脉窦血栓形成血管内治疗方法的选择、溶栓药物的使用及其疗效和安全性。方法8例重症颅内静脉窦血栓形成患者均采用经静脉接触性溶栓治疗,其中2例联合机械性破栓术治疗,2例联合静脉窦内支架置入术治疗,2例动静脉联合溶栓治疗。结果除1例患者出现脑内血肿,留有一侧肢体轻瘫外,其余7例患者术中、术后均未出现与血管内治疗相关的并发症。出院时,患者格拉斯哥昏迷评分(GCS)评分由术前平均11分恢复到15分,原有的临床症状均得到改善(100%),闭塞的静脉窦均再通。平均随访12个月,所有患者腰穿压力均恢复正常,未出现血栓再形成和新的神经系统症状。结论对重症颅内静脉窦血栓形成患者采用合理的血管内介入治疗手段是有效的,对溶栓药物的使用、提高治疗安全性等问题上有待进一步研究。     

静脉侧支回流在多发性脑静脉窦血栓病中的作用(附89例分析)

目的 探讨静脉侧支回流在多发性脑静脉窦血栓病程中的作用。方法对我科收治的89例多发性脑静脉窦血栓病人采用经颈动脉溶栓、静脉窦内留置微导管连续溶栓等治疗方法，同时辅以全身抗凝治疗，观察临床效果和侧支循环的变化。结果所有病例治疗后颅内压均明显下降，DSA示残留静脉窦有回流63例，海绵窦代偿性引流75例，椎静脉丛引流35例，头皮静脉代偿引流14例。结论血管内溶栓和抗凝是治疗脑静脉血栓较为可靠和安全的方法：静脉侧支回流的建立和加强对于多发性脑静脉窦血栓的治疗和预后判断意义重大。     

经血管内溶栓并支架成形术治疗侧窦血栓形成

目的观察静脉窦内溶栓并支架成形术治疗侧窦血栓形成的效果。方法对21例诊断明确的侧窦血栓形成患者施行经静脉窦内留置微导管连续尿激酶溶栓治疗,并辅以肝素钠全身抗凝治疗,其中9例溶栓效果欠佳者采用静脉窦内自膨式支架(Wallstent或Smart)成形术。结果经静脉窦内直接溶栓及窦内支架成形术治疗后,21例中静脉窦完全再通者11例,部分再通9例,1例未通。其中8例静脉侧支循环明显改善,建立以海绵窦代偿性引流、椎静脉丛引流以及头皮静脉代偿引流等3种方式。手术后所有患者颅内压均降至≤200mmH2O(2kPa),8例于手术后7d内再次出现不同程度颅内压水平升高,经持续肝素钠抗凝治疗后恢复至正常值水平。随访3个月～6年,20例患者症状持续缓解,未复发。结论静脉窦内持续尿激酶溶栓并支架成形术治疗侧窦血栓形成、促进静脉窦血液回流、降低颅内压安全可靠,手术后继续应用抗凝药物可以维持长期疗效。     

上矢状窦远端置管持续尿激酶泵入接触性溶栓治疗颅内静脉窦血栓形成(9例报道)

目的 探讨上矢状窦远端置管持续尿激酶泵入接触性溶栓治疗颅内静脉窦血栓形成的疗效和安全性. 方法 聊城市人民医院神经内科自2008年1月至2011年1月对9例难治性颅内静脉窦血栓形成患者进行了上矢状窦远端置管持续尿激酶泵入接触性溶栓治疗,辅以机械性血栓切割,以血栓全部或大部分溶解、闭塞的脑静脉窦主干再通为停止溶栓指征.术后积极治疗原发病及抗血小板聚集治疗6个月.出院后随访9～30个月,内容包括腰穿、眼底检查和MRV或DSA检查. 结果 出院时9例患者的闭塞静脉窦均再通,动静脉循环时间正常,皮层静脉和深静脉恢复正常,临床症状改善,颅内压恢复,眼底水肿明显减轻或消失,GCS评分由术前平均10分恢复到15分,未出现与血管内治疗相关的并发症;平均随访20个月后无一例患者血栓再形成,未出现新的神经功能缺失症状. 结论 上矢状窦远端置管持续尿激酶泵入接触性溶栓治疗颅内静脉窦血栓形成是一种安全、有效的治疗手段.     

Individual propensity for thrombosis: comparison of venous and arterial circulations

Introduction

The pathogenesis of venous thrombosis has been attributed to complex interaction between environmental and inherited variables. A basal predisposition for venous thrombophilia independent of environmental variables has not been previously defined experimentally. Both to address the existence of an individual propensity to venous thrombosis and to establish an animal model in which variables governing this propensity could be tested, we provoked venous thrombi in a cohort of pigs of uniform size and age. We furthermore sought to determine whether the thrombotic propensity in the venous circulation is associated with similar propensity for arterial thrombosis.

Materials and methods

Bilateral iliac venous stents were deployed and 2 h later, thrombi were harvested and weighed. The thrombotic response was compared to carotid arterial thrombi generated by crush injury within the same pig. Venous and arterial thrombus platelet deposition were measured by scintillation detection of autologous ¹¹¹In-platelet content.

Results

In a cohort of 27 pigs, venous thrombus weights and platelet content varied over greater trrhan 10-fold range from least to greatest responders. There was strong intra-individual correlation of thrombus platelet deposition (r = 0.86; p = 0.008) and thrombus weights (r = 0.68; p = 0.015) between stented iliac vein pairs. Venous thrombosis correlated with whole blood platelet counts but not carotid platelet-rich thrombus formation.

Conclusions

The wide variation in venous thrombotic response to a standardized injury appears to represent an intrinsic propensity of the individual. The poor correlation with arterial thrombosis implies unique mechanisms responsible for this propensity in arteries and veins.     

Lipopolysaccharide augments venous and arterial thrombosis in the mouse

BACKGROUND: Animal models of diseases are essential for therapeutic target validation, drug discovery and development. Increasing evidence has demonstrated the importance of inflammation in thrombosis. Here, murine models of vena cava thrombosis and carotid arterial thrombosis augmented by lipopolysaccharide (LPS) were established and characterized to study the association between inflammation and thrombosis. MATERIALS AND METHODS: Murine (C57BL/6 mice) models of ferric chloride (FeCl(3))-induced carotid arterial and vena cava thrombosis were established. Thrombus formation was measured indirectly by Doppler blood flow (i.e., clot functional interference with blood flow) in the arterial thrombosis model and directly by protein content of the clot in the venous thrombosis model. An optimal concentration of FeCl(3) was defined to induce thrombus formation and used to study the effects of LPS (i.e., a well-known inflammatory stimulus under these conditions). Real-time polymerase chain reaction (PCR) was used to examine the effect of LPS on TNFalpha and IL-1beta mRNA expression in thrombus formation. RESULTS: Dose-dependent analysis demonstrated that 2 mg/kg, i.p., LPS provided a maximal prothrombotic effect in 2.5% ferric chloride-induced vena cava thrombosis, with a 60% increase in thrombus size (n=8, p<0.05) compared to vehicle treatment. In contrast, 2 mg/kg LPS had no significant effect on thrombus formation in a more severe, 3.5% FeCl(3)-induced vena cava thrombosis. A similar prothrombotic effect was observed for LPS in 2.5% FeCl(3)-induced carotid arterial thrombosis model. Treatment of 2 mg/kg LPS significantly augmented arterial thrombosis immediately (between 5-30 minutes) following FeCl(3) injury as assessed by change of Doppler blood flow (n=8, p<0.05). Real-time PCR demonstrated significant induction of TNFalpha and IL-1beta mRNA expression in the thrombus formation in the vessels in response to LPS challenge. CONCLUSION: These data demonstrate that LPS augments thrombus formation in acute vascular injury and that LPS-augmented thrombosis might be a useful tool to study the relationship between inflammation and thrombosis.     

Dural sinus thrombosis: a mechanism-based classification and review of 42 cases

Cranial venous outflow obstruction due to dural sinus thrombosis may result in venous hypertension, cerebral infarction, cerebral haemorrhage or impaired cerebrospinal fluid (CSF) absorption with consequent pseudotumour syndrome. We propose a mechanism based classification of dural sinus thrombosis from these four outcomes. Forty two cases of dural sinus thrombosis presenting to Royal Prince Alfred Hospital between 1986-1997 were retrospectively reviewed. These cases were classified according to mechanism of presentation and relevance of this to site of thrombosis, treatment and prognosis. This study shows that the superior sagittal sinus and transverse sinus are the commonest sites of thrombosis, and multiple sites of thrombosis (69%) are more frequent than a single site. Magnetic resonance imaging (MRI) with venous flow studies is the investigation of first choice for diagnosis but angiography remains the gold standard. A pseudotumour syndrome is the commonest presentation (43%) followed by cerebral haemorrhage (31%). The overall prognosis for sinus thrombosis is good, with 71% of cases recovering to normal function.     

Antiphospholipid antibodies and thrombosis

Antiphospholipid syndrome is an autoimmune disease which combines vascular thrombosis and/or pregnancy complications with the presence of antiphospholipid antibodies. It could be a devastating and sometimes life-threatening condition. As vascular thrombosis presents as typical venous or arterial thromboembolism diagnosis is based on laboratory data. Therefore proper performance and interpretation of laboratory tests is crucial. Broader knowledge about clinical and laboratory aspects of the syndrome and their associations are essential for proper evaluation and management of the patients.     

Comparison of catheter-related large vein thrombosis in centrally inserted versus peripherally inserted central venous lines in the neurological intensive care unit

Objective

To compare cumulative complication rates of peripherally (PICC) and centrally (CICVC) inserted central venous catheters, including catheter-related large vein thrombosis (CRLVT), central line-associated bloodstream infection (CLABSI), and line insertion-related complications in neurological intensive care patients.

Methods

Retrospective cohort study and detailed chart review for 431 consecutive PICCs and 141 CICVCs placed in patients under neurological intensive care from March 2008 through February 2010. Cumulative incidence of CRLVT, CLABSI, and line insertion-related complications were compared between PICC and CICVC groups. Risk factors for CRLVT including mannitol therapy during dwell time, previous history of venous thromboembolism, surgery longer than 1 h during dwell time, and line placement in a paretic arm were also compared between groups.

Results

During the study period, 431 unique PICCs were placed with cumulative incidence of symptomatic thrombosis of 8.4%, CLABSI 2.8%, and line insertion-related complications 0.0%. During the same period, 141 unique CICVCs were placed with cumulative incidence of symptomatic thrombosis of 1.4%, CLABSI 1.4%, and line insertion-related complications 0.7%. There was a statistically significant difference in CRLVT with no difference in CLABSI or line insertion-related complications.

Conclusions

In neurological critical care patients, CICVCs appear to have a better risk profile compared to PICCs, with a decreased risk of CRLVT. As use of PICCs in critical care patients increases, a prospective randomized trial comparing PICCs and CICVCs in neurological critical care patients is necessary to assist in choosing the appropriate catheter and to minimize risks of morbidity and mortality associated with central venous access.