介入开通治疗症状性颅内动脉慢性闭塞的临床效果

目的：评价介入开通治疗症状性颅内动脉慢性闭塞的疗效和安全性。 方法：回顾性分析2008年12月至2017年12月在我科住院的27例症状性颅内动脉慢性闭塞患者,均采用介入开通治疗,分析开通情况和手术相关并发症,于术前和术后采用血流评定（TICI）分级和改良Rankin量表（mRS）评分评价治疗效果。 结果：27例患者中,颈内动脉床突上段闭塞6例;椎-基底动脉交界区闭塞7例;双侧椎动脉颅内段或优势侧闭塞8例;大脑中动脉水平段闭塞6例。25例颅内闭塞血管成功开通,TICI由术前0级提升为3级。治疗主要采用支架和球囊扩张。2例患者围手术期出现并发症死亡,其余23例患者,在术后24个月的随访中,20例患者预后良好（mRS评分0~1分）,2例患者预后中等（mRS评分2~3分）,1例患者预后较差（mRS评分4~5分）,随访过程中无死亡患者。 结论：介入治疗症状性颅内血管闭塞效果肯定,再通技术要求高,但是术后仍存在一定的并发症,仍需进一步大量临床研究证实。     

急诊血管成形及支架植入术治疗急性大脑中动脉闭塞

目的 评估急诊血管支架成形术治疗急性大脑中动脉闭塞的可行性、有效性及安全性.方法 回顾分析2008年8月至2011年5月收治的12例行急诊支架开通术的急性大脑中动脉闭塞患者.在支架植入术后对再通结果进行TIMI评分,并对术中及术后并发症、治疗前后的神经功能进行评估.术后3个月进行随访.结果 12例患者在大脑中动脉支架植入术后随即进行DSA造影,结果显示血流均达到部分或完全再通(TIMI:2和3).1例患者在术后当天因大脑中动脉再次闭塞而死亡.随访中9例患者预后较好(mRS:0 ～2),2例患者预后欠佳.术后CTA及MRA随访显示11例患者中有2例血管再发轻度狭窄.结论 急诊行血管支架成形术治疗急性大脑中动脉闭塞可行,有较高再通率,且安全有效.     

症状性非急性期椎基底动脉闭塞介入再通初步探讨

【摘要】 目的 通过与症状性大动脉粥样硬化性急性椎基底动脉闭塞资料对比,评估症状性非急性期椎基底动脉闭塞再通的可行性、有效性和安全性。方法 回顾性分析2017年6月至2019年4月郑州大学附属洛阳中心医院采用介入再通手术治疗的18例优势侧椎基底动脉非急性闭塞患者和32例急性粥样硬化性椎基底动脉闭塞患者一般资料和手术资料。单因素分析两组患者脑梗死溶栓（TICI）治疗后血流分级≥2b比例、血管开通时间、术前术后改良Rankin 量表（mRS）评分、术后症状改善、围手术期并发症以及90 d mRS 评分、支架内再狭窄差异。结果 非急性闭塞组、急性闭塞组分别有16例、30例术后即刻TICI血流分级≥2b,血管成功开通率分别为88.9%（16/18）、93.8%（30/32）（P=0.948）;术后分别有13例、23例症状改善（P=0.979）;围手术期发生并发症分别有4例（22.2%）、4例（12.5%）（P＞0.05）;术后90 d再狭窄发生率分别为33.3%（6/18）、9.4%（3/32）（P=0.075）;术后90 d mRS评分≤2分比例分别为55.6%（10/18）、65.6%（21/32）（P=0.481）。结论 非急性椎基底动脉闭塞血管内开通术虽操作复杂、存在一定风险,但可行、安全有效。确切疗效仍有待大样本、多中心前瞻性研究证实。     

急性前循环大血管闭塞机械取栓术后血管复流程度与中性粒细胞和淋巴细胞比值的关系

目的 探讨前循环大血管闭塞患者接受机械取栓术后闭塞血管复流程度与治疗前外周静脉血中性粒细胞和淋巴细胞比值（neutrophil-to-lymphocyte ratio,NLR）的关系。方法 回顾性分析2016年6月至2022年3月苏州大学附属第一医院接受机械取栓治疗的前循环大血管闭塞性急性缺血性脑卒中（acute ischemic stroke,AIS）患者的临床资料。根据改良脑梗死溶栓分级（modified thrombolysis in cerebral infarction,m TICI）评估术后闭塞血管的复流程度，将所有成功复流患者分为部分复流组（mTICI=2b级）及完全复流组（m TICI=3级）。比较两组患者的基本临床资料、疾病特征、介入治疗及预后的相关数据，多因素logistic分析术后复流程度的影响因素。结果 共纳入患者214例，其中部分复流65例，完全复流149例。单因素分析结果显示，两组患者的术前NLR、闭塞血管位置、血栓负荷量、穿刺至再通时间、取栓次数、术后90 d预后良好率差异均有统计学意义（均P<0.05）。与部分复流患者相比，完全复流患者的NLR更低...     

急性串联型椎基底动脉闭塞伴对侧椎动脉闭塞或发育不良患者血管内开通策略

【摘要】 目的 探讨急性串联型椎基底动脉闭塞伴对侧椎动脉闭塞或发育不良患者血管内开通治疗策略。方法 回顾性分析2021年1月至12月在空军军医大学第一附属医院接受急诊血管内开通治疗的6例急性基底动脉闭塞伴双侧椎动脉闭塞或优势侧椎动脉闭塞且对侧椎动脉发育不良患者临床资料。根据病变类型和侧支循环条件差异,选择采用不同的开通治疗策略。结果 6例患者均为男性,中位年龄62.7岁。其中经颈深动脉逆向开通椎动脉1例,经颈升动脉逆向造影并在椎动脉闭塞远端滞留对比剂影指引下正向开通椎动脉1例,经优势侧正向开通椎动脉4例;随后均接受基底动脉取栓治疗。术后6例基底动脉改良溶栓治疗脑梗死（mTICI）血流分级达到2b/3,基底动脉开通成功率为6/6。术后3例患者因非手术因素死亡,其余3例改良Rankin量表（mRS）评分分别为0分、0分和3分,预后良好率为2/6。结论 对于急性串联型椎基底动脉闭塞伴对侧椎动脉闭塞或发育不良患者,积极的椎动脉正向或逆向再通术是治疗急性基底动脉闭塞的可行方法。     

急性颅内大血管闭塞机械再通患者预后影响因素分析

【摘要】 目的 探讨机械取栓治疗急性颅内大血管闭塞的有效性和安全性及影响预后的相关因素。 方法 回顾性分析2012年1月至2019年7月在郑州大学第一附属医院接受机械取栓治疗的急性颅内大血管闭塞性脑卒中患者临床和影像学资料。根据术后3个月改良Rankin量表（mRS）评分,将337例入组患者分为预后良好组［mRS评分0～2分,188例（55.8%）］和预后不良组［mRS评分3～6分,149例（44.2%）］。分析两组患者年龄、高危因素、入院时美国国立卫生研究院卒中量表（NIHSS）评分、闭塞部位（颈内动脉、大脑中动脉和椎-基底动脉）、发病-股动脉穿刺时间（OTP）、股动脉穿刺-血管再通时间（PTR）、术后即刻再通效果［改良脑梗死溶栓（mTICI）治疗后血流分级］、症状性脑出血[欧洲急性脑卒中协作研究（ECASS）组Ⅱ标准］及术后3个月预后。对预后影响因素进行多因素logistic回归分析。 结果 两组患者年龄、入院NIHSS评分、伴高血压、伴糖尿病、血管闭塞部位比较,差异均有统计学意义（P＜0.05）;其他基线资料差异均无统计学意义（P＞0.05）。大脑中动脉闭塞再通患者预后良好率显著高于颈内动脉、椎-基底动脉闭塞患者（P=0.02）。预后良好组患者OTP、PTR显著短于预后不良组（360 min对405 min,P=0.01;80 min对100 min,P＜0.001）。预后良好组患者血管成功再通率显著高于预后不良组（91.0%对78.5%,P＜0.001）,术后症状性脑出血发生率显著低于预后不良组（8.5%对28.9%,P＜0.001）。多因素logistic回归分析显示,高龄（OR=1.042,95%Cl=1.018～1.066）、伴糖尿病（OR=1.930,95%Cl=1.100～3.385）、入院高NIHSS评分（OR=1.286,95%C1=1.190～1.390）、PTR较长（OR=1.007,95%CI=1.001～1.013）、术后症状性脑出血（OR=3.082,95%Cl=1.419～6.695）均为预后不良的危险因素（P＜0.05）。结论 机械取栓治疗急性颅内大血管闭塞有较高的血管再通率和预后良好率。高龄、伴糖尿病、入院高NIHSS评分、PTR较长、术后症状性脑出血均为预后不良的危险因素。     

补救性支架植入治疗急性缺血性脑卒中13例北大核心CSCD

目的探讨支架植入作为补救性措施治疗急性缺血性脑卒中的有效性与安全性。方法回顾性分析13例大脑前循环大血管闭塞发病8 h内并接受补救性支架植入治疗的急性缺血性脑卒中患者临床资料。所有患者治疗前均经其它再通术式(静脉溶栓、动脉溶栓、Penumbra装置吸栓、Solitaire支架取栓)未果。根据脑梗死溶栓(TICI)治疗后血流分级评价血管再通,记录围手术期出血及梗死并发症。根据美国国立卫生研究院卒中量表(NIHSS)评分评价术后1周神经功能改善情况。根据改良Rankin量表(m RS)评分评价术后3个月预后指标。结果 13例接受补救性治疗患者共植入支架16枚,支架植入前采用Solitaire可回收支架取栓10例,Penumbra装置吸栓3例,经静脉尿激酶溶栓1例,经动脉尿激酶溶栓1例。12例(92.3%)患者闭塞血管部分或全部再通(TICI≥2B/3)。NIHSS评分由术前平均(16.15±5.81)分改善为术后1周平均(8.08±5.61)分,差异有统计学意义(P<0.05)。术后3个月,7例(53.8%)预后良好(m RS≤2),2例死亡。术后发生颅内出血2例,手术相关栓塞3例。结论颅内支架植入术作为不同组合药物溶栓治疗急性缺血性脑卒中患者血管再通的补救性措施,安全有效。     

椎动脉开口闭塞合并椎基底动脉急性闭塞的血管内治疗策略

目的：探讨椎动脉开口闭塞合并椎基底动脉急性闭塞的血管内治疗策略、临床疗效及安全性。 方法：选取2014年6月—2017年7月我院收治的8例合并椎动脉开口闭塞的急性后循环大血管闭塞患者。采取经股动脉常规途径、经股动脉及肱动脉途径、结合椎动脉内膜剥脱途径联合Solitaire支架取栓开通血管。分析血管开通前后的改良TIMI灌注分级、入院与出院NIHSS评分、90 d后的mRS评分。 结果：血管内治疗策略及血管开通情况：经股动脉常规途径行血管内治疗5例,经股动脉及肱动脉途径2例,结合椎动脉内膜剥脱开通血管1例。2例患者闭塞椎动脉开口未能开通,手术失败;6例患者椎动脉以及基底动脉获得良好开通;出院时NIHSS评分（11.88±7.06）明显低于入院NIHSS评分（30.75±8.21）,差异有统计学意义（t=3.297,P=0.013）。死亡2例,步行出院4例。90 d随访临床结果显示优良5例（mRS为0~2分）,1例患者中度残障,mRS评分3分。 结论：多种血管内治疗途径能使合并椎动脉开口闭塞的急性后循环闭塞大血管获得较好的再通率,显著改善后循环急性缺血性脑卒中患者的预后。     

介入再通治疗非急性期基底动脉闭塞的中长期随访研究

目的：评价介入再通治疗非急性期基底动脉闭塞的中长期临床疗效。 方法：收集2010年2月—2012年4月在我中心行介入再通治疗的闭塞超过24 h的非急性期基底动脉闭塞患者12例。记录围手术期并发症、随访期间短暂性脑缺血发作及卒中发生情况,使用非参数秩和检验比较手术前后及随访期间的改良Rankin量表（mRS）评分变化情况。 结果：12例患者中有11例闭塞动脉（91.7%）成功开通。围手术期并发症发生2例,导致患者病情加重。8例患者获得影像学随访,中位随访时间12（6～30）个月,再狭窄2例,均为症状性。12例患者获得临床随访,中位随访时间51.5（0.5～73）个月,再发同侧性卒中2例,同侧性短暂性脑缺血发作1例。存活患者中,术后1周的mRS评分低于术前,术后3个月的mRS评分低于术后1周,差异均有统计学意义（P<0.05）。 结论：介入再通治疗非急性期基底动脉闭塞可在中远期预防再发缺血事件的发生,同时术后3月内患者的残疾功能改善明显,但再狭窄问题值得进一步关注。     

Solitaire AB型支架用于急性脑动脉闭塞取栓术31例

目的探讨Solitaire AB型支架用于急性脑动脉闭塞动脉取栓术的效果及安全性。方法 2010年5月至2011年5月采用Solitaire AB型支架用于急性脑动脉闭塞的动脉取栓术,共31例,其中颈内动脉闭塞6例,大脑中动脉闭塞12例,基底动脉闭塞9例,合并大脑中动脉及基底动脉闭塞1例,颈内动脉末段合并大脑中动脉闭塞3例。回顾性分析其即时取栓效果,术后出血情况,并比较其随访90 d时的MRS评分情况。结果大脑中动脉和基底动脉闭塞患者均成功再通,颈内动脉有6例(6/9)获再通。12例患者因为再通后仍存在管腔狭窄而放置支架。术后颅内出血4例(12.9%),死亡8例(25.8%)。在死亡患者中,5例责任动脉在颈内动脉,3例在基底动脉。从发病到获得再通时间超过8 h者8例,其中死亡2例,均为颈内动脉闭塞患者。90 d随访患者中,出院MRS评分预后良好(<2)的有15例(48.4%)。结论用Solitaire AB型支架进行动脉取栓对于大脑中动脉及基底动脉闭塞患者能获得较高的再通率,改善临床结局,但对颈内动脉闭塞患者效果不理想,再通率低,死亡率高。     

Self-expanding stents for recanalization of acute cerebrovascular occlusions

BACKGROUND AND PURPOSE: Stent-assisted revascularization increases prevailing recanalization rates ( congruent with 50%-69%) for vessel occlusions recalcitrant to thrombolytics. Although balloon-mounted coronary stents can displace thrombus (via angioplasty) and retain clot along vessel walls, intracranial self-expanding stents are more flexible and exert less radial outward force during deployment, increasing deliverability and safety. To understand the effectiveness of self-expanding stents for recanalization of acute cerebrovascular occlusions, we retrospectively reviewed our preliminary experience with these stents. MATERIALS AND METHODS: Eighteen patients (19 lesions) presenting with a clinical diagnosis of acute stroke underwent catheter-based angiography documenting focal occlusion of an intracranial artery. A self-expanding stent was delivered to the occlusion and deployed. Stent placement was the initial mechanical maneuver in 6 cases; others involved a combination of pharmacologic and/or mechanical maneuvers prestenting. GP IIb/IIIa inhibitors were administered in 10 cases intraprocedurally or immediately postprocedurally to avoid acute in-stent thrombosis. RESULTS: Stent deployment at the target occlusion (technical success) was achieved in all cases. Thrombolysis in Cerebral Ischemia (TICI)/Thrombolysis in Myocardial Ischemia (TIMI) 2/3 recanalization (angiographic success) was achieved in 15 of 19 lesions (79%). All single-vessel lesions (n=8) were recanalized, but only 7 of 11 combination internal carotid artery and middle cerebral artery lesions were recanalized. No intraprocedural complications occurred. Seven in-hospital deaths occurred: stroke progression, 4; intracranial hemorrhage, 2; respiratory failure, 1. Seven patients had >or=4-point National Institutes of Health Stroke Scale improvement within 24 hours after the procedure, 6 had modified Rankin Score (mRS) 相似文献   

Acute Combined Revascularization in Acute Ischemic Stroke with Intracranial Arterial Occlusion: Self-expanding Solitaire Stent during Intravenous Thrombolysis

PurposeTo investigate the safety and efficacy of the self-expanding Solitaire stent used during intravenous thrombolysis (IVT) for intracranial arterial occlusion (IAO) in acute ischemic stroke (AIS).Materials and MethodsConsecutive nonselected patients with AIS with IAO documented on computed tomographic angiography or magnetic resonance angiography and treated with IVT were included in this prospective study. Stent intervention was initiated and performed during administration of IVT without waiting for any clinical or radiologic signs of potential recanalization. Stroke severity was assessed by National Institutes of Health Stroke Scale (NIHSS), and 90-day clinical outcome was assessed by modified Rankin scale (mRS), with a good outcome defined as an mRS score of 0–2. Recanalization was rated by thrombolysis in cerebral infarction (TICI) scale.ResultsFifty patients (mean age, 66.8 y ± 14.6) had a baseline median NIHSS score of 18.0. Overall recanalization was achieved in 94% of patients, and complete recanalization (ie, TICI 3 flow) was achieved in 72% of patients. The mean time from stroke onset to maximal recanalization was 244.2 minutes ± 87.9, with a median of 232.5 minutes. The average number of device passes was 1.5, with a mean procedure time to maximal recanalization of 49.5 minutes ± 13.0. Symptomatic intracerebral hemorrhage occurred in 6% of patients. The median mRS score at 90 days was 1, and 60% of patients had a good outcome (ie, mRS score 0–2). The overall 3-month mortality rate was 14%.ConclusionsCombined revascularization with the Solitaire stent during IVT appears to be safe and effective in the treatment of acute IAO.     

经皮血管腔内成形术治疗髂股动脉硬化闭塞症

目的评价经皮腔内成形术及支架植入术治疗髂股动脉硬化闭塞症的临床疗效。方法自1999年4月-2004年8月,为13例髂股动脉硬化闭塞症患者联合应用导管接触性溶栓和导丝机械性开通的方法开通闭塞段,行腔内成形及支架植入术,共植入25枚Wallstent支架,采用多普勒超声或DSA随访。结果13例患者均一次性开通血管闭塞段并植入支架。经8个月～5年(平均26.2个月)随访,1例于术后23d支架内急性血栓闭塞,经导管接触性溶栓治疗再次成功开通;1例于术后19个月临床症状加重,造影证实支架处髂总和髂外动脉闭塞并同侧股浅动脉闭塞,于外科行血管旁路术,其余病例于随访期内血流通畅,临床疗效满意。结论接触性溶栓结合导丝机械性开通法开通闭塞血管成功率高,血管腔内成形术作为髂股动脉硬化闭塞症的有效治疗方法创伤小,再狭窄率低。     

Reocclusion of recanalized arteries during intra-arterial thrombolysis for acute ischemic stroke

BACKGROUND AND PURPOSE: Early reocclusion of recanalized arteries has been observed after thrombolysis for acute coronary occlusion and has been attributed to platelet activation after exposure to thrombolytic agents. We conducted a retrospective study to determine the rate of reocclusion during intra-arterial thrombolysis for acute ischemic stroke and the effect of reocclusion on functional outcome. METHODS: Patients treated for acute ischemic stroke at our center between September 2000 and May 2002 received a maximum total dose of 4 U of reteplase intra-arterially in 1-U increments via superselective catheterization. Pharmacologic thrombolysis was supplemented by mechanical thrombolysis with balloon angioplasty or snare manipulation at the occlusion site. Angiography was performed after each unit of reteplase or mechanical maneuver, and the images were interpreted by a blinded reviewer. Reocclusion was defined as partial or complete initial recanalization with occlusion recurring at the same site as documented by angiography during the endovascular treatment. Reocclusions were treated by further pharmacologic and/or mechanical thrombolysis according to the discretion of the treating physician. Clinical evaluations were performed before and 24 hr, 7 to 10 days, and 1 to 3 months after treatment. RESULTS: Forty-six consecutive patients underwent intra-arterial thrombolysis. Reocclusion was observed in eight (17%). Among these patients, initial sites of occlusion were in the following arteries: intracranial internal carotid artery (n = 2), M1 segment of the middle cerebral artery (n = 3), M1 and M2 segments of the middle cerebral artery (n = 2), and basilar artery (n = 1). The mean initial National Institutes of Health Scale score for these eight patients was 23.3 +/- 6.2; mean time from symptom onset to treatment was 4.4 +/- 1.2 hr. The reocclusions were treated by using additional doses of reteplase alone (n = 1), reteplase with snare maneuver and/or angioplasty (n = 5), reteplase with angioplasty or snare and then stent placement (n = 1), and angioplasty with stent placement (n = 1). The reocclusions resolved in six of eight patients after further treatment. Six patients died and two survived but were severely disabled at 1 month (modified Rankin Scale scores of 4 and 5, respectively). Independent functional outcome scores (modified Rankin Scale scores of 0-2) were significantly lower among patients with angiographically shown reocclusion than in those without (0 of 8 versus 17 of 38, P =.02). CONCLUSION: Reocclusion occurs relatively frequently during intra-arterial thrombolysis for ischemic stroke and seems to be associated with poor clinical outcomes.     

血栓抽吸（ADAPT）与支架取栓在治疗急性大血管闭塞性脑梗死的比对研究

目的回顾性对比分析血栓抽吸与支架取栓在治疗急性前循环大血管闭塞性脑梗死中的有效性与安全性。 方法回顾性收集2018年6月至2019年10月在我院行急性脑血管病血管内治疗的33例患者资料,其中17例行支架取栓,16例行血栓抽吸,主要观察指标为闭塞血管再通率（mTICI 2b级以上）,次要观察指标为血管再通时间（股动脉穿刺到再通时间）、远期良好预后率（3月后mRS评分0～2分）、血栓逃逸率、需补救措施率、出血率、死亡率等,采用t检验对不同手术手术时间的差异进行检验,采用卡方检验对不同手术方式定性结果的差异性进行检验。 结果两组患者术前的NHISS评分中位数分别为血栓抽吸组（13分,2～23分）,取栓组（11分,3～19分）,二者之间差异无统计学意义（P>0.01）。血栓抽吸治疗闭塞血管开通率（mTICI 2b级以上）为87.5%（14/16）,支架取栓治疗闭塞血管开通率（mTICI 2b级以上）为70.6%（12/7）,二者差异无统计学意义（χ²=1.41,P>0.01）。两种手术方式在血管开通时间、远期良好预后率、血栓逃逸率、需补救措施率、出血率及死亡率之间差异均无明显统计学意义。 结论对比支架取栓,血栓抽吸技术治疗急性缺血性大血管闭塞性脑卒中是有效的和安全的。但仍然需要大样本的研究去进一步验证血栓抽吸技术的疗效性与安全性。     

Endovascular Procedures versus Intravenous Thrombolysis in Stroke with Tandem Occlusion of the Anterior Circulation

PurposeStroke with tandem occlusion within the anterior circulation presents a lower probability of recanalization and good clinical outcome after intravenous (IV) thrombolysis than stroke with single occlusion. The present study describes the impact of endovascular procedures (EPs) compared with IV thrombolysis alone on recanalization and clinical outcome.Materials and MethodsThirty patients with symptom onset less than 4.5 hours and tandem occlusion within the anterior circulation were analyzed retrospectively. Recanalization was assessed per Thrombolysis In Cerebral Infarction (TICI) classification on computed tomography, magnetic resonance imaging, or digital subtraction angiography within 24 hours. Infarct size was detected on follow-up imaging as a dichotomized variable, ie, more than one third of the territory of the middle cerebral artery. Clinical outcomes were major neurologic improvement, independent outcome (90-d modified Rankin Scale [mRS] score), symptomatic intracerebral hemorrhage (sICH; per European Cooperative Acute Stroke Study criteria), and death within 7 days.ResultsPatients treated with EPs (n = 14) were significantly younger and had a history of arterial hypertension more frequently than patients treated with IV thrombolysis alone (n = 16). Recanalization (ie, TICI score 2b/3; EP, 64%; IV, 19%; P = .01), major neurologic improvement (EP, 64%; IV, 19%; P = .01), and independent outcome (mRS score ≤ 2; EP, 54% IV, 13%; P = .02) occurred more often in the EP group, whereas infarct sizes greater than one third of the MCA territory (EP, 43%; IV, 81%; P = .03) were observed less often. Rates of sICH (P = .12) and death within 7 days (P = .74) did not differ significantly.ConclusionsHigher recanalization rate, smaller infarct volume, and better clinical outcome in the EP group should encourage researchers to include this subgroup of patients in prospective randomized trials comparing IV thrombolysis versus EP in stroke.     

Internal carotid artery stent implantation in 25 patients with acute stroke: preliminary results

PURPOSE: To evaluate retrospectively the outcome for patients with acute ischemic stroke in the territory of the middle cerebral artery (MCA) who had undergone stent implantation in the proximal segment of the internal carotid artery (ICA) in addition to intraarterial thrombolysis (IAT). MATERIALS AND METHODS: Stent implantation and retrospective analysis of clinical and radiologic data were approved by the institutional ethical committee. Endovascular treatment was performed after obtaining informed consent from patients or their closest relatives. Informed consent for retrospective review was not required. After pharmacologic and/or mechanical IAT, 25 consecutive patients (seven women, 18 men; mean age, 59 years +/- 14 [standard deviation]) underwent stent implantation in the proximal segment of the ICA (endovascular group). The clinical and radiologic characteristics (ie, interval from symptom onset to arrival at the emergency department, prevalence of vascular risk factors, causes of stroke, stroke severity, early signs of cerebral ischemia, duration of endovascular intervention, type of occlusion, and prevalence of leptomeningeal collateral vessels), recanalization rates, and clinical outcomes for patients in the endovascular group were compared with those for patients in the medical group (10 women, 21 men; mean age, 62 years +/- 12) who experienced ischemic stroke in the territory of the MCA as a result of ICA occlusion and who received antithrombotic treatment only. Differences between groups were assessed by using the chi2 test. A logistic regression analysis was performed to assess the effect of clinical and radiologic factors on recanalization rates and outcome. RESULTS: ICA recanalization was successful in 21 patients. Good recanalization of the MCA was achieved in 11 patients. In nine of these patients, recanalization of the MCA was achieved by using mechanical IAT only. In the remaining 12 patients, administration of intraarterial urokinase was performed in addition to mechanical thrombolysis. Two patients from the endovascular group experienced symptomatic intracerebral hemorrhage. At 3 months, 56% of the endovascular group and 26% of the medical group had a favorable outcome. Mortality was 20% in the endovascular and 16% in the medical group. CONCLUSION: IAT and stent implantation in the proximal segment of the ICA seem to improve the outcome for patients with ischemic stroke caused by occlusion of the cervical portion of the ICA.     

Thrombolytic therapy of acute ischemic stroke: correlation of angiographic recanalization with clinical outcome

BACKGROUND AND PURPOSE: The effect of vessel patency, following recombinant tissue plasminogen activator (rtPA) administration, on clinical outcome in acute ischemic stroke (AIS) has been controversial. We studied the effect of recanalization following intraarterial (IA) and intravenous/IA (IV/IA) rtPA on clinical outcome in AIS. METHODS: Recanalization was classified angiographically as complete (as compared with unoccluded vessel, thrombolysis in myocardial infarction classification [TIMI] 3), none (with no change from prethrombolysis, TIMI 0), and partial (when a change in the flow from baseline was noted, TIMI 1-2). Outcomes were symptomatic intracranial hemorrhage (sICH), 90-day modified Rankin scale (< or = 2 as a good outcome), and 3-month mortality. RESULTS: Ninety-six patients had either combined IV/IA (41) or IA (55) rtPA for AIS during a 7-year period. Any recanalization occurred in 69%; 55% of those had a good outcome versus 23% in the rest (Odds ratio = 3.9; 95% confidence interval [CI] = 1.4-11.2; P = .007). Only 24% had complete recanalization; 74% had a good outcome versus 36% in the nonrecanalization group (OR = 5.1; 95% CI = 1.6-16.8; P = .002). When adjusted to time to therapy and vessel occluded, these results lessened but remained significant. The sICH rate with any recanalization was 7.6% versus 13.3% in patients with persistent clot (relative risk (RR) = 0.6; 95% CI = 0.2-2.0; P = .45). Death occurred in 19.7% of those whose vessels recanalized versus 33.3% in the rest (RR = 0.56; 95% = 0.26-1.19; P = .2). CONCLUSION: A total of 24% and 69% of patients had complete and any recanalization, respectively, following endovascular rtPA therapy of AIS. The degree of recanalization was directly related to time to therapy and associated with good clinical outcome without an increase in the rate of adverse effect.     

Percutaneous management of superior vena cava occlusions

Purpose To assess the use of percutaneous endovascular stent insertion in the management of superior vena cava (SVC) occlusion.Methods Percutaneous endovascular stent insertion was attempted in 13 patients, age range 20–72 (mean 55.5) years, with symptomatic total occlusion of the SVC. Twelve patients had known malignant disease of the thorax. The other patient (age 20) had chronic SVC obstruction, the cause of which was unknown at the time of the procedure. There was initial angiographic assessment and removal of thrombus by thrombolysis (10 patients) and/or clot aspiration (3 patients). Following successful lysis or aspiration, single or multiple endovascular stents were inserted.Results The inability to cross the lesion with a guidewire prevented stent insertion in 2 patients (15.4%). There was primary success in the remaining 11 patients (84.6%), with associated symptomatic relief. Some recurrence of symptoms occurred in 5 of the 11 patients (45.5%) after a time interval ranging from 14 to 183 days. In all cases of symptomatic recurrence, patency was reestablished with further thrombolysis and/or further stent insertion. All successfully treated patients have since died. All 11 patients remained symptomatically free of SVC occlusion until death, with postprocedure survival ranging from 5 to 243 days.Conclusion The percutaneous management of complete SVC occlusion with thrombolysis and/or clot aspiration followed by stent insertion is safe and effective, giving sustained symptomatic relief.     

Intraarterial thrombolysis in vertebrobasilar occlusion.

PURPOSETo report our experience using intraarterial thrombolysis in the treatment of vertebrobasilar occlusion.METHODSTwelve patients with 13 angiographically proved thromboses of the vertebrobasilar system underwent local intraarterial thrombolysis with urokinase. Angiographic and clinical outcomes were analyzed with respect to clinical examination at presentation, arterial occlusion patterns, and time to recanalization.RESULTSThe overall mortality was 75%. Recanalization could not be achieved in 3 of 13 treatments; all patients in whom recanalization failed died. The mortality rate was 60% in those patients in whom recanalization was successful. Coma or quadriparesis at the time of therapy uniformly predicted death. There were two cases each of bilateral proximal vertebral occlusions and midbasilar occlusions and nine cases of bilateral distal vertebral occlusions. There were three cases of fatal rethrombosis after initial successful thrombolysis. The mortality rate in the recanalized group before rethrombosis was 30%. There were two fatal hemorrhages of the central nervous system.CONCLUSIONRecanalization of the vertebrobasilar system is necessary but not sufficient for effective treatment of vertebrobasilar occlusive disease. The site of occlusion may help predict angiographic and clinical outcome. Time to initiation of thrombolysis is not an invariable correlate of survival, although clinical condition at presentation may be. Rethrombosis and hemorrhage are significant problems affecting mortality after successful thrombolysis.