大血管闭塞残端形态对急性缺血性脑卒中早期血管内机械开通术式及疗效的影响

目的 探讨急性大血管闭塞残端对缺血性脑卒中早期血管内机械开通术式选择及疗效的影响。方法 纳入河南中医药大学附属人民医院2019-03—2022-01大血管闭塞所致急性缺血性脑卒中机械取栓患者为研究对象。按照首次给予机械开通术式分为吸栓组（31例）和支架取栓组（25例）;每组依据急性闭塞大血管残端形态分为无残端亚组及有残端亚组;共纳入18项指标。结果 56例患者中共41例开通成功,总开通率为73.21%。吸栓组23例成功开通,支架取栓组18例成功开通。吸栓组平均DRT时间明显短于支架取栓组（P<0.05）;吸栓组并发症发生率明显低于支架取栓组（P<0.05）。吸栓组内无残端亚组开通率明显高于有残端亚组（P<0.05）;支架取栓组内无残端亚组开通率高于有残端亚组（P<0.05）。结论 对于无残端的急性大血管闭塞,抽吸取栓与支架取栓血管开通率相当,但直接抽吸技术DRT时间明显缩短,手术相关并发症少;对于有残端的血管闭塞,无论是吸栓或支架取栓效果均欠佳;术前对急性闭塞大血管残端形态评估,对术中机械取栓方式的选择有一定指导意义并影响临床疗效。     

高分辨率磁共振血管壁成像在慢性颈内动脉闭塞血管再通治疗中的应用

目的探讨高分辨率磁共振血管壁成像(HR-VWI)在慢性颈内动脉闭塞血管再通治疗中的应用价值。方法 2018年3月至2019年9月采用血管再通治疗11例症状性慢性颈内动脉闭塞患者,术前根据HR-VWI所示闭塞段起止部位以及闭塞段有无残腔、腔内血栓和动脉夹层分为Ⅰ型闭塞(眼段闭塞)、Ⅱ型闭塞(起始部至床突段及其近端颅内段闭塞)和Ⅲ型闭塞(起始部至眼段及其以远闭塞),以及A型闭塞(有残腔但无腔内血栓和动脉夹层)、B型闭塞(有残腔且有腔内血栓和动脉夹层)、C型闭塞(无残腔且无腔内血栓和动脉夹层)和D型闭塞(无残腔但有腔内血栓和动脉夹层),并与术前和术中实时DSA对比,记录血管再通率、围手术期并发症和预后。结果术前HR-VWI分型Ⅰ型闭塞2例、Ⅱ型闭塞6例、Ⅲ型闭塞3例,A型闭塞4例、B型闭塞2例、C型闭塞1例、D型闭塞2例;与术中DSA相比,术前HR-VWI对残腔、腔内血栓和动脉夹层的阳性检出率为10/11,余1例(1/11)HR-VWI分型Ⅲ型闭塞患者经DSA证实为Ⅱ型闭塞。10例(10/11)血管再通成功,1例失败病例为HR-VWI分型Ⅲ-C型闭塞;2例(2/11)出现围手术期并发症。术后1和3个月病情好转者为6和7例、稳定为5和4例;术后6个月1例发生支架内再狭窄。结论术前HR-VWI显示闭塞段有残腔提示血管再通成功率和手术安全性较高,管腔内有血栓增加围手术期并发症风险,但不降低血管再通成功率和预后。     

血管内再通术治疗非急性动脉粥样硬化性颈内动脉颅外段闭塞的疗效观察

目的 研究血管内再通术治疗非急性动脉粥样硬化性颈内动脉颅外段闭塞患者的安全性和有效性。 方法 对2015年3月-2017年5月入组的17例非急性动脉粥样硬化性颈内动脉颅外段闭塞患者行血管 内再通治疗并连续随访。所有患者在围手术期均给予强化抗血小板药物治疗。采用数字减影血管造 影（digital subtraction angiography,DSA）和改良Rankin量表（modified Rankin Scale,mRS）随访评价血管 内再通的疗效和围手术期并发症,如过度灌注综合征、颅内出血、支架内血栓、夹层等。 结果 所有17例患者中,11例成功开通,6例未成功开通。17例患者临床随访中位时间为3（1,3,6）个 月,术后6个月mRS中位数为1（0～4）分。术后6个月评估11例成功开通患者中有9例病情好转,2例稳定; 6例未成功开通患者中,1例病情好转,2例稳定,3例仍有缺血事件发作。7例接受影像随访的患者中,1 例出现支架内再狭窄。通过Wilcoxon秩和检验成功开通患者手术前后mRS评分比较,差异具有统计学 意义（Z =－2.807,P =0.005）。所有患者在围手术期均未出现并发症。 结论 非急性动脉粥样硬化性颈内动脉颅外段闭塞患者行血管内再通治疗在技术上可行,患者短期 预后改善明显,但远期疗效还有待进一步观察。     

症状性头颈部慢性动脉闭塞血管内治疗疗效分析

目的 探讨症状性头颈部慢性动脉闭塞血管内治疗的可行性及安全性。方法 回顾性分析2013年3月至2015年12月血管内治疗的24例头颈部慢性动脉闭塞的临床资料,其中椎动脉颅内段慢性闭塞3例、颈总动脉慢性闭塞3例、锁骨下动脉慢性闭塞5例、颈内动脉慢性闭塞13例。结果 24例中,22例目标血管成功开通,开通率为91.7%（22/24）,术后头晕、乏力等症状得到改善;2例颈内动脉慢性闭塞未开通,后期行颞浅动脉-大脑中动脉搭桥手术,术后头部CTA、DSA造影均显示灌注良好。1例左侧颈总动脉慢性闭塞血管内治疗中出现血栓脱落,造成同侧颈内动脉急性闭塞,术中通过急诊行SolitaireTM FR取栓治疗,术后患者病情平稳。术后随访5~14个月,NIHSS评分、mRS评分均为较术前有所改善,均无缺血性卒中事件再发生。结论 症状性头颈部慢性动脉闭塞血管内治疗具有可行性,近期疗效良好,长期疗效有待于进一步观察。     

复合手术开通慢性症状性颈内动脉长节段闭塞的初步应用(附24例报道)

目的 总结复合手术开通长节段慢性症状性颈内动脉闭塞的初步经验。方法 回顾性总结分析本院2013年8月～2017年4月行颈内动脉复合手术开通24例慢性症状性颈内动脉长节段闭塞患者的临床资料。结果 24例患者均成功开通,出院后3个月复查头颈CTA示开通的颈内动脉皆通畅,1例术中出现医源性颈内动脉海绵窦瘘,1周后成功闭塞瘘口,颈内动脉通畅,20例术后3个月复查DSA示颈内动脉通畅,4例电话随访诉说无异常表现。结论 对慢性症状性颈内动脉长节段闭塞行复合手术开通是一项安全有效的治疗手段,但需谨慎开展。     

经皮冠状动脉支架置入开通冠状动脉慢性闭塞病变：随访比较★

目的：回顾分析成功进行冠状动脉慢性闭塞支架置入治疗患者的随访资料，观察经皮冠状动脉支架置入术治疗对冠状动脉慢性闭塞患者的疗效及对预后的影响，并与未成功者对照分析。 方法：选择2003-06/2006-04在北华大学附属医院行冠状动脉慢性闭塞病变的经皮冠状动脉支架置入术治疗患者115例。其中陈旧性心肌梗死38例,不稳定性心绞痛51例,稳定性心绞痛26例;男78例,女37例;平均年龄(61.9±8.6)岁。排除急性心肌梗死和急性血管闭塞者。81例成功开通闭塞冠状动脉并置入支架(开通组),34例闭塞冠状动脉未开通(未开通组)。冠状动脉支架均选用美国强生cordis金属裸支架，患者对实验和治疗均知情同意。经右股动脉径路按Judkins常规方法进行冠状动脉造影后行闭塞冠状动脉内支架置入。支架置入操作由同一手术组完成。所有患者随访1～3年，观察两组的临床不良事件（死亡、心绞痛、再梗死、心力衰竭）和超声心动图（包括左室射血分数和左室舒张末期直径）的变化。 结果：参加实验患者均获得随访。两组临床随访期间,开通组的心绞痛、心力衰竭发生率明显低于未开通组[45%，68%；31%，53%；P < 0.05]。开通组的左室射血分数高于未开通组[（59.3±8.7）%，（54.5±9.2）%]，差异有显著性意义(P < 0.05)。开通组的左室舒张末期直径低于未开通组 [（48.2±5.3） mm，（53.6±6.1） mm]，差异有显著性意义(P < 0.05)。两组的死亡率及再梗死率比较差异无显著性意义（P > 0.05）。 结论：经皮冠状动脉支架置入治疗可改善冠状动脉慢性闭塞病变患者的临床症状和左室功能。     

症状性颈内动脉闭塞患者介入开通治疗的疗效分析

目的观察介入开通治疗症状性颈内动脉闭塞患者的有效性和安全性。方法对8例症状性颈内动脉闭塞患者行数字减影血管造影术(DSA)后,用微导丝携带微导管通过病变,然后给予小球囊对病变部位进行全段扩张(必要时)建立前向血流,再给予肝素泵入1周,开通后行CT检查排除颅内出血,最后行病变部位支架成形术。随访6个月,对所有患者进行美国国立卫生研究所脑卒中量表(NIHSS)评分。结果 8例患者均成功开通,2例出现开通后症状加重;支架术后1例出现高灌注损伤,1例出现再扩张后出血。结论症状性颈内动脉闭塞患者介入开通是一项有意义的治疗手段,但须严格筛选,谨慎处理并发症。     

急性颈内动脉T型闭塞血管内开通治疗体会

目的 总结急性颈内动脉T型闭血管内开通治疗的经验。方法 回顾性分析2015年12月至2018年12月采用血管内开通治疗的17例急性颈内动脉T型闭塞的临床资料。结果 17例均成功开通，其中采用逆向半回收-改良的Solumbra取栓术11例，采用双支架取栓术6例。开通后发生大面积脑梗死致脑疝6例，其中1例放弃治疗，5例行去骨瓣减压手术（2例死亡，3例重残）。其余11例康复出院，术后90 d预后良好（改良Rankin量表评分0~2分）8例，预后不良3例（改良Rankin量表评分3~5分）。结论 急性颈内动脉T型闭塞血栓负荷量大，血管内开通闭塞血管时，需要根据不同情况结合多种技术。     

132例缺血性脑血管病患者DSA分析

目的采用经颅多普勒（TCD）进行缺血性脑血管病（ICVD）筛查,并与DSA检查进行对比研究,以了解TCD在诊断缺血性脑血管病中的价值,同时分析缺血性脑血管病患者颅内外动脉狭窄或闭塞发生的特点。方法回顾性分析132例诊断为缺血性脑血管病的患者,先有21例患者同时行DSA及TCD检查,进行对比研究。另有111例ICVD患者行DSA检查,明确有无脑供血动脉的狭窄或闭塞及其位置,判断责任血管。结果与DSA结果相比较,TCD特异性为98.5%,敏感性为61.9%。132例ICVD患者中发现脑供血动脉狭窄或闭塞85例（64.4%）,烟雾病9例（6.8%）,动脉瘤5例（3.8%）,1例颈内动脉海绵窦瘘,1例颈内动脉起始部狭窄合并另一侧颈内动脉起始部夹层,可判断责任血管68例（68.0%）,脑梗死组的脑供血动脉狭窄或闭塞发生率高于短暂性脑缺血发作（TIA）组（P〈0.05）,脑梗死患者中颅内病变多于颅外病变（P〈0.05）,而TIA患者颅内外病变发生率差异无统计学意义。结论 TCD可作为筛查缺血性脑血病的常用方法,特异性高,但敏感性一般。中国人缺血性脑血管病患者中,脑梗死颅内动脉病变发生率高于颅外动脉,但在TIA患者中,差异无统计学意义。     

症状性颈内动脉重度狭窄或闭塞患者的侧支循环评估

目的 探讨症状性颈内动脉重度狭窄或闭塞患者的侧支循环评估。方法 选取中国人民解放军火箭军总医院(原第二炮兵总医院)神经内科住院的症状性颈内动脉重度狭窄或闭塞患者41例,首先采用德国EME公司TC-2000S型经颅彩超多普勒(Transcranial Doppler,TCD)仪,常规检测双侧颈总动脉及颈内动脉、颅内Willis环及相关主要动脉分支,进行侧支循环评估; 进一步采用德国西门子64层螺旋CT扫描机行CT血管成像(CT angiography in diagnosis,CTA)检查,明确颈内动脉病变的存在; 再应用PHILIPS FD20 DSA数字减影机行全脑血管造影术并进行侧支循环评估,评估颈内动脉闭塞性病变后的侧支循环代偿能力,评估眼动脉侧支循环通路的开放情况及作用。结果 41例患者颈内动脉重度狭窄24例,颈内动脉闭塞17例。TCD显示ACoA开放5例,占12.2%,DSA为4例,占9.76%; TCD显示PCoA开放5例,占12.20%,DSA为3例,占7.32%; TCD判断OA开放25例,占60.98%,DSA为23例,占56.11%; TCD提示LA开放3例,占7.32%,DSA提示2例,占4.88%; TCD显示无侧支循环开放者16例,占39%,DSA为14例,占34.15%。TCD和DSA在评估侧支血管开放数量方面无显著差异(P>0.05)。TCD评估眼动脉开放在颈内动脉重度狭窄和闭塞的患者中有显著差异(P<0.05)。颈内动脉重度狭窄患者和闭塞患者的TCD及DSA侧支循环评估无显著差异(P>0.05)。OA单独开放患者较无OA开放患者PI值高。狭窄组MCA的PI值低于闭塞组,狭窄组OA最高流速低于闭塞组(P<0.05)。颈内动脉狭窄组OA单独开放数量<闭塞组(P<0.05)。结论(1)TCD与DSA在评估侧支循环血管开放数量方面的作用基本一致,TCD可作为CTA和DSA侧支评估之前的初筛手段,可以独立作为侧支循环评估的检查手段;(2)眼动脉是否参与侧支循环及眼动脉的的开放程度与颈内动脉本身病变程度有关。眼动脉作为次级侧支通路参与侧支循环的程度与病情严重程度具有一定相关性,在颈内动脉慢性闭塞性患者眼动脉单独开放的比例>重度狭窄的患者,重度狭窄的患者OA最高流速低于闭塞组患者,这说明颈内动脉慢性闭塞性患者其OA开放后提供的灌注代偿作用相对更大。     

磁共振对颈内动脉狭窄与闭塞患者卒中解剖模式诊断价值的初步探讨

摘要】 目的 研究单侧动脉粥样硬化性颈内动脉狭窄与闭塞的急性缺血性卒中患者在磁共振上的病灶模式,探讨颈内动脉病变引起卒中的发病机制。 方法 利用数字减影脑血管造影定位动脉粥样硬化性颈内动脉重度狭窄（≥70%）或闭塞而无同侧大脑中动脉闭塞性病变。利用常规磁共振成像（magnetic resonance imaging,MRI）和液体衰减翻转恢复（fluid-attenuated inversion recovery,FLAIR）序列研究颈内动脉闭塞性病变引起缺血性卒中的形态学表现。有潜在心源性栓子患者除外。 结果 94例患者中,颈内动脉重度狭窄（≥70%）45例,颈内动脉闭塞49例。磁共振上缺血病灶的局部解剖模式分为4种：区域梗死、皮质下梗死、边缘带梗死、弥散小梗死。颈内动脉闭塞组中区域梗死的发生率较颈内动脉狭窄组高（47% vs 22%;P<0.05）;颈内动脉狭窄组中边缘带梗死的发生率较颈内动脉闭塞组高（42% vs 22%;P<0.05)。 结论 动脉粥样硬化性颈内动脉闭塞患者多见于区域梗死,而颈内动脉重度狭窄（≥70%）患者多见于边缘带梗死。     

脑白质区域非腔隙性梗死灶与颅内外血管狭窄关系的探讨

目的 探讨脑白质区域非腔隙性梗死灶与颅内外血管狭窄的关系.方法 对30例脑白质区域非腔隙性梗死患者的头颅MRI以及主动脉弓、全脑数字减影血管造影(DSA)检查资料进行分析.结果 本组MRI示12例单侧基底节区片状异常信号中,DSA表现为一侧颈内动脉(ICA)起始部闭塞或高度狭窄9例,一侧大脑中动脉(MCA)M1段高度狭窄2例,无明确血管病变1例.6例基底节以及侧脑室旁白质区域病灶中,一侧ICA起始部闭塞或高度狭窄3例,一侧ICA C5段闭塞1例,一侧MCA M1段闭塞2例.4例侧脑室旁或半卵圆中心白质区域病灶中,一侧ICA C6段闭塞1例,一侧MCA M1段高度狭窄2例,无明确血管病变1例.8例皮质下上型或皮质下侧型分水岭脑梗死患者中,一侧ICA起始部闭塞或高度狭窄6例,双侧ICA起始部闭塞1例,一侧MCA M1段高度狭窄1例.结论 脑白质区非腔隙性梗死灶的发生与ICA系统大血管的狭窄或闭塞有密切的关系.     

急性脑梗死散在和单一弥散加权成像病损与其供血动脉狭窄的关系

目的 探讨急性脑梗死弥散加权磁共振成像(DWI)上大脑中动脉(MCA)供血区散在性或单一性缺血性病损与其脑供血动脉狭窄或闭塞的关系.方法 回顾性分析73例连续积累的DWI显示一侧MCA供血区脑梗死的病例,入组病例均排除心源性栓塞性脑梗死,所有患者均在发病24 h内进行MRI和MRA等检查,7例患者并进行DSA.采用DWI急性缺血性病损分类方法 分为散在病损组和单一病损组,比较两组的病灶同侧MCA、颈内动脉(ICA)颅内段和颅外段狭窄或闭塞的发生率.结果 散在病损组42例,单一病损组31例.在病损同侧ICA颅外段和MCA闭塞或重度狭窄方面两组差异有统计学意义(28.6%与0,x2=10.6,P=0.001).在病损同侧ICA颅内段并MCA轻中度狭窄方面,两组间差异具有统计学意义(31.0%与9.7%,x2=4.717,P=0.03).散在病损与MCA和(或)ICA严重或多发狭窄呈正相关(OR值为13.7,95%CI:3.6～52.5).在MRA或DSA未发现颅内外大血管狭窄方面,两组间差异具有统计学意义(11.9%与32.3%,x2=4.526,P=0.033).散在病损组与无明显血管狭窄呈负相关(OR值为0.284,95%CI:0.09～0.94).结论 (1)脑梗死急性期DWI显示的MCA区散在性病损患者,MCA和ICA狭窄、甚至闭塞的可能性较大,以ICA颅外段闭塞较为常见;(2)DWI显示单一病损时提示脑供血动脉狭窄程度较轻,范围较局限,小血管病变的可能性相对较高,很少为严重的ICA颅外段狭窄或闭塞.

Abstract：

Objective To investigate the relationship between scattered or single lesion of acute cerebral infarction in middle cerebral artery territory on diffusion-weighted imaging (DWI) and stenosis of middle cerebral artery (MCA) or internal carotid artery (ICA). Methods With exclusion of cardioembolism, 73 consecutive patients with acute cerebral infarction of the unilateral MCA territory on DWI were analyzed. All patients got magnetic resonance imaging (MRI) and angiography (MRA) within 24 hours after onset, and 7 patients also had digital subtraction angiography (DSA). The patients were classified into single lesion group or scattered lesions group according to the DWI findings. The incidence of stenosis or occlusion of ipsolateral MCA, intracranial and extracranial ICA were compared between the two groups. Results 42 patients had scattered lesions and 31 patients had single lesion. The scattered-lesions group had a high incidence of ipsilateral extracranial ICA or MCA occlusion or severe stenosis ( 25.6%versus 0, x2 = 10.6, P = 0.001 ) and a high incidence of ipsilateral intracranial ICA or MCA moderate or mild stenosis (31.0% versus 9.7% ,x2 =4.717, P =0.03 ). A positive correlation was found between the scattered lesions and severe or multifocal stenosis of ipsilateral ICA and MCA ( OR: 13.7, 95% CI: 3.6 to 52.5). There was a low incidence of absence of extra- and intracranial stenosis on MRA or DSA in the scattered-lesions group ( 11.9% versus 32.3%, x2= 4.526, P = 0.033 ). A negative correlation was found between the scattered lesions and absence of large-artery stenosis ( OR: 0.284, 95% CI: 0.09 to 0.94).Conclusions ( 1 ) Patients with acute cerebral infarction and scattered lesions on DWI were more likely to suffer from stenosis or occlusion of ICA or MCA, especially over the extracranial ICA. (2) Patients with single lesion were less likely to have severe or multiple stenosis of MCA and ICA, indicating the relevance of small-vessel pathogenesis.     

Emergency revascularization of acute internal carotid artery occlusion: Follow the spike,it guides you

The present study sought to examine the incidence of the angiographic “spike sign” and to assess its predictive significance for achieving carotid revascularization in 54 patients with acute internal carotid artery (ICA) occlusions that required urgent endovascular revascularization. Clinical and imaging files of consecutive patients with ICA occlusion who were treated in a tertiary care academic medical center from 2011–2015 were retrospectively examined under Institutional Review Board approval with a waiver of the requirement for informed consent. All proximal ICA occlusions were treated by stent-assisted carotid angioplasty, and all distal embolic occlusions were managed with stent-assisted mechanical thrombectomy. The study included 24 patients with acute ICA occlusion (group 1) and 30 patients with tandem ICA-intracranial occlusions (group 2). The spike sign was seen in 16/24 patients in group 1 (67%), and successful ICA revascularization was achieved in 14/16 (88%). The sign was seen in 26/30 patients in group 2 (87%), and ICA revascularization was successful in all 26 (100%). The remaining 12 patients had no spike sign, and ICA revascularization was successful in only 7/12 (58%). The spike sign is a transient finding that represents the proximal patent remnant of the stenotic corridor in fresh clot. Acute ICA occlusion frequently leaves the spike sign as a marker of the recent thrombotic event. The spike vertex points to the “path of least resistance” for the guidewire to cross the occlusion and engage the true arterial lumen, a critical step during ICA endovascular revascularization.     

DSA评价颈内动脉重度狭窄或闭塞患者侧支循环与临床表现的关系

目的 利用数字减影血管造影（digital s ubtraction angiography,DSA）技术研究颈内动脉重度狭窄或闭 塞患者侧支循环状态,评估其与临床表现的相关性。 方法 本研究为回顾性研究,连续纳入首都医科大学附属北京天坛医院介入神经病学科2014年6 月-2015年9月经DSA诊断为颈内动脉重度狭窄（≥70%）或闭塞患者137例,根据是否出现与责任血管 相关的脑缺血症状和（或）神经系统定位体征,分为症状性狭窄组98例和无症状性狭窄组39例,收 集所有患者DSA检查结果,记录患者侧支循环代偿情况。将患者侧支循环状态按以下情况进行分类： ①侧支循环开放数量：分为未出现侧支和出现侧支组;根据侧支出现数量多少,分为出现侧支数＜2 和出现侧支数≥2两组。②各侧支循环开放情况：前交通动脉（anterior communicating artery,ACoA）, 后交通动脉（posterior communicating artery,PCoA）,眼动脉（ophthalmic artery,OA）,软脑膜吻合支 （leptomeningeal anastomoses,LMA）。③组合侧支开放情况：组合侧支按两种分类,一种根据Willis环开 放情况,一种根据是否出现二级侧支循环,分析组合侧支循环状态与两组间的关系。 结果 共137例患者,年龄范围34～82岁,平均（59.7±10.5）岁,其中男性97例（70.8%）,所有患者 出现侧支循环者94例（68.6%）,出现功能完整Willis环、ACoA、PCoA、OA、LMA的概率分别为14.6%、 58.5%、46.8%、43.6%、48.9%。无症状组39例,33例（84.6%）侧支循环开放;症状组98例,61例 （62.2%）侧支循环开放,无症状组侧支开放率显著高于症状组[84.6% vs 62.2%,P =0.011,优势比 （odds ratio,OR）=3.336],无症状组侧支数量≥2的患者所占比例显著高于症状组（64.1% vs 38.3%, P =0.007,OR =2.820）,无症状组功能完整Willis环者显著高于症状组（36.4% vs 13.1%,P =0.009, OR =3.786）。 结论 在颈内动脉重度狭窄或闭塞时,侧支循环与患者的临床表现密切相关,无症状的患者有更丰 富的侧支循环代偿途径及更完整Willis环,Willis环在侧支循环代偿中起重要作用。     

Local intra-arterial fibrinolysis in acute hemispheric stroke: effect of occlusion type and fibrinolytic agent on recanalization success and neurological outcome

BACKGROUND: To evaluate the effect of occlusion type and fibrinolytic agent on recanalization success and clinical outcome in patients undergoing local intra-arterial fibrinolysis (LIF) in acute hemispheric stroke. METHODS: LIF was performed in 137 patients with angiographically established occlusion in the carotid circulation within 6 h of stroke onset. Retrospective analysis included recanalization success, recanalization time, type of occlusion and fibrinolytic treatment mode. Five types of occlusion were categorized: intracranial bifurcation (carotid 'T') of the internal carotid artery (ICA; n = 35); proximal segment of the middle cerebral artery (MCA; n = 66); distal segment of the MCA (n = 20); extracranial ICA with MCA embolism (n = 8); multiple peripheral branches of the anterior cerebral artery and the MCA (n = 8). Neurologic outcome was evaluated after 3 months by Barthel Index (BI) as good (BI >90), moderate (BI 50-90), poor (BI <50) or death. RESULTS: Recanalization was achieved in 74 patients (54%). Mean recanalization time in recanalized patients was 91 min. Neurologic outcome was good in 48 patients (35%), moderate in 34 (25%), poor in 30 (22%) and 25 died (18%). Outcome was significantly better in recanalized than in nonrecanalized patients (p < 0.001). Treatment results were significantly better in proximal and distal MCA occlusion than in carotid 'T' occlusions (p < 0.001). Recanalization success hardly differed between urokinase and rt-PA. Combined treatment with rt-PA and lys-plasminogen tended toward a faster recanalization. Parenchymal hemorrhage occurred in 13 patients (9%). CONCLUSION: The type of occlusion is of high prognostic value for successful fibrinolysis in the anterior circulation. However, recanalization is a time-consuming process even with an intra-arterial approach. Recanalization did not differ between type or dosage of plasminogen activators. Further innovative attempts are warranted towards hastening recanalization time in endovascular acute stroke treatment.     

基底动脉动脉瘤合并胚胎型大脑后动脉自发性闭塞的诊治分析(附1例报道并文献复习)

目的 总结基底动脉动脉瘤合并胚胎型大脑后动脉（FPCA）自发性闭塞致枕叶梗死的诊治经验,以提高此类疾病的认识,避免将FPCA残端误诊为动脉瘤。方法 回顾性分析1例基底动脉动脉瘤合并FPCA自发性闭塞致枕叶梗死的临床资料。结果 病人以突发右上肢麻木及视物模糊起病,外院DWI显示左侧枕叶内侧面梗死伴左侧丘脑灶样梗死,外院头颈部CTA示左侧颈内动脉后交通动脉动脉瘤（呈梭形）、基底动脉动脉瘤以及颅内多发血管硬化狭窄。我院左侧颈内动脉造影见左侧后交通动脉闭塞残端,残端远端可见中断后又部分显影,左侧大脑后动脉P1、P2均闭塞,椎动脉造影未见P1段发育,基底动脉中段动脉瘤。结合病人DWI梗死部位及术前灌注成像所示灌注失代偿区,考虑为左侧FPCA急性闭塞引起同侧枕叶梗死,CTA所谓的“梭样动脉瘤”其实为闭塞后的残端。采用双支架套叠辅助弹簧圈栓塞治疗基底动脉中段动脉瘤,出院时改良Rankin量表评分1分。结论 FPCA自发性闭塞临床极其罕见,急性闭塞后是否行血管内治疗依然存在争议;应加强对其影像学特征的认识和了解,以避免将其闭塞后残端误当做动脉瘤。     

Accuracy of conventional plus transoral carotid ultrasonography in distinguishing pseudo-occlusion from total occlusion of the internal carotid artery

BACKGROUND: To investigate the accuracy of conventional carotid ultrasonography (CCU) combined with transoral carotid ultrasonography (TOCU) for distinguishing pseudo-occlusion from total occlusion of the internal carotid artery (ICA). METHODS: This study included 95 patients who were suspected of having an occlusion of the ICA on magnetic resonance angiography (MRA) and underwent both CCU and conventional digital subtraction angiography (DSA) in order to confirm the diagnosis. TOCU was also performed to observe the cervical portion of the ICA distal to the stenosis. We compared the ultrasonographic findings with the DSA findings. RESULTS: Twelve of the 95 patients were defined as having an ICA pseudo-occlusion on DSA. On B-mode images with CCU color Doppler, slight residual flow signals in the ICA lumen were shown in 20 patients. Among them, 2 patients had a pulsed Doppler waveform of the distal ICA occlusion pattern. Among the remaining 18 patients, 4 had a pulsed Doppler waveform of the to and fro flow pattern, and 14 had a weak antegrade flow pattern in the ICA lumen. The conventional ultrasonographic method showed 100% sensitivity with 93% specificity for diagnosing an ICA pseudo-occlusion. The addition of TOCU findings increased the specificity to 98%. In 2 patients, who were overdiagnosed as having an ICA pseudo-occlusion even using TOCU, DSA revealed an occlusion of the ICA distal to the ophthalmic artery with a severe stenosis of the proximal ICA. CONCLUSIONS: Using conventional and transoral carotid ultrasonography, an ICA pseudo-occlusion can be diagnosed with higher accuracy.     

Accuracy and Criteria for Localizing Arterial Occlusion With Transcranial Doppler

The authors determined transcranial Doppler (TCD) accuracy for the proximal internal carotid artery (ICA), distal ICA, proximal middle cerebral artery (MCA), distal MCA, anterior cerebral artery (ACA), posterior cerebral artery (PCA), terminal vertebral artery (tVA), and basilar artery (BA) occlusion in cerebral ischemia patients. Detailed diagnostic criteria were prospectively applied for TCD interpretation independent of angiographic findings. Of 320 consecutive patients referred to the neurosonology service with symptoms of cerebral ischemia, 190 (59%) patients also underwent angiography (MRA or DSA). 48 of those 190 patients had angiographic occlusion and 12 of those 48 patients had involvement of multiple vessels. Median time from TCD until angiography was performed was 1 hour (41 patients had angiography before TCD). TCD showed 40 true positive, 8 false negative, 8 false positive, and 134 true negative studies with sensitivity 83.0%, specificity 94.4%, positive predictive value 83.0%, negative predictive value 94.4%, and accuracy 91.6% to determine all sites of occlusion. Sensitivity for each individual occlusion site was: proximal ICA 94%, distaiiCA 81%, MCA 93%, tVA 56%, BA 60%. Specificity ranged from 96% to 98%. TCD is sensitive and specific in determining the site of the arterial occlusion using detailed diagnostic criteria, including proximal ICA and distal MCA lesions. TCD has the highest accuracy for ICA and MCA occlusions. If the results of TCD are normal, there is at least a 94% chance that angiographic studies will be negative. Key words: ultrasound, transcranial Doppler sonography, stroke, occlusion, angiography.     

支架辅助弹簧圈栓塞治疗前交通动脉宽颈动脉瘤

目的 分析支架辅助弹簧圈栓塞治疗前交通动脉宽颈动脉瘤的安全性和有效性.方法 该回顾性研究纳入昆明医科大学第二附属医院脑血管病科2016年7月-2020年7月经DSA诊断的应用支架辅助栓塞治疗的前交通动脉宽颈动脉瘤患者.收集所有患者的临床相关资料,评价支架辅助栓塞治疗的疗效和安全性.治疗技术指标采用术后即刻DSA Ray...