颈动脉狭窄血管重建术后过度灌注综合征

随着颈动脉狭窄血管重建术 (包括颈动脉内膜切除术、颈动脉成形术和支架置入术 )的开展 ,术后过度灌注综合征已引起广泛重视。对于其发生机制、临床监测和治疗方法等问题尚在研究探索中。     

Early recognition of cerebral hyperperfusion syndrome after carotid stenting--a case report

The hyperperfusion syndrome is a recognized complication of carotid endarterectomy. Reports of cerebral hyperperfusion injury following internal carotid artery angioplasty and stenting are few We report a case of 76-year-old hypertensive man who was admitted to our hospital for assessment 2 years after experiencing an ischemic stroke of right hemisphere. Angiography confirmed 60% stenosis of left internal carotid artery (ICA). Percutaneous transluminal stenting of left internal carotid artery was performed without any immediate complications. Two hours after the procedure, the patient suddenly deteriorated. Computed tomography (CT) of the brain revealed extensive intracerebral hemorrhage and he died 5 days later. There was precipitating migranous headache, and his blood pressure was moderately elevated at the time of deterioration. Sentinel headache could solely indicate the early sign of hyperperfusion injury after carotid stenting, especially in the presence of arterial hypertension. Patients with sentinel headache after angioplasty should be recognized early and they deserve intensive study for other features of cerebral hyperperfusion injury and prompt early management.     

Ipsilateral intracerebral hemorrhage following carotid stent-assisted angioplasty: a manifestation of hyperperfusion syndrome--a case report

A case of hyperperfusion syndrome manifested as intracerebral hemorrhage following carotid stent-assisted angioplasty while using intravenous abciximab is described. Review of literature regarding hyperperfusion syndrome in patients undergoing carotid artery revascularization is presented. Possible mechanisms of hyperperfusion and the role of arterial hypertension, anticoagulation, and antiplatelet treatment in the genesis of hyperperfusion syndrome are discussed. Widening use of percutaneous carotid revascularization necessitates physicians' awareness of early recognition of this complication.     

颈动脉支架置入术围手术期血压调控的探讨

目的探讨粥样硬化性颈动脉狭窄患者,经皮血管内支架置入血管成形术(PTAS)围手术期血压调控的必要性及初步经验。方法回顾性分析293例粥样硬化性颈动脉狭窄患者经全脑数字减影血管造影术诊断后,采用自膨式支架经股动脉入路行PTAS,围手术期对血压严密监控,并根据血压的高低采取综合措施及时进行调整,以避免发生高灌注性脑病或心、脑缺血。结果 293例患者中支架置入成功292例(99.7%)。术前狭窄率70%～95%平均(82.0±13.1)%,术后残余狭窄率为0～20%,平均(9.2±6.8)%,术后患者脑缺血症状及体征均有明显改善。有1例患者在术中及术后血压控制不理想,发生了高灌注性脑出血而死亡。通过采取综合措施调节血压后未再发生高灌注性脑病,血压降至90～120/60～90 mm Hg(1 mm Hg=0.133 kPa)后,所有患者均未发生心、肾、脑等脏器缺血。结论 PTAS微创安全有效,但术中及术后调整血压非常必要,围手术期有效地调控血压是减少术后高灌注性综合征发生的重要手段之一。     

颈动脉血管成形和支架置入术的并发症及其处理

颈动脉狭窄是导致脑梗死的重要原因之一。颈动脉血管成形和支架置入术(CAS)已被证实能够预防卒中发生,临床应用越来越广。尽管CAS是一种微创治疗方法,但仍然有许多潜在的并发症,如血流动力学异常、过度灌注综合征、脑梗死和再狭窄等。文章对CAS的并发症及其处理方法进行了综述。     

颈动脉支架置入术后过度灌注综合征的危险因素分析

目的探讨颈动脉支架置入术(CAS)后发生过度灌注综合征(CHS)的危险因素。方法纳入419例患者的临床资料,其中48例同时行双侧CAS,共计行467次CAS。根据是否发生CHS分为CHS组15例和无CHS组404例。采用分层分析法分析术后发生CHS的危险因素。结果与无CHS组比较,CHS组糖尿病、术后高血压比例明显升高,差异有统计学意义(P<0.05,P<0.01)。单因素分析显示,术前糖尿病、术后高血压与CHS相关(P<0.05)。经分层分析显示,术前糖尿病(OR=3.168,95%CI:1.008～9.222,P=0.025)及术后高血压(OR=5.033,95%CI:1.733～14.646,P=0.001)为术后发生CHS的主要危险因素。结论 CAS术前糖尿病及术后伴高血压的患者更容易出现CHS。临床上对于术前有糖尿病史及术后出现高血压的CAS患者必须加以重视,尽早发现和处理CHS。     

Bilateral carotid angioplasty and stenting.

Bilateral carotid stenosis is generally treated by staged stenting procedure and rarely simultaneously due to concerns about hemodynamic impairment from stimulation of the carotid sinus baroreflex (severe bradycardia, hypotension) and the risk of cerebral hyperperfusion syndrome. Most of the accounts of bilateral carotid stenting are of small series. The aim of this study was to evaluate the feasibility and safety of simultaneous bilateral carotid angioplasty and stenting (CAS) in comparison with staged procedure. We retrospectively analyzed the procedural outcome and complications of bilateral CAS done between February 1995 and June 2004 in a consecutive series of 57 high-risk patients. Mean age was 64 +/- 9 years (male, 43; female 14). One hundred fifteen arteries were treated (one patient had bilateral internal carotid artery stenosis associated to an ostial common carotid artery stenosis). Thirty-nine patients were symptomatic (70%). Thirty-six patients had severe coronary artery disease. Seventeen patients underwent a simultaneous bilateral CAS (group 1), 40 in a staged manner (group 2). Among these 40 patients 10 were treated with a time interval of 24 hr, while the 30 other ones were treated with a time interval of 2 days to 2 months. A neuroprotection device was used in the last 42 patients. There was technical success in all patients and transient bradycardia and/or hypotension in 25 patients (44%). There was no prolonged bradycardia or hypotension. At 30 days, we observed in group 1 (simultaneous bilateral CAS) no transient ischemic attack (TIA), no minor stroke, one (5.8%) major stroke (hyperperfusion syndrome with brain hemorrhage leading to death in a patient under IIb/IIIa inhibitors), one myocardial infarction leading to death, and two (11.7%) death/stroke/myocardial infarction; in group 2 (staged procedure), two (5%) TIAs, no minor stroke, no major stroke, and one (2.5%) hyperperfusion syndrome with rapid recovery. Among the 10 patients treated with a time interval of 24 hr, we observed one TIA. Among carefully selected patients, bilateral CAS is feasible simultaneously or the day after, with a safety and complication rate comparable to that of large published series of CAS or endarterectomies in high-risk patients. Nevertheless, careful monitoring of the patient, blood pressure, and heart rate is mandatory to avoid complications related to hyperperfusion syndrome. Routine use of neuroprotection device and meticulous technique should improve the outcomes of bilateral CAS.     

颈动脉内膜切除术后高灌注综合征的诊断与治疗

目的探讨颈动脉内膜切除术后高灌注综合征的机制、临床表现和治疗方法。方法回顾性分析3例颈动脉内膜切除术后高灌注综合征患者的临床资料，特别是术中和术后的血压管理、经颅多普勒超声（TCD）监测脑血流速度和最终的治疗及转归。结果2例患者经严格控制血压1～3d后，脑血流速度恢复正常，脑高灌注状态得以缓解。1例患者因血压控制不佳，导致脑高灌注状态，诱发脑出血而死亡。结论颈动脉内膜切除术后高灌注综合征有潜在的危险，经严格控制血压后，多于术后1～3d缓解。     

Intracranial hemorrhage and hyperperfusion syndrome following carotid artery stenting: risk factors, prevention, and treatment

OBJECTIVES: The study defined the incidence of cerebral hyperperfusion syndrome and intracranial hemorrhage (ICH) and the risk factors for their development following carotid artery stenting (CAS). BACKGROUND: Hyperperfusion syndrome and ICH can complicate carotid revascularization, be it endarterectomy or CAS. Although extensive effort has been devoted to reducing the incidence of ischemic stroke complicating CAS, little is known about the incidence, etiology, and prevention strategies for hyperperfusion and ICH following CAS. METHODS: We retrospectively reviewed the prospective database of 450 consecutive patients who were treated with CAS in our department to identify patients who developed hyperperfusion syndrome and/or ICH. RESULTS: The mean age of the patients was 72.7 +/- 10.9 years, and the mean diameter narrowing was 84 +/- 12.8%. Five (1.1% [95% confidence interval 0.4% to 2.6%]) patients developed hyperperfusion. Three (0.67%) of the five developed ICH. Two of these patients died (0.44%). Symptoms developed within a median of 10 h (range, 6 h to 4 days) following stenting. All five patients had correction of a severe internal carotid stenosis (mean 95.6 +/- 3.7%) with a concurrent contralateral stenosis >80% or contralateral occlusion and peri-procedural hypertension. These same risk factors are involved in cerebral hyperperfusion following carotid endarterectomy. The use of platelet glycoprotein IIb/IIIa receptor blockers did not appear to increase the risk ICH. CONCLUSIONS: The hyperperfusion syndrome occurs infrequently following CAS, and ICH occurs in 0.67% of patients. Patients with severe bilateral carotid stenoses may be predisposed to ICH, particularly if there is concurrent arterial hypertension. Patients with these factors may require more intensive hemodynamic monitoring after CAS, including prolongation of hospitalization in some cases.     

Assessment of flow changes in the circle of Willis after stenting for severe internal carotid artery stenosis.

PURPOSE: To assess flow velocities in the cerebral arteries after carotid artery stenting (CAS) in patients with unilateral versus bilateral lesions and analyze velocities in patients with neurological complications after CAS. METHODS: Ninety-two patients (68 men; mean age 63.2 +/- 8.4 years, range 44-82) with internal carotid artery (ICA) stenoses were divided according to unilateral (group I, n = 72) or bilateral (group II, n = 20) disease. Fifty age- and gender-matched patients without lesions in the extra- or intracranial arteries served as a control group. Transcranial color-coded Doppler ultrasound was performed prior to and within 24 hours after CAS in the test groups; systolic velocities were assessed ipsilateral (i) and contralateral (c) to the CAS site in the middle cerebral artery (MCA) and anterior cerebral artery (ACA). RESULTS: Collateral flow via the anterior communicating artery (ACoA) was found in all group-II patients and 90% of group-I patients. After CAS, collateral flow through the ACoA ceased, and the velocity increased by 26% in the iMCA in group I compared to controls (p < 0.001). In group II, iMCA flow increased by 30% (p < 0.001) and flow via the ACoA (p < 0.001) increased, resulting in normalization of cMCA velocities (p = 0.928). In 89 (96.7%) subjects, CAS was uncomplicated. Hyperperfusion syndrome occurred in 2 (2.2%) patients, both with bilateral ICA stenoses; 1 (1.1%) transient ischemic attack was seen in a patient with unilateral disease. In the patients with hyperperfusion syndrome, the MCA velocities were 2.7- and 7.4-fold higher, respectively, versus before CAS and 2-fold higher than in controls. CONCLUSION: Uncomplicated CAS results in an iMCA velocity increase >25% compared to controls. MCA velocities in hyperperfusion syndrome were greatly increased versus before CAS and in controls.     

Cerebrovascular resistance and blood flow velocity changes after carotid endarterectomy

BACKGROUND: To study the pattern of cerebral blood flow velocity and cerebral resistance changes after carotid endarterectomy. PATIENTS AND METHODS: In 81 patients (mean age +/- SD, 64 +/- 8 years) with unilateral carotid endarterectomy (CEA) the systolic, diastolic and mean blood velocities, and the pulsatility index (PI) were recorded in both middle cerebral arteries preoperatively and repetitively postoperatively with the use of transcranial Doppler ultrasound (TCD). RESULTS: In the middle cerebral artery ipsilateral to CEA mean blood velocity was increased 6 hours (64 +/- 25 cm/sec; p < 0.005) and 7 days (54 +/- 15 cm/sec; p < 0.05) after CEA and had returned to the preoperative level (49 +/- 11 cm/sec) after 3 months. Compared to preoperatively (0.86 +/- 22), the PI was significantly increased at 6 hours examination (1.03 +/- 23, p < 0.005), and remained increased thereafter. A pathologically increased mean blood velocity (> 83 cm/sec) 6 hours after CEA occurred in 11 patients, two of them developed a slight hyperperfusion syndrome. In the contralateral middle cerebral artery, only the diastolic blood velocity showed significant changes (preoperatively, 35 +/- 12 cm/sec; 3 months after CEA, 33 +/- 8 cm/sec; p < 0.05). CONCLUSIONS: Using TCD, hemodynamic changes occur predominantly in the middle cerebral arteries ipsilateral to CEA. Early postoperative TCD studies may be of help to identify patients at risk to develop a hyperperfusion syndrome.     

Can the diameter of endoluminal shunt influence the risk of hyperperfusion syndrome after carotid endarterectomy?

AIM: The aim of this study was to evaluate if there is a possible relation between the size of endoluminal shunt, in carotid endarterectomy (CEA), and the risk of postoperative hyperperfusion syndrome. METHODS: We retrospectively studied prospectively collected data from 156 patients, who were subjected to CEA using shunting and vein patch angioplasty. One hundred and thirty-eight of the patients had bilateral, high grade (> or = 90%) internal carotid lesions and the remaining 18 had a high-grade stenosis (> or = 90%) and a contralateral internal carotid artery (ICA) occlusion. In 81 patients varying diameters of shunts were used (8-14 Fr) according to the diameter of ICA (group A) and in the other 75 patients (group B) only the smallest shunt was used (8 Fr). Development of hyperperfusion syndrome was evaluated both clinically and radiologically with magnetic resonance imaging. RESULTS: Fifteen patients developed hyperperfusion syndrome (9.6%), between 0 to 6 days postoperatively. Thirteen belonged to group A (86.6%), and 2 (13.3%) belonged to group B (P<0.05). One had an intracerebral hemorrhage (0.6% of the study group) the 3rd postsurgical day. CONCLUSIONS: During CEA in patients with high-grade bilateral lesions, we recommend the use of a shunt with small diameter: this aims at reducing the risk of hyperperfusion syndrome.     

Transluminal angioplasty of the brachiocephalic artery with cerebral protection]

The authors report one case of percutaneous angioplasty of atherosclerotic symptomatic stenosis of brachiocephalic artery. Angioplasty had been performed using an occlusive balloon in internal carotid artery to realize a cerebral protection. This safer technics allowed to heal the stenosis and the brachiocephalic steal syndrome, without cerebral embolies.     

Seizures and loss of vision in a patient with systemic lupus erythematosus

Posterior reversible encephalopathy syndrome (PRES) is a rare neurological condition identifiable by clinical presentation and MRI appearance.1 Patients present with headache, seizures, loss of vision and altered mental function. The pathogenesis of the syndrome is poorly understood. One hypothesis is that cerebral vasospasm results in cerebral ischaemia and subsequent development of T2 hyperintensity, and the other is a temporary failure of the autoregulatory capabilities of the cerebral vessels, leading to hyperperfusion, breakdown of the blood-brain barrier, and consequent vasogenic oedema. It is believed that a rapid rise in blood pressure overcomes cerebral autoregulatory mechanisms with abrupt dilatation of cerebral arterioles. We report a patient with systemic lupus erythematosus and PRES after recurrent spontaneous abortion.     

Carotid artery reconstruction for Takayasu's arteritis the necessity of all-autogenous-vein graft policy and development of a new operation.

BACKGROUND: We have adopted an all-autogenous-vein-graft policy in carotid reconstruction for Takayasu arteritis, namely an ascendo-right carotid and right subclavian (axillary) arteries bypass using a pantaloon vein graft for patients all of whose arch branches are occluded, and an extra-anatomical bypass from the right subclavian artery for patients whose brachiocephalic artery is the only arch branch that remains patent. This report is to elaborate on these operations and to assess the long-term outcome. METHODS: Six patients were operated on according to this policy; (5 women, 1 man, age range: 14 to 59 years (mean: 30). The indications for surgery were severe cerebral ischaemia that significantly interfered with their daily lives. The pantaloon vein graft bypass was performed in four patients, and an extra-anatomical bypass in two. The specific management protocol to prevent the "postbypass hyperperfusion syndrome" and cerebral oedema included a shunt procedure to the internal carotid artery using one limb of the pantaloon vein graft, induced hypotension just before the completion of the carotid reconstruction and the administration of a glycerine-fructose solution. RESULTS: Cerebral ischaemic symptoms disappeared in all patients. All but one, who died of a ruptured thoraco-abdominal aneurysm on the 35th postoperative month, are living a normal life with a patent graft. No suture line complications have as yet been encountered (follow-up: 10 to 205 months, mean: 126 months). CONCLUSIONS: Carotid vein bypass for Takayasu arteritis, particularly, the pantaloon vein graft bypass is recommended for those of whom all aortic arch branches are occluded, resulting in severe brain ischaemia. Perioperative blood pressure control is important for prevention of the hyperperfusion syndrome.     

血管内支架成形术治疗有症状大脑中动脉狭窄

目的探讨血管内支架成形术在有症状大脑中动脉狭窄治疗中的应用。方法对3例临床诊断脑梗死和3例短暂性脑缺血发作患者行全脑血管造影术,发现大脑中动脉M1段存在不同程度狭窄,对狭窄段大脑中动脉行颅内支架成形术。结果6例大脑中动脉支架成形术均获得成功。大脑中动脉M1段平均直径狭窄程度从92·8%降至6%(P<0·01)。1例患者在支架置入10min后出现急性血栓形成,术中经微导管注入尿激酶接触性溶栓,25min后血栓溶解。术后随访6个月,所有患者均无脑缺血事件发生。结论采用血管内支架成形术治疗有症状大脑中动脉狭窄可行。     

脑血管造影评估在血管内支架成形术治疗脑供血动脉狭窄中的价值

目的探讨脑血管造影评估在血管内支架成形术治疗脑供血动脉狭窄中的价值。方法对105例症状性脑缺血发作患者进行术前全脑血管造影，对相关影像学信息进行全面评估，根据评估结果对136支狭窄血管行血管内支架成形术，术后不同时期进行脑血管造影随访。结果70处血管狭窄恢复正常血管直径，54处残余狭窄〈20％，7处残余狭窄为50％～80％。5例因支架不能输送到位而放弃手术；术中血栓保护伞完全被封堵1例。患者术前症状均有不同程度缓解。70例患者获得术后1～36个月的脑血管造影随访，颈动脉再狭窄2例，椎动脉起始部再狭窄6例，颅内动脉再狭窄6例。结论 术前充分评估脑血管造影结果并据此制定个体化治疗策略是保证血管内支架成形术安全性的前提。     

Neuroform支架在治疗症状性颅内动脉狭窄中的应用

目的评价使用Neuroform支架在治疗症状性颅内动脉狭窄的安全性、可行性。方法症状性颅内动脉狭窄患者11例,其中前循环狭窄2例(1例狭窄位于颈内动脉眼段交通段,1例狭窄位于大脑中动脉M1段),后循环狭窄9例(3例狭窄位于基底动脉,6例狭窄位于基底动脉交界处);均进行支架成形术治疗,术后全脑血管造影复查及使用美国国立卫生研究院脑卒中量表(NIHSS)进行评定。结果11例患者支架全部置放成功,造影复查显示动脉直径狭窄率从术前(85.6±7.4)%降至术后(35.7±12.1)%。按NIHSS评分评估,11例患者术后症状明显改善,其中1例患者术后15天出现Wallenberg综合征,随访1~12个月,其他患者未出现脑缺血再发作及支架内再狭窄。结论应用Neuroform支架治疗症状性颅内动脉狭窄合并路径血管纡曲不光滑的患者,可以提高手术成功率,减轻临床缺血症状和改善预后。     

鼻咽癌放疗后主动脉弓上动脉狭窄血管内支架置入的疗效分析

目的探讨血管内支架置入治疗鼻咽癌放疗后主动脉弓上动脉狭窄病变的疗效。方法回顾性分析8例鼻咽癌放疗后症状性主动脉弓上动脉中重度狭窄行血管内支架置入术患者的临床资料,观察治疗后脑缺血症状的改善情况。通过颈部血管彩色多普勒血流显像随访。结果 8例患者均经全脑DSA证实,主动脉弓上颅外段共有中重度狭窄动脉24处,其中包括颈内动脉11处,颈总动脉2处,椎动脉10处,锁骨下动脉1处。(1)经血管扩张成形及支架置入后,血管腔残余狭窄率平均20%。术后复查头部CT未见出血。术后定期复查颈部血管彩色多普勒血流显像,显示血管形态良好,血流通畅,未见支架内血栓形成及再狭窄,无过度灌注等不良事件发生。(2)随访1年所有患者无再发脑缺血症状,颈部血管彩色多普勒血流显像未发现明显再狭窄。结论血管内支架置入是鼻咽癌放疗后主动脉弓上动脉狭窄可以选择的治疗方法。     

急性基底动脉闭塞后行Solitaire AB型支架取栓术六例

目的 探讨Solitaire AB型支架用于急性基底动脉闭塞后动脉取内栓的效果及安全性 方法 回顾性分析2010年5-11月广东省中医院脑病中心采用Solitaire AB型支架进行急性基底动脉闭塞后动脉取栓术6例,若治疗后残余狭窄率≥50%则同时行支架成形术.分析其即时取栓效果,术后出血情况,比较患者治疗前后NIHSS评分及预后情况.结果 ①6例患者经1～3次取栓后,基底动脉均获得冉通;对其中5例有残余狭窄者联合使用球囊扩张支架成形术.②1例患者支架释放后.支架内急性血栓形成,经处理后复查造影显示基底动脉通畅.③5例患者术后3～7d复查头部MRI,均未见脑梗死灶扩大,基底动脉通畅.1例患者术后1 d脑出血,7d后死亡.④5例患者出院时NIHSS评分较入院时降低2～15分;5例患者出院时改良Ptaglkin评分0分1例,1分2例,2分2例.结论 在急性基底动脉血栓形成的患者中,使用Solitaire AB型支架取栓术是相对安全、有效的,患者预后良好.