Trevo支架与Solitaire支架对急性缺血性脑卒中的血管再通疗效比较

目的 比较Trevo支架和Soliatire支架对急性缺血性脑卒中(acute ischemic stroke,AIS)机械取栓术中血管再通及术后并发症的影响。方法 回顾性纳入200例在本院接受支架取栓术的AIS患者,根据选用的支架类型将患者分为Solitaire支架组(102例)和Trevo支架组(98例); 以NIHSS评分和改良Rankin量表(mRS)评估患者的神经功能预后; 以脑梗死溶栓分级(thrombolysis in cerebral infarction,TICI)评估血管再灌注情况,比较患者术后并发症的发生率,并通过logistics回归分析确定影响并发症发生及血管再通的独立危险因素。结果 Trevo组的30d NIHSS评分显著低于Solitaire组[3(0～13)vs 6(0～17),P<0.05],且90d的mRS评分也显著低于Solitaire组[2(0～5)vs 3(0～6),P<0.05],但2组术后脑卒中进展、远端血栓或栓子形成、术后出血、死亡等并发症发生率无明显差异(P>0.05)。与Solitaire支架组比较,Trevo支架组的取栓时间更短[51(30～165)min vs 70(27～160)min,P<0.05]、取栓次数更少[2.1(1～6)次 vs 2.9(1～8)次,P<0.05]、取栓1次成功率更高(40.8% vs 27.5%,P<0.05)、TICI达2b或3级的血管再通率更高(89.8% vs 79.4,P<0.05)。发病到治疗时间≥360 min是影响术后并发症发生的独立危险因素(OR=1.084,95% CI=1.041～1.223,P=0.029),而血管再通TICI达2b或3级是预防术后并发症的独立保护性因素(OR=0.858,95% CI=0.761～0.977,P=0.016)。使用Trevo支架是促进血管再通的独立保护性因素(OR=0.722,95% CI=0.541～0.928,P=0.018,而取栓次数≥2次则是影响血管再通的独立危险因素(OR=1.460,95% CI=1.248～2.303,P=0.015)。结论 与Solitaire支架比较,Trevo支架能够减少AIS患者的取栓次数、缩短取栓时间,并提高闭塞血管的再通率和促进神经功能恢复。     

Endovascular Therapy for Ischemic Stroke

The utility of intravenous tissue plasminogen activator (IV t-PA) in improving the clinical outcomes after acute ischemic stroke has been well demonstrated in past clinical trials. Though multiple initial small series of endovascular stroke therapy had shown good outcomes as compared to IV t-PA, a similar beneficial effect had not been translated in multiple randomized clinical trials of endovascular stroke therapy. Over the same time, there have been parallel advances in imaging technology and better understanding and utility of the imaging in therapy of acute stroke. In this review, we will discuss the evolution of endovascular stroke therapy followed by a discussion of the key factors that have to be considered during endovascular stroke therapy and directions for future endovascular stroke trials.     

Recurrent Cardioembolic Stroke Treated Successfully with Repeated Mechanical Thrombectomy within the Acute Index Stroke Period

Background

The safety of repeated mechanical thrombectomy within the acute stroke period has not yet been clearly demonstrated. We describe herein a patient who was successfully treated with repeated mechanical thrombectomy within the acute index stroke period.

Case Report

A 50-year-old woman with atrial fibrillation presented with left-sided weakness caused by occlusion of the right middle cerebral artery (MCA). Emergent mechanical thrombectomy with the Solitaire device achieved complete recanalization. The left MCA occlusion redeveloped at 6 days after the first treatment, at which time her international normalized ratio (INR) was 2.3. Endovascular thrombectomy was reattempted rapidly and complete recanalization was achieved again. Her neurologic symptoms resolved after the thrombectomy.

Conclusions

This case demonstrates that repeated mechanical thrombectomy can be safely and successfully performed even in a patient with a high INR and a recurrent stroke during the acute period after the index stroke.     

“Missing clot” during mechanical thrombectomy in acute stroke using Solitaire stent retrieval system

Stent retrieval system is an established treatment modality in acute ischemic stroke with large vessel occlusion. Here, we describe a complication which occurred during mechanical thrombectomy in three cases where the clot dislodged during retrieval. There was a possibility of the clot getting reinjected into the artery with possible dire consequences.     

急性缺血性脑卒中患者介入取栓后出血转化的相关危险因素

目的探讨急性缺血性脑卒中(AIS)患者介入取栓后出血转化(HT)的危险因素.方法选择本院2017年1月一2020年1月收治的AIS患者226例,所有患者均接受介入取栓治疗,比较2组年龄、性别、既往史、吸烟史、饮酒史、溶栓治疗情况、闭塞血管等临床资料,多因素Logistic回归分析AIS患者取栓术后HT发生的危险因素.结...     

Revascularization in acute ischaemic stroke using the penumbra system: the first single center experience

Background and purpose:  This is the first single center experience illustrating the effectiveness of the penumbra system (PS) in the treatment of large vessel occlusive disease in the arena of acute ischaemic stroke. The PS is an innovative mechanical thrombectomy device, employed in the revascularization of large cerebral vessel occlusions in patients via the utilization of an aspiration platform.
Methods:  This is a prospective, non-randomized controlled trial evaluating the clinical and functional outcome in 29 patients with acute intra-cranial occlusions consequent to mechanical thrombectomy by the PS either as mono-therapy or as an adjunct to current standard of care. Patients were evaluated by a neurologist and treated by our in house interventional neuro-radiologists. Primary end-points were revascularization of the occluded target vessel to TIMI grade 2 or 3 and neurological outcome as measured by an improvement in the NIH Stroke Scale (NIHSS) score after the procedure.
Results:  Complete revascularization (TIMI 3) was achieved in 21/29 (72.4%) of patients. Partial revascularization (TIMI 2) was established in 4/29 (13.8%) of patients. Revascularization failed in four (13.8%) patients. Nineteen (19) patients (65.5%) had at least a four-point improvement in NIHSS scores. Modified Rankin scale scores of ≤2 were seen in 37.9% of patients. There were no device-related adverse events. Symptomatic intra-cranial hemorrhage occurred in 7% of patients.
Conclusions:  The PS has the potential of exercising a significant impact in the interventional treatment of ischaemic stroke in the future.     

急性缺血性脑卒中机械取栓术中困难通路的处理策略

目的 探讨在急性缺血性脑卒中机械取栓术中困难通路的处理策略。方法 回顾性分析2016年6月至2021年5月该院收治的42例急性缺血性脑卒中机械取栓术中困难通路患者的临床资料,男性24例,女性18例,年龄为56~82岁,平均年龄(70±12)岁。患者术前美国卫生研究院卒中量表(NHISS)评分为(17±2)分,取栓前闭塞动脉血流的改良脑梗死溶栓分级(mTICl分级)均为0级。术中采用Solitaire AB取栓支架动脉内取栓或抽吸导管直接抵近栓子抽栓。术中分别运用同轴技术、导丝交换技术、中间导管、球囊或支架锚定、直接桡动脉穿刺等技术处理困难通路。结果 困难通路中主动脉弓路径迂曲12例,颈动脉路径迂曲15例,大脑中动脉路径迂曲12例,双侧椎动脉闭塞2例,双侧股动脉闭塞1例。术后4例血管未开通,其余38例患者成功开通闭塞血管,血流达2b/3级,开通率达90%。术后90 d的改良Rankin评分良好(0~2级)24例,残疾(3~4级)14例,死亡4例。术中平均所用时间为(40±7.7)min。结论 困难通路是急性缺血性脑卒中机械取栓预后差的一个重要因素,正确识别与处理困难通路可以节省手术时间,改善患者临床结局。     

Endovascular management of extracranial occlusions at the hyperacute phase of stroke with tandem occlusions

Background and purpose

The management of cervical artery occlusions in hyperacute stroke with tandem cervical/intracranial occlusions has not yet become standardized, especially when the circle of Willis is effective.

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。