基底动脉闭塞的溶栓治疗

基底动脉闭塞的临床诊断通常比较困难,预后较差。动脉和静脉溶栓治疗使闭塞的基底动脉再通是最有效的治疗手段。动脉溶栓与静脉溶栓治疗的患者临床预后相似,但静脉溶栓技术简单,易于操作和推广。     

急性基底动脉闭塞应该进行动脉溶栓治疗吗?

急性基底动脉闭塞临床上较少见,但病情进展迅速且凶险,病死率高达40%～85%.对于这一疾病的紧急治疗是否应采取动脉溶栓,抑或静脉溶栓,甚至保守治疗,目前尚存在争论.有人认为,为了挽救患者的生命,应采取动脉溶栓;也有人认为,急性基底动脉闭塞采用动脉溶栓治疗的有效性目前尚缺乏有力的证据,让患者承担动脉溶栓带来的操作风险和经济负担并不值得.因此主张在有条件的医疗中心开展随机对照试验,以获得有力的证据.     

急性脑动脉闭塞的血管造影分级及溶栓治疗疗效评估系统

重组组织型纤溶酶原激活剂（rt-PA）静脉内溶栓治疗已成为公认的治疗急性缺血性卒中的有效方法，但该治疗方法仅限于发病3h以内的患者，且有较高的颅内出血发生率，治疗时间窗很窄，因此，其临床应用受到很大限制，只有一小部分患者能得到及时治疗。而现代医学影像技术指导下的动脉溶栓治疗，能够确定是否存在可逆性缺血脑组织，使溶栓治疗适应证选择更科学，显著延长溶栓治疗的时间窗，提高血管再通率和改善神经功能预后。研究表明，急性期全脑血管造影（DSA）所反映的脑血管闭塞的部位、程度、侧支循环、血管再通和血流灌注情况等诸多因素均与预后密切相关。因此，对急性脑缺血患者全面、客观的血管造影分级对介入治疗适应证选择、预测血管再通率及临床疗效具有重要作用。现就目前常用的急性缺血性卒中DSA分级标准进行综述如下。     

急性基底动脉闭塞再通治疗及临床预后影响因素研究进展

急性基底动脉闭塞的患病率低,却伴随着高病死率及致残率。早期再通可改善患者的临床预后及降低患者病死率,然而其临床预后受到多种因素的影响,如年龄、发病机制、发病至再通时间、血管再通率、侧支循环开放程度等。作者就急性基底动脉闭塞再通治疗及临床预后影响因素的研究进展进行综述。     

椎基底动脉闭塞致急性脑卒中的血管内治疗

缺血性卒中占脑血管事件的86%,其中约20%发生在椎基底动脉系统。急性椎基底动脉闭塞(AVBAO)预后不佳,其死亡率可达80%~95%。由于常规的内科药物治疗预后较差,人们一直在探索动脉溶栓及其他血管内介入治疗等方法。椎基底动脉闭塞再通的患者更有可能获得良好的功能预后,因此近年来机械辅助溶栓,取栓、碎栓装置越来越多应用于临床。     

急性椎基底动脉闭塞性脑梗死患者血管内治疗后无效再通的影响因素分析

目的 探讨急性椎基底动脉闭塞（AVBO）性脑梗死患者血管内治疗后无效再通的影响因素。方法回顾性选取2018年10月—2022年12月南阳市中心医院收治的行血管内治疗的AVBO性脑梗死患者196例为研究对象。收集患者的临床资料,术后90 d采用改良Rankin量表（mRS）评分评估患者预后情况,并将其分为有效再通（mRS评分≤3分）和无效再通（mRS评分>3分）。采用ROC曲线分析中性粒细胞与淋巴细胞比值（NLR）、美国国立卫生研究院卒中量表（NIHSS）评分、后循环Alberta卒中项目早期CT评分（pc-ASPECTS）、基底动脉CT血管成像（BATMAN）评分、急性基底动脉闭塞血管造影侧支分级系统（ACGS-BAO）分级预测AVBO性脑梗死患者血管内治疗后无效再通的最佳截断值;采用多因素Logistic回归分析探讨AVBO性脑梗死患者血管内治疗后无效再通的影响因素。结果 196例AVBO性脑梗死患者中,无效再通110例（56.1%）。有效再通与无效再通者收缩压、有糖尿病史者占比、NLR、NIHSS评分、pc-ASPECTS、BATMAN评分、ACGS-BAO分级比较,差异有统...     

基底动脉闭塞溶栓后迟发性再通一例

患者男,51岁。主因“突发右侧肢体麻木、乏力,饮水呛咳3周”于2009年6月30日以“脑梗死”收入外院。患者于3周前无明显诱因突然出现右侧肢体麻木、乏力,饮水呛咳,声音嘶哑,伴头晕;无头痛,无恶心、呕吐,无意识障碍,无肢体抽搐。既往有高血压病史10年。体检：血压170／90mmHg,意识清楚,查体合作,轻度构音障碍,双侧瞳孔等大等圆,     

动脉溶栓和支架置入术治疗急性基底动脉闭塞

目的:探讨和评价急性基底动脉闭塞(BAD)预后的预测因素以及动脉溶栓和支架置人术治疗BAO的临床疗效.方法:52例BAO患者,在3～48 h内采用重组组织型纤溶酶原激活剂或尿激酶动脉溶栓,溶栓后血管残余狭窄＞50%的部分再通者行支架置入术.术前进行美国国立卫生研究院卒中量表(NIHSS)评分,术后3个月时进行改良Rankin量表(mRS)评分.临床资料应用逐步多因素logistic回归分析和Fisher确切概率检验.结果:血管完全再通24例(46.2%),部分再通16例(30.7%),未再通12例(23.1%).mRS评分:转归良好22例(42.3%),生存32例(61.5%),死亡20例(38.5%).BAD预后与NIHSS评分(P＜0.01)、治疗时间窗(P＜0.05)以及溶栓后血管再通程度(动脉溶栓和支架置入术后)(P＜0.01)显著相关;动脉溶栓后血管良好再通与NIHSS评分(P＜0.01)和治疗时间窗(P＜0.05)显著相关.多因素分析显示,NIHSS评分(P＜0.01)和血管再通程度(P＜0.01)可独立预测BAO预后.结论:NIHSS评分＜14分和血管再通良好是BAO预后良好的独立预测因素,快速及时地动脉溶栓和支架置人术是治疗BAD安全有效的措施.     

急性基底动脉闭塞的血管内介入治疗研究进展

急性基底动脉闭塞（ABAO）是一组因动脉粥样硬化、血栓形成、栓子脱落或其他原因导致的急性基底动脉血流阻断,引起小脑、脑干等重要部位急性缺血而出现相应神经功能缺损的症候群.研究显示,ABAO占所有缺血性卒中的3％、症状性椎基底缺血性卒中的8％,未经治疗的ABAO患者病死率高达90％;早期行血管再通能挽救缺血半暗带,有效改善患者的预后.血管内介入技术可明显提高血管再通率,其治疗方法包括动脉溶栓（IAT）、静脉溶栓（IVT）＋IAT、支架辅助取栓术、血栓吸除术及机械性血栓摘除术等.本文结合文献对ABAO的血管内介入治疗研究进展综述如下.     

血管内机械再通治疗急性基底动脉闭塞的疗效分析

目的探讨机械再通治疗急性基底动脉闭塞患者的近期疗效。方法回顾性分析12例基底动脉急性闭塞并接受支架辅助血管内再通治疗的患者资料。对8例患者使用Apollo或Wingspan支架,4例使用Solitaire AB支架。血管内介入治疗后按照脑梗死溶栓等级系统(TICI)分级评定血管再通情况。评估3个月后的临床结局。结果①基底动脉远段闭塞3例,近段闭塞4例,椎动脉颅内段延伸至基底动脉近段闭塞3例,基底动脉全程闭塞2例。术前美国国立卫生研究院卒中量表(NIHSS)评分的中位数为20(15～24)分。②血管内机械再通治疗的技术成功率为100%,10例达到充分再通标准。2例患者术中发生血管痉挛,无临床症状。1例发生症状性颅内出血。③患者出院时NIHSS评分中位数为10(4～22)分,同最初NIHSS评分相比,7例患者NIHSS评分改善≥5分。④4例术后3个月的功能转归良好,死亡3例。结论血管内机械再通治疗急性基底动脉闭塞具有较高的再通率,可改善3个月时的临床结局。针对基底动脉闭塞不同病因需要个性化的血管内治疗方法。     

临床症状与弥散加权成像不匹配的基底动脉急性闭塞患者的血管内再通治疗

目的 探讨临床症状与弥散加权成像不匹配(CDM),且起病时间≥24h的基底动脉急性闭塞(BAO)患者行血管内再通治疗(ERT)的可行性. 方法 共纳入11例起病时间≥24h入院时格拉斯哥昏迷量表(GCS)评分＜8分、弥散加权成像( DWI)未发现脑干网状结构和双侧丘脑有损害的患者.单独或联合使用重组组织型纤溶酶原激活剂...     

Diagnosis and thrombolytic therapy of acute basilar artery occlusion: a review

Acute basilar artery (BA) occlusion is associated with an extremely high mortality. The pathogenesis in younger patients is usually embolism form cardiac sources or less frequently from vertebral artery dissection. Local atherothrombosis is more common in elderly patients. Differently to the carotid territory, for the vertebrobasilar territory there are no placebo controlled studies proving efficacy of thrombolytic treatment. Furthermore, neither the best route of administration nor the best fibrinolytic agent have been evaluated. Several uncontrolled series, however, indicate that intraarterial thrombolysis reduces mortality of patients with BA occlusion. Recanalization rates average 60% and are associated with occlusions of embolic etiology. Mortality with an average rate of 40-60% is significantly lower in the recanalization group in most series. Other independent variables affecting mortality are identified as length of obstruction, proximal BA occlusion, collateralization, high age, and initial poor clinical state. Time from onset of symptoms to start of intraarterial thrombolysis, however, is not associated with recanalization or mortality rate. This indicates that differently from thrombolytic treatment in the anterior circulation there is no fixed time window in BA thrombosis. Rate ofparenchymal hemorrhage seems to be lower with an average of 6% compared with systemic thrombolytic therapy in hemispheric stroke. Recanalization of the BA is clinically beneficial under certain circumstances only: (1) BA occlusion should affect only one segment; (2) an effective collateral supply is essential; and (3) the patient should not already be tetraplegic or comatose for a longer period of time. Clinical outcome and assessment of quality of life on follow-up of survivors with successful recanalization encourage thrombolysis in acute BA occlusions of embolic origin.     

EkoSonicSV endovascular system for recanalization of the basilar artery occlusion

The interventional management of stroke may consist of the use of angioplasty, stenting or mechanical thrombus removal technique. For this purpose several retrieval devices are being used. Recently the new alternative device - EkoSonicSV has been introduced, which is particularly suitable for recanalization of the occluded basilar artery (BA). Here we are presenting a complete recanalization of BA using this device in two patients with stroke over a short period of time together with the intra-arterial use of recombinant tissue plasminogen activator and application of intravascular ultrasound.     

Late thrombotic occlusion of saphenous vein grafts: successful recanalization using thrombolytic therapy

We report two cases in which thrombosis was the primary cause of vein graft occlusion many years after bypass surgery. Both displayed minimal thrombolysis immediately after a selective infusion of streptokinase but were patent when reimaged hours later. Such therapy may be helpful when graft occlusions are associated with a large volume of thrombus.     

Prediction of infarct coronary artery recanalization after intravenous thrombolytic therapy

Clinical assessment of patients with evolving acute myocardial infarction may suggest recanalization of the infarct coronary artery if chest pain, electrocardiographic ST-segment elevation and reperfusion arrhythmia are diminished. These 3 criteria, however, have not been correlated with immediate coronary angiography. Determination of which patients will achieve myocardial reperfusion after intravenous fibrinolytic therapy would allow for appropriate triage; those in whom it fails may be considered for mechanical or surgical recanalization. Fifty-six patients were studied: 28 received intravenous streptokinase and 28 intravenous recombinant tissue-type plasminogen activator. None of these clinical criteria, considered separately, was predictive of infarct artery recanalization status. Using the presence or absence of all 3 criteria, the specificity and predictive value increased to 100%. However, only 9% of patients in the series had all 3 criteria present (all had a patent infarct artery) and 34% had no criteria present (all had an occluded vessel). Noninvasive clinical markers are simple and practical, but only concordance of all 3 major criteria, when present, accurately predicts results of thrombolytic therapy.     

颈动脉完全闭塞患者血管再通术的预后变化及相关因素分析

目的探讨症状性颈动脉完全闭塞患者血管再通术的安全性、有效性及相关影响因素。方法选择62例症状性颈动脉完全闭塞患者,分为介入组21例(血管再通术)和药物组41例。随访发病2年时功能预后,以改良的Rankin量表(mRS)评分表示,行多因素logistic回归分析。结果介入组患者在3、6个月、1及2年随访时,mRS平均秩次均低于药物组(P<0.05,P<0.01)。logistic回归分析显示,mRS评分与吸烟(P=0.036)、美国国立卫生研究院卒中量表评分(P=0.018)、介入治疗(P=0.003)相关,其中介入治疗是预后独立保护因素。结论血管再通术治疗症状性颈动脉完全闭塞患者可能是安全有效的,可能是患者功能预后的独立保护因素。     

Endovascular therapy for acute basilar artery occlusion caused by vertebral artery dissection: Case report

Rationale:The best endovascular therapy revascularization strategies for acute ischemic stroke caused by vertebral artery dissection (VAD) are unclear. We describes a case of basilar artery (BA) occlusion caused by extracranial VAD, in which we used a stent-retriever to achieve thrombectomy in the BA through the contralateral vertebral artery (VA).Patient concerns:A 32-year-old male presented with a sudden-onset headache accompanied by articulation disorder, left-sided weakness, and tinnitus in the left ear.Diagnosis:Digital subtraction angiography showed the V1 to V2 segment dissection of the left VA and occlusion of the BA.Interventions:Thrombectomy was performed through the thinner right VA with three passes of the Solitaire FR device 4 × 20 mm in the BA, and angiograms showed modified treatment in cerebral ischemia 3 reperfusion of BA and left VA V4 segment still occluded.Outcomes:The patient had a modified Rankin Scale of 2 at 90 days, and re-established blood flow of the left VA and BA.Lessons:When extracranial VAD complicated with BA occlusion, choosing the clean-road path to perform a BA thrombectomy may be a fast and effective treatment strategy.     

动脉内超选择性溶栓治疗急性缺血性脑梗死

目的 观察动脉内超选择性尿激酶溶解血栓以治疗急性缺血性脑梗死的疗效及并发症。方法 对46例发病于6h内的急性缺血性脑梗死患者行动脉内超选择性尿激酶溶解血栓治疗。结果 经溶解血栓治疗后完全再通24例(52，2％)，部分再通7例(15．2％)，未通15例(32．6％)；溶解血栓治疗后3个月恢复良好的患者22例，中残5例，重残5例，植物生存6例，死亡8例。31例溶通患者中良好、中残者20例(64.5％)，15例未溶通患者中良好、中残者4例(26．7％)，溶栓后脑出血6例(13％)。结论 动脉内超选择性尿激酶溶解血栓能明显提高闭塞血管再通率，明显改善预后，是治疗急性缺血性脑梗死的一种有效和相对安全的方法。     

Intracoronary fibrin-specific thrombolytic infusion facilitates percutaneous recanalization of chronic total occlusion

OBJECTIVES: We sought to investigate the benefit, predictors of procedural success, and safety of pre-procedural intra-coronary fibrin-specific lytic infusion (ICL) in patients with failed prior percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). BACKGROUND: Percutaneous coronary intervention for CTO remains a challenge with a high incidence of procedural failure secondary to inability to cross the occlusion with the guidewire. METHODS: Eighty-five patients who underwent unsuccessful PCI procedures of CTO (more than three months' duration) had a repeat attempt of recanalization with the use of pre-procedural ICL. Patients received a weight-adjusted dose of either alteplase (tPA) (2 to 5 mg/h) or tenecteplase (TNK) (0.5 mg/h) for a total of 8 h. The total dose of ICL therapy was infused split between the guiding catheter and an intracoronary infusion catheter. A step-down multivariate logistic regression analysis was completed to determine the best predictors of procedural success. In-hospital major adverse cardiac events (MACE) including myocardial infarction, acute reocclusion, stroke, and death, as well as bleeding complications, were also examined. RESULTS: The procedure was successful in 46 of 85 cases (54%). Four of 85 (5%) contained dissections that did not result in perforations, tamponade, or MACE. The incidence of groin complications was 7 of 85 (8%) and of bleeding complications requiring transfusions was 3 of 85 (3.5%). On multivariate analysis, predictors of success were tapering morphology (odds ratio, 15.5; 95% confidence interval, 3.73 to 63; p = 0.0002) and lack of bridging collaterals (odds ratio, 5.08; 95% confidence interval, 1.53 to 17; p = 0.008). CONCLUSIONS: Intracoronary infusion of fibrin-specific thrombolytic therapy may provide a valuable and safe option for facilitating percutaneous revascularization of CTO.