Categorization of cerebrovaCategorization of cerebrovascular intervention methods

BACKGROUND: Cerebrovascular intervention is a medical strategy to diagnose and treat cerebrovascular disease by intravascular intervention techniques. With the continual developments of computer technology, imageology, and angiography, cerebrovascular intervention techniques have developed rapidly. OBJECTIVE: To summarize and to evaluate vascular imaging diagnostic techniques, vascular intra-arterial thrombolysis, vascular intra-arterial angioplasty, and vascular embolization in clinical applications. RETRI...     

尿激酶动脉内溶栓联合血管内干预治疗急性脑梗死分析

目的分析尿激酶动脉内溶栓联合血管内干预治疗急性脑梗死的疗效和安全性。方法回顾分析我科住院治疗13例患者进行尿激酶动脉内溶栓及血管内干预治疗的急性脑梗死患者临床资料。结果 13例患者中,颈动脉系统病变11例,其中颈内动脉闭塞2例,大脑中动脉主干及分支闭塞8例,大脑前动脉闭塞1例(包含脑血管造影未见异常者3例),椎基底动脉闭塞2例。溶栓开始时间3～12h,平均7.5h,其中10例在6h内开始。使用尿激酶30万～100万U,平均70万U。溶栓后2例给予血管内支架治疗,4例给予球囊扩张血管成形治疗。基本痊愈5例,显著进步5例,无效3例。闭塞血管成功再通7例,未成功再通3例。并发脑出血1例,死亡1例,无并发消化道出血等其他情况。结论对急性脑梗死患者进行尿激酶动脉内溶栓联合血管内干预治疗是安全有效的。     

缺血性脑血管病腔内成形术围手术期并发症的预防及处理

目的:探讨缺血性脑血管病腔内成形术围手术期并发症的预防及处理。方法:采用血管腔内成形术治疗52例缺血性脑血管病患者,其中症状性颅内动脉狭窄29例,颈动脉狭窄患者23例。结果:52例患者中共有51例成功置入56枚支架,技术成功率达98.1%。48例患者术后均未再发生脑缺血发作,1例因支架置入困难仅行PTA术,术后症状明显改善;基底动脉支架成形术后1例出现动眼神经麻痹;1例出现再灌注损伤;1例出现颅内出血;7例患者出现血压下降。结论:缺血性脑血管病腔内成形术围手术期可能发生严重的并发症,正确预防和处理这些并发症,是避免患者致残、致死的关键。     

血管内支架成形材料在脑供血动脉狭窄治疗中的应用

目的：总结近年来血管内支架成形材料在脑供血动脉狭窄治疗中的应用情况。 方法：由作者应用计算机检索维普数据库中与血管内支架置入治疗脑供血动脉狭窄有关的文章,检索时限2000-01/2010-10。检索关键词：血管内支架成形术;脑供血动脉狭窄;缺血性脑卒中;并发症。纳入标准：血管内支架置入治疗脑供血动脉狭窄的文章。排除标准：重复研究或较陈旧文献。 结果：金属内支架进入临床治疗后取得了令人瞩目的效果,但具有一定的致血栓形成性、永久性存留体内、再狭窄仍较高、金属表面难以附载药物等缺点。针对以上不足,近些年对支架材料、构形设计、制作工艺等均作了不少改进,更引人注目的是20世纪80年代末和90年代初覆膜支架的出现和生物学支架概念的提出,使血管内支架又进入了一个新的阶段。 结论：随着血管内技术的发展,脑保护装置下血管内支架置入已成为治疗颅内外动脉狭窄的主要方法之一,支架技术的安全性和有效性已显著提高,但仍存在如血栓形成、脑出血、再狭窄以及过度灌注等问题。 关键词：血管内支架成形术;脑供血动脉狭窄;缺血性脑卒中;并发症;生物材料 doi:10.3969/j.issn.1673-8225.2011.08.037     

脑血管腔内支架置入治疗症状性脑动脉狭窄20例

景：关于脑血管支架置入后局部机械性血管壁损伤后发生血管内再狭窄研究中涉及的安全性、病理生理机制及临床疗效尚无确切的结论。 目的：探讨脑血管腔内支架置入治疗症状性脑动脉狭窄的安全性、近期临床疗效。 方法：对20例症状性脑动脉狭窄患者行脑血管腔内支架置入治疗,狭窄病变22处,位于大脑中动脉6处、颈内动脉6处、椎动脉4处、基底动脉3处,3例为椎-基底动脉狭窄;狭窄长度为3~10 mm,平均为7 mm,其中6处狭窄长度超过10 mm。行自膨式及球囊膨胀式支架置入,使用脑保护装置保护伞12例。 结果与结论：20例患者22枚支架均1次放置成功, 无一例发生严重并发症,置入后即刻血管造影结果显示,病变段动脉残余狭窄程度小于20%,与治疗前相比较,管腔狭窄明显改善。同时再造影的实质期可见脑组织血流灌注得到改善,临床症状全部得到改善。置入后临床随访6~24个月,20例未再有脑缺血发作,数字减影血管造影随访12~24个月7例,1例出现支架内内膜轻度增生,未引起临床症状。经颅超声多普勒随访结果示狭窄部位血流通畅,支架内未见内膜过度增生,无主要分支血管的闭塞。结果说明脑血管腔内支架置入治疗症状性颅内动脉狭窄安全,近期疗效明显,其长期疗效还需进一步随访观察。     

动脉内溶栓联合支架治疗基底动脉闭塞临床报道

目的探讨溶栓后即刻置入支架的方法治疗急性椎基底动脉系统卒中溶栓术后血管重新闭塞的有效性和安全性。方法回顾性分析北京宣武医院2003年7月-2004年12月采用动脉内溶栓加支架置入治疗的7例脑卒中患者的临床资料，采用尿激酶超选择动脉溶栓，溶栓后对血管狭窄行支架成形术。结果7例溶栓后均再通。基底动脉尾段狭窄1例，主干狭窄4例，头段狭窄2例．动脉狭窄率平均为85％．即刻置入冠脉支架。置入支架后造影显示血管形态良好．残留狭窄率小于20％。术后复查点片状脑出血2例。术后症状好转或消失6例，围手术期死亡1例。结论超选择动脉溶栓联合支架治疗能够防止血管再闭塞及卒中复发，改善病人预后。     

症状性基底动脉高度狭窄血管内介入治疗的临床研究

目的对血管内介入治疗症状性基底动脉高度狭窄的有效性、安全性,以及近期疗效进行探讨。方法对经磁共振血管造影(magnetic resonance angiography,MRA)、CT血管成像(computed tomography angiography,CTA)或脑血管造影术(digital subtraction angiograyhy,DSA)证实为基底动脉高度狭窄(90%)并有相应临床症状的213例患者进行血管内介入治疗,对临床症状变化、手术成功率以及随访结果进行评估。结果 209例(209/213)基底动脉高度狭窄患者成功的进行血管内介入治疗,手术成功率为98.12%,平均狭窄率从术前的(93.70%±2.51%)降至术后的(11.60%±3.90%)。围手术期并发症8例(3.76%),缺血性卒中7例,蛛网膜下腔出血1例。平均随访(18.70±3.80)个月,202例患者再次行DSA,平均狭窄率为(13.80%±4.20%)。5例患者发生支架内再狭窄,其中1例表现为症状性狭窄。结论基底动脉高度狭窄的血管内介入治疗具有有效、安全的优点,术后1.5年随访结果显示血管通畅率好以及能够较好的预防后循环缺血事件的发生。     

A 70-year-old woman with poor grade subarachnoid hemorrhage complicated by carotid stenosis, cerebral vasospasm, and cerebral rebleed

Introduction: Subarachnoid hemorrhage is one of the most common entities encountered in neurocritical care units. Knowledge of disease sequelae and their management is paramount for all neurointensivists. Materials and Methods: This study relates the case of a 70-year-old woman with poor grade subarachnoid hemorrhage who underwent endovascular detachable coil embolization of a right internal carotid artery aneurysm. Her hospital course was subsequently complicated by symptomatic carotid stenosis and cerebral vasospasm requiring intervention. Discussion: The discussants present their views regarding five main questions pertaining to management of the patient regarding the choice of endovascular versus surgical aneurysm occlusion, stent-supported angioplasty in a patient with a recent subarachnoid hemorrhage, and treatment options for vasospasm.     

Clinically successful late recanalization of basilar artery occlusion in childhood: what are the odds? Case report and review of the literature

BACKGROUND AND PURPOSE: Acute basilar artery occlusion is an infrequent but potentially fatal cause of stroke, both in adults and children. We present our experience with a 6-year-old child and we investigate the rationality for late treatment of acute basilar occlusion in children. METHODS: We report the case of a 6-year-old boy with acute basilar artery occlusion presented with a full blown locked-in syndrome, admitted to the endovascular suite 44 h after the stroke onset, and we review all the reported cases of basilar artery occlusions presented with locked-in syndrome in children. RESULTS: Six hours following admission the basilar artery was partially recanalized by intra-arterial thrombolysis combined with mechanical clot angioplasty. After 12 h, the patient was awake, oriented, his speech function was fully restored and he had only a mild right hemiparesis that recovered completely after a month. CONCLUSIONS: To our knowledge, this is the first report of complete clinical recovery after delayed (50 h) endovascular recanalization of basilar artery in a child. Intra-arterial thrombolysis combined with cerebral angioplasty, can successfully restore the patency of the basilar artery and the neurologic deficit of children with acute basilar artery occlusion, even after a considerable delay.     

12例脑动脉狭窄支架置入术的临床观察

目的观察脑动脉狭窄血管内支架成型术的安全性、近期临床疗效及治疗经验。方法包括颈内动脉起始部狭窄9处,椎动脉开口部狭窄5处,基底动脉狭窄3处的12例患者共17处行自膨式及球囊膨胀式支架置入术,共使用保护伞10例,围手术期给予抗血小板聚集。结果12例病人共置入支架17枚,成功率100%。1例术中发生低血压性休克,治疗后好转;6~17个月随访9例无症状复发,DSA复查9例,其中1例内膜增生,1例再狭窄。结论血管内支架置入术治疗脑血管狭窄安全有效,近期疗效明显,但仍需长期随访观察远期疗效。     

缺血性脑血管病患者颅内外动脉狭窄分布研究

目的 研究缺血性脑血管病患者颅内外动脉狭窄分布特点.方法 本研究收集了1031例在院脑梗死和TIA患者的DSA资料,对其中资料完整的1000例患者进行分析.结果 DSA显示,1000例患者中有680例存在脑动脉狭窄,累计有1417条血管狭窄.发生部位依次为:大脑中动脉狭窄337条、椎动脉远端及基底动脉狭窄291条、颈内动脉颅外段狭窄280条、椎动脉起始段狭窄207条、颈内动脉虹吸段狭窄115条、大脑前动脉狭窄100条、大脑后动脉狭窄70条.大脑中动脉、椎基底动脉系统和颈动脉颅外段是最常见的动脉狭窄好发部位.颅内动脉狭窄331例,颅外动脉狭窄134例,颅内外动脉均见狭窄215例.结论 颅内动脉粥样硬化性狭窄仍是缺血性卒中的重要原因,最近三年,多发病变、颅外动脉病变检出率明显上升,值得关注,控制血压、血糖、血脂可预防脑动脉粥样硬化性狭窄的发生.     

血管内超声在缺血性脑血管疾病支架置入过程中的应用与评价

目的：脑血管内支架置入已逐渐成为治疗缺血性脑血管疾病一种重要方法,但支架置入后的再狭窄成为当前疾病治疗的主要局限。为此对超声在判断和减少血管支架置入再狭窄的应用效果和价值进行探讨。 方法：由第一作者检索维普数据库和中国期刊全文数据库有关缺血性脑血管疾病支架置入的超声评价方面的文献,共检索到22篇文献,对资料进行初审,最终纳入6篇进行分析。纳入标准：①血管内超声在颈动脉支架置入前的应用。②血管内超声指导支架置入及其效果评价。③彩色多普勒超声及经颅彩色多普勒超声对颈动脉支架置入后近期及远期效果的评价。排除标准：较陈旧的文献和重复研究。 结果：①血管内超声在支架置入前可精确测量血管管腔的狭窄程度、狭窄长度及血管腔面积,以便选择大小、长度适合的支架,指导支架行之有效的放置。②血管内超声探头可以观察到支架扩张是否完全,扩张后的支架是否对称,精确测量扩张后支架的大小以及支架与血管壁的紧贴程度。③彩色多普勒超声及经颅彩色多普勒超声可以监测血管支架置入后的近期及远期效果,早期发现、早期治疗,减少血管再狭窄的发生。明确血管支架内发生再狭窄的原因,指导对支架内发生再狭窄的治疗,降低再狭窄的发生率,进一步改善支架置入效果。 结论：血管内超声弥补了数字减影血管造影的不足,在其指导下的支架置入可获得较大的支架面积和较小的再狭窄率。在血管支架置入后,血管内超声可准确检测支架的扩张程度及血管壁内贴壁情况,彩色多普勒超声及经颅彩色多普勒超声定期监测支架内的血流情况,对血管内支架置入后再狭窄的评估及预防再狭窄具有重要的应用价值。     

夹闭术治疗栓塞后复发的颅内动脉瘤的疗效分析

目的探讨栓塞后复发的颅内动脉瘤的手术治疗方法及其疗效。方法回顾性分析夹闭术治疗的10例栓塞后复发的颅内动脉瘤的临床资料,其中后交通动脉动脉瘤4个,前交通动脉动脉瘤3个,大脑中动脉动脉瘤2,基底动脉顶端动脉瘤1个。结果 10例动脉瘤夹闭完全,其中5个动脉瘤内弹簧圈术中全部或部分去除,5个动脉瘤内弹簧圈予以保留。术后CTA或DSA显示动脉瘤夹闭完全,载瘤动脉通畅。10例出院时GOS评分5分8例,4分1例,3分1例。术后平均随访20个月,GOS评分5分9例,4分1例(术后发生脑血管痉挛造成脑梗死);随访期间无动脉瘤复发。结论栓塞后复发的颅内动脉瘤具有较高的手术难度,夹闭术仍然是一种安全有效的治疗方法。     

头颈部少见类型动-静脉瘘的血管内栓塞治疗

目的探讨头颈部少见类型动-静脉瘘血管内栓塞治疗的方法及临床价值。方法创伤性伴有基底动脉动脉瘤的基底动脉-基底静脉丛瘘、原始三叉动脉动脉瘤破裂臻致三叉动脉-海绵窦瘘、自发性和创伤性颈外动脉-海绵窦瘘、创伤性颈内动脉-海绵窦瘘伴有椎动-静脉瘘及创伤性颈内动脉-海绵间窦瘘各1例，对此6例少见类型动-静脉瘘患分别采用机械解脱弹簧圈、电解脱弹簧圈以及可脱性球囊技术进行血管内栓塞治疗。结果创伤性伴有基底动脉动脉瘤的基底动脉-基底静脉丛瘘和创伤性颈内动脉-海绵窦瘘伴有椎动-静脉瘘患分两次伶塞，而原始三叉动脉动脉瘤破裂致三叉动脉-海绵窦瘘、自发性和刨伤性颈外动脉-海绵窦瘘、刨伤性颈内动脉-海绵间窦瘘患均一次完成栓塞治疗。手术后临床症状和体征完全消失。无并发症发生。结论血管内栓塞是治疗头颈部少见类型动-静脉瘘的最佳方法，其操作简单．安全可靠，疗效好，并发症发生率低。应作为首选。     

Interventional endovascular therapy (stenting) for residual stenosis after lysis of the basilar artery

Despite the introduction of local thrombolytic therapy, there is still a very high mortality rate in basilar thrombosis. We report three cases of successful intra-arterial thrombolysis of acute basilar artery occlusion and consecutive interventional endovascular therapy. In all cases, the acute thrombosis of the basilar artery probably developed from preexisting atherosclerotic stenoses. The clinical outcomes were excellent. We discuss early consecutive stenting as a possible therapeutic option in cases of residual stenosis after successful intra-arterial lysis of basilar artery occlusion.     

Intraaneurysmal embolization of an unruptured basilar tip aneurysm associated with moyamoya disease.

We describe a patient with moyamoya disease associated with an unruptured basilar tip aneurysm which was treated by endovascular embolization using Guglielmi detachable coils (GDCs). A 53-year-old man presented with left hemiparesis persisting for 3 mon ths before admission. Cerebral angiography revealed occlusion of the bilateral middle cerebral arteries and the left anterior cerebral artery, stenosis of the right anterior cerebral artery, and basal moyamoya vessels. In addition, a saccular small aneurysm was seen at the top of the basilar artery. The aneurysm was completely embolized by intraaneurysmal GDCs. Direct surgical clipping is often selected for the treatment of posterior fossa aneurysms in moyamoya disease. However, complete clipping is usually difficult due to the difficulties in operative technique associated with moyamoya disease. We suggest that the endovascular treatment using GDCs is comparatively safe and effective for the treatment of surgically difficult aneurysms in patients with moyamoya disease.     

后循环动脉瘤的血管内介入治疗

目的探讨后循环动脉瘤血管内介入治疗的临床应用。方法 14例后循环动脉瘤患者Hunt&Hess分级分为Ⅱ级11例,Ⅲ级2例,Ⅳ级1例;数字减影血管造影(DSA)显示椎动脉瘤2例,小脑后下动脉远端动脉瘤5例,基底动脉尖动脉瘤2例,基底动脉末端动脉瘤1例,小脑前下动脉瘤2例,大脑后动脉瘤2例。入组者均给予血管内介入治疗,其中7例囊性动脉瘤采用单纯弹簧圈栓塞术,5例采用Onxy胶载瘤动脉局部栓塞术,分别有1例应用支架辅助微弹簧圈栓塞术及支架塑形术。结果术后DSA显示动脉瘤完全栓塞10例,近全栓塞3例。1例支架塑形术后梭形膨出明显好转。格拉斯哥预后量表评分为5分12例,3分1例,2分1例。随访3个月～5年,8例恢复正常,1例左侧偏瘫,1例死亡,4例失访。结论颅内后循环动脉瘤多为复杂动脉瘤,个体化血管内介入治疗是安全、有效的方法。     

症状性椎基底动脉狭窄的血管内治疗(附95例报告)

目的 总结椎基底动脉系统症状性血管狭窄的血管内治疗的策略、方法 、术中风险及术后疗效.方法 回顾性分析2004年1月至2008年7月治疗的95例采用支架置入治疗的症状性椎基底动脉狭窄患者的临床资料.结果 采用支架置入治疗的患者中,椎动脉起始部狭窄者21例,椎动脉颈段狭窄者3例,椎动脉颅内段狭窄者16例,椎基底动脉交界处狭窄者15例,基底动脉段狭窄者36例,大脑后动脉P2段狭窄者4例.所有狭窄均>50%.手术的技术成功率为97%(92/95).术后平均狭窄率从76.1%(50%～95%)下降到9.2%(0～20%).所有患者均在术后6个月-2年内随访,其中88例患者效果良好.结论 脑血管狭窄处支架置入术是目前治疗该类疾病的有效方法 ,其长期疗效还有待进一步观察.     

脑后循环血管支架置入并发症与其解剖特征的相关性

背景：后循环动脉管径细、行程长、生理弯曲多、分支多,血管内支架置入治疗相当困难。 目的：分析后循环动脉解剖特征与支架置入过程中并发症发生的相互性。 设计、时间及地点：回顾性分析,病例来自2004-11/2008-02郧阳医学院附属人民医院神经内科。 对象：选择郧阳医学院附属人民医院神经内科住院患者25例,27个后循环动脉狭窄性病变,男13例,女12例,年龄50~76岁;其中锁骨下动脉盗血综合征4例,V1段、V2段、V4段以及基底动脉中下段狭窄分别为1例、1例、14例、2例,基底动脉尖综合征3例,大脑后动脉P1段狭窄2例,狭窄程度均大于70%。Mori分型均为A型和B型。锁骨下选用自膨式支架,其他选用球扩式支架。 方法：颅外段支架置入均在局部麻醉下,颅内段于气管插管全麻下进行。若行锁骨下动脉狭窄支架置入成形术,将8F导引导管上至左侧锁骨下动脉开口处或者右侧头臂干。若经椎动脉起始部或V2段支架置入,就将6F导引导管上至锁骨下动脉起始部。若行椎动脉颅内段、基底动脉、大脑中动脉P1段支架置入或球囊扩张术,就将6F导引导管上至第二颈椎高度,甚至更高。导引导管到位后在路途下将支架输送到狭窄部位,造影确认支架到位准确后释放支架,撤下输送系统,再造影,观察支架覆盖狭窄的情况及狭窄解除的程度。 主要观察指标：支架覆盖狭窄性病变的情况、狭窄解除的程度,支架移位、病变部位的血管破裂及支架内长血栓的情况,通过体检、CT或MRI检查支架置入后脑梗死的发生。 结果：27处病变中,26处为支架置入,1处为单纯球囊扩张术,成功率达96%。锁骨下动脉起点到椎动脉开口之间的距离短,尤其右侧,导引导管固定困难,支架容易移位;椎动脉V3段相对固定、弯曲大,限制了能通过支架的长度;基底动脉分支多,支架置入或球囊扩张后容易发生分支闭塞;基底动脉尖为5分支结构易破裂出血或分支闭塞,应该作为置入治疗的禁忌证。置入并发症包括支架移位1例、基底动脉穿通支闭塞性梗死1例、血管破裂出血2例。其他患者支架置入顺利,无置入期并发症发生,恢复良好。 结论：置入过程中并发症的发生与后循环动脉解剖特点密切相关。     

Transluminal angioplasty for arteriosclerotic disease of the distal vertebral and basilar arteries.

OBJECTIVE: Percutaneous transluminal angioplasty (PTA) for the distal vertebral and basilar artery is now being performed in selected patients with haemodynamically significant lesions of the posterior cerebral circulation. Its effect and overall results were examined. PATIENTS AND METHODS: A balloon dilatation catheter specifically developed for these procedures, with a 2.0-3.5 mm balloon diameter, at 6 atmospheres of pressure, was used. Angioplasty was performed in 12 patients (including six whose initial results have been reported) with angiographically documented stenotic lesions involving either the intracranial vertebral artery (C1-C2 portion) or the basilar artery, and satisfying the following criteria: (1) clinical symptoms suggestive or consistent with a transient ischaemic attack refractory to medical treatment, or small infarction of the posterior circulation; and (2) angiographically documented stenosis greater than 70%. Two of 12 patients had complete thrombosis of the distal vertebral and basilar artery and PTA was performed after successful intra-arterial thrombolysis. RESULTS: Successful results, without complications, were obtained in eight patients, with complete resolution of vertebrobasilar ischaemic symptoms. Immediate complications occurred in four patients including two with vessel dissection, and two with thromboembolism. The two patients with acute arterial dissection were reoperated but developed small infarctions with permanent neurological deficits. The two patients with thromboembolic complication showed transient neurological deficit. The overall stenosis ratio decreased from a mean of 84% pretreatment to 44% after the angioplasty procedure. Restenosis occurred in two patients. Long term clinical follow up in 11 patients who survived more than six months showed resolution of ischaemic symptoms after PTA in all except for one with a restenosis who had recurrent transient ischaemic attacks. CONCLUSION: Transluminal angioplasty may be an effective procedure to treat vertebrobasilar ischaemia secondary to high grade arteriosclerotic disease affecting either the distal vertebral or basilar artery regions that do not respond to medical treatment.