多发颈动脉重度狭窄/闭塞患者的临床干预研究

目的评价血管内支架置入术和内科药物治疗双侧重度颈动脉狭窄/闭塞患者的疗效。方法一侧颈动脉闭塞,对侧颈动脉重度狭窄患者21例,随机分成两组：A组8例,接受颈动脉血管内支架置入治疗；B组13例,接受内科药物治疗。临床和超声波随访1年半。结果A组患者术前颈动脉狭窄程度为70％～98％,颈内动脉支架放置成功,术后狭窄程度小于10％,除1例偶发一次TIA外,其他患者未再出现TIA和卒中发作,颈动脉超声随访1年半,未见明显的管腔再狭窄（狭窄≥30％）。B组患者9例（9/13）再次卒中（5例发生脑梗死,其中2例死亡,4例反复TIA）,另4例（4/13）病情无变化,超声波检查发现7例（7/11）患者颈动脉内中膜增厚、动脉粥样斑块增多增大,管腔进一步狭窄。结论血管内支架置入术是治疗双侧颈动脉重度狭窄/闭塞安全有效的治疗手段,其短-中期疗效优于内科药物治疗。     

血管内支架置入术治疗颈内动脉狭窄疗效分析

目的 探讨颈动脉支架置入术（carotid artery stenting,CAS）治疗颈内动脉狭窄疗效及具体应用血管内治疗时的注意事项。方法 共收集70例颈内动脉狭窄程度均大于70%的患者,均有不同程度短暂性脑缺血发作（TIA）及脑梗死病史。32例符合介入手术适应证的患者接受了自膨式支架置入手术,介入手术组均采用脑保护装置。另38例未做手术的患者服用小剂量阿司匹林及波立维等药物干预。所有病例均随访1年,统计病例的转归情况,评估介入手术组的再狭窄情况。结果 介入手术组支架置入成功率为100%,术后残余狭窄<50%。1年内随访,介入手术组：6例仍有TIA发作,2例新发脑梗死（为中灶梗死,且均有支架内再狭窄）,年卒中发生率为6.25%;单纯药物干预组：38例患者中4例有新发脑梗死（2例中灶,2例大灶）,18例依然有TIA发作,年卒中发生率为10.5%。两组病例1年内TIA及脑梗死卒中事件的比较有统计学意义（P <0.05）。结论 应用脑保护装置行血管内支架置入术是治疗颈动脉狭窄预防卒中较为有效、安全的方法,但远期效果尚有争议。     

症状性颈动脉狭窄伴有同侧中动脉狭窄的介入治疗效果研究

目的   比较单纯颈动脉支架置入术治疗和联合颈动脉、大脑中动脉支架置入术治疗症状性颈动脉狭窄伴有中动脉狭窄的缺血性卒中或短暂性脑缺血发作（transient ischemic attack,TIA）患者短期终点事件发生率。 方法  回顾2010年1月～2013年12月采用血管内支架治疗症状性颈动脉狭窄伴有同侧大脑中动脉狭窄的缺血性卒中或TIA患者的临床资料。根据治疗情况将患者分为单纯颈动脉支架置入术治疗组和联合颈动脉、大脑中动脉支架置入术治疗组。比较两组术后90?d终点事件（包括同侧缺血性卒中复发、症状性脑出血及死亡风险）的发生率。 结果  共有21例患者纳入本研究,男性15例,女性6例,平均年龄（58.5±3.6）岁,其中16例患者进行了颈动脉支架治疗,5例患者进行了颈动脉联合中动脉支架治疗。颈动脉支架治疗组90?d终点事件发生3例（18.75%）,颈动脉联合中动脉支架治疗组发生1例终点事件（20%）,两组间差异无显著性（P=0.952）。两组发生的终点事件均为缺血性卒中复发,无症状性脑出血及死亡患者。 结论  对于伴有颈动脉及大脑中动脉狭窄的缺血性卒中或TIA患者,与单纯颈动脉支架治疗相比同时进行颈动脉及大脑中动脉支架治疗手术未减少术后90?d同侧缺血性卒中复发风险。     

经皮血管内成形及支架置入术治疗脑梗死伴重度颈动脉狭窄的研究

目的探讨脑梗死伴颈动脉狭窄患者采用经皮血管内成形及支架置入术治疗的可行性与安全性。方法选择2016-05—2017-05的脑梗死伴重度颈动脉狭窄的69例患者为研究对象,分为对照组(34例)与观察组(35例)。对照组只是单纯药物治疗,观察组采用经皮血管内成形及支架置入术治疗,比较2组患者治疗效果与安全性。结果观察组NIHSS评分降低幅度比对照组高,2组间比较差异具有统计学意义(P0.05)。观察组脑梗死复发率与病死率分别为2.86%、2.86%,对照组脑梗死复发率与病死率分别为17.65%、11.76%。观察组复发率与病死率明显低于对照组,2组间比较差异具有统计学意义(P0.05)。结论脑梗死伴重度颈动脉狭窄患者采用经皮血管内成形及支架置入术治疗,有助于减少患者复发率与病死率。经皮血管内成形及支架置入术治疗脑梗死伴重度颈动脉狭窄疾病具有较高的可行性与安全性。     

血管内支架置入术对无症状重度颈动脉狭窄患者认知功能的影响

目的探讨血管内支架置入术对无症状重度颈动脉狭窄患者认知功能的影响。方法无症状重度颈动脉狭窄患者60例。按照患者及家属意愿,同意在常规内科治疗基础上接受血管内支架置入术为观察组,接受常规内科治疗的为对照组,每组30例。对比2组患者治疗半年后的颈动脉狭窄率,并用简易精神状态量表(MMSE)和蒙特利尔认知评估量表(Mo-CA)评价2组患者认知功能。结果 2组患者治疗前颈动脉狭窄率无显著差异,治疗后观察组狭窄率(21.2±3.1)%,明显低于对照组的(59.5±5.4)%;2组患者治疗前MMSE评分无显著差异,治疗后观察组MMSE评分(26.54±4.20)分,明显优于对照组的(21.21±3.51)分;2组患者治疗前MoCA评分无显著差异,治疗后观察组MoCA评分(21.9±3.8)分,明显优于对照组的(17.1±4.5)分,差异均有统计学意义(P0.05)。结论血管内支架置入术对无症状重度颈动脉狭窄患者有很显著的效果,有利于减少颈动脉的狭窄率,改善患者认知功能,值得推广。     

血管内支架成形术治疗颈动脉狭窄性短暂性脑缺血发作的疗效评价

目的探讨血管内支架成形术(PTAS)对严重颈动脉狭窄所致的短暂性脑缺血发作(TIA)的疗效及手术安全性.方法对11例严重颈动脉狭窄患者行PTAS术,在狭窄部位先用球囊行预扩张,再植入支架;对于3例(27%)颈动脉狭窄＞90%或者有斑块者,在狭窄血管的远端安置保护滤过伞,再行预扩张及支架植入;如果颈动脉残余狭窄＞40%,则再行后扩张,最后回收保护滤过伞.对照组为10例严重颈动脉狭窄的患者仅行抗凝治疗.结果颈动脉狭窄经PTAS术后管腔内径由术前(2.79±1.22)mm到术后的(5.93±0.64)mn,两者比较有显著性差异(P＜0.001),随访6月术后无1例发生TIA或脑梗死,而且术中和术后无严重的并发症及再狭窄的发生;药物治疗组5例(50%)发生TIA,4例(40%)发生脑梗死.结论PTAS是治疗颈动脉严重狭窄的安全、有效的方法.     

颈内动脉起始段支架置入术血压管理护理体会

颈动脉狭窄是缺血性脑卒中的常见原因。多由动脉内粥样硬化斑块形成,中层组织变性、钙化,管腔内继发血栓,导致管腔狭窄甚至闭塞[1]。它的治疗方法目前有内科药物治疗、颈动脉内膜剥脱术和血管内介入支架治疗。近些年因神经介入技术的不断进步,具有创伤小、病人痛苦小、见效快、并发症少的特点[2],CAS(颈动脉支架植入术)发展迅速,被更多的患者接受。但支架置入过程中及术后血压、心率的     

颈动脉支架植入术及药物治疗症状性颈动脉狭窄的临床研究

目的 探讨颈动脉支架植入术在症状性颈动脉狭窄治疗中的安全性、疗效及并发症,并与传统内科药物治疗进行比较. 方法 自2005年5月至2010年5月徐州医学院第二附属医院神经内科共对52例症状性颈动脉狭窄患者行颈动脉支架植入术治疗(支架组),同期63例症状性颈动脉狭窄患者行内科药物治疗(药物组).分别在发病后3个月、6个月、12个月、1年后比较两组患者狭窄血管相关性卒中及短暂性脑缺血发作(TIA)发生率、美国国立卫生院卒中量表神经功能缺损评分(NIHSS). 结果 支架组1例由于路径较差支架无法到位而手术终止;9例术中、术后出现颈动脉窦反射,2例术中出现血管痉挛,4例术中出现高灌注综合征,及时有效处理后均未造成严重后果.随访中,支架组1例手术失败者3个月时卒中复发,余患者12个月内无卒中及TIA事件发作,1年后1例复发;药物组发病后3个月、6个月、12个月、1年后分别有11例、9例、7例及12例卒中或TIA事件发作.支架组发病后3个月、6个月、12个月及1年后NIHSS评分均明显低于药物组,差异有统计学意义(P＜0.05). 结论 颈动脉支架植入术治疗症状性颈动脉狭窄安全、可行,与内科药物治疗相比较能更好地预防卒中复发,值得临床推广应用.     

支架植入与药物治疗无症状性颈动脉重度狭窄的疗效评估

目的探讨支架植入与药物治疗无症状重度颈动脉狭窄的疗效。方法选取我院神经内科无症状性颈动脉重度狭窄患者60例,分为支架组28例和药物组32例,治疗后3个月、6个月比较2组患者狭窄血管相关性卒中及短暂性脑缺血发作(TIA)发生率、美国国立卫生院卒中量表神经功能缺损评分(NIHSS)。结果 (1)支架组3例术后出现颈动脉窦反射,2例出现高灌注综合征,2例出现脑血管痉挛;(2)药物组1例患者服药期间出现上消化道出血;(3)支架组在治疗后3个月、6个月无狭窄血管相关性卒中及短暂性脑缺血发作(TIA)发生,药物组患者在治疗后3个月、治疗后6个月分别有6例、4例发生狭窄血管相关性卒中及短暂性脑缺血发作(TIA);(4)支架组发病后6个月后NIHSS评分均明显低于药物组,差异有统计学意义(P0.05)。结论对于无症状性重度颈动脉狭窄,支架植入较药物治疗的并发症多,但在预防脑卒中方面更有优势。     

颅内动脉狭窄的支架成形术与内科治疗的疗效观察

目的比较血管内支架成形术与内科药物治疗对颅内动脉狭窄的疗效.方法符合入选标准的96例颅内动脉狭窄患者根据其经济承受能力及自愿原则,分为支架成形术（SAA）组30例和内科药物治疗组66例.每半年临床随访一次,随访时间6-36个月,平均18.9个月.详细记录（1）随访期间的卒中复发率及病死率;（2）MMSE评分;（3）mRS（modified rankin scale）评分,以mRS 2分以下为生存质量高,3分以上为生存质量差.结果SAA组有2例（6.7%）发生原狭窄动脉供血区的轻微卒中,内科治疗组10例（15.2%）再发卒中（P＜0.01）;MMSE评分提示SAA组患者的认知功能改善优于内科治疗组（P＜0.05）;两组mRS评分比较提示SAA组患者的生存质量优于内科治疗组.结论血管内支架成形术治疗颅内动脉粥样硬化性狭窄是安全的、可行的,其疗效优于内科保守治疗.     

Prognosis of asymptomatic carotid occlusion

Ninety-four asymptomatic patients with internal carotid artery occlusion were followed for a mean of 44 months, 16% suffered strokes and 11.7% reported transient ischemic attacks (TIA). The annual stroke and TIA rates were 4.4% and 3.2%, respectively, the annual mortality was 11.3%. In 27 asymptomatic patients progression of extracranial arterial disease to occlusion was observed: 7.4% of these patients suffered from stroke and 18.5% reported TIA's during that period. Thus the annual stroke rate was lower (1.9%) but the TIA rate higher (4.7%) than post-occlusive rates. These data reflect an increase risk in patients with progressive high-degree carotid stenosis which continues after occlusion. This may favour carotid endarterectomy for selected patients in the pre-occlusive state because medical treatment has not been shown to prevent progression of stenosis to occlusion.     

Is the endovascular treatment of carotid stenosis in high-risk patients really safer than carotid endarterectomy?

BACKGROUND: We assess the outcomes of patients who would have been considered at high-risk from carotid endarterectomy (CEA), who have undergone endovascular treatment. METHODS: High-risk patients were classed as those with occlusion of the contralateral internal carotid artery, recurrent stenosis following CEA, stenosis secondary to neck irradiation or treatment prior to coronary bypass surgery. RESULTS: 103 procedures fulfilled at least one inclusion criterion. 58.3% had symptomatic disease. The all stroke/death rate was 9.7%. The major disabling stroke/stroke-related death rate was 3.9%. 63 had a contralateral occlusion, 15 post-CEA, 17 post-radiation and 33 pre-coronary surgery. The major disabling stroke/stroke-related death rates for each subset were 4.8, 6.7, 0 and 0%, respectively. CONCLUSIONS: These results suggest that this category of patients is at high-risk of stroke regardless of method of carotid intervention.     

TIA患者颈动脉狭窄与临床症状发作的相关性

目的探讨频发型短暂性脑缺血发作(TIA)与症状相关侧颈动脉狭窄程度的相关性。方法应用颈动脉超声、经颅彩色多普勒超声联合对114例颈内动脉系统TIA患者进行检查,按照患者首次发作到入院当天(时间范围<7d)的TIA发作次数分为非频发组TIA(发作次数<3次)和频发组TIA(发作次数≥3次),以及按患者TIA发病年龄分>50岁组和≤50岁组,比较频发组与非频发组,以及各年龄段组间患者责任侧颈动脉狭窄程度发生情况。结果①TIA频发组的责任侧颈动脉发生狭窄以及中重度狭窄的发生率高于非频发组(P<0.05);②114例TIA患者以50～79岁居多,且重度狭窄及闭塞发生率随年龄增长而呈升高的趋势,但差异无统计学意义(P>0.05)。结论颈动脉系TIA频发作与颈动脉血管狭窄程度相关,颈动脉狭窄是发生颈动脉系TIA的重要因素。     

Treatment of posterior circulation ischemia with extracranial percutaneous balloon angioplasty and stent placement.

BACKGROUND AND PURPOSE: Vertebrobasilar territory ischemia (VBI) leads to disabling neurological symptoms and poses a risk for stroke by an embolic or flow-related mechanism. We present our clinical experience in the endovascular treatment of patients with symptomatic VBI from severe atherosclerosis or dissection of the vertebral and subclavian arteries that was unresponsive to medical therapy. METHODS: Twenty-one patients (9 female, 12 male) with a mean age of 65.7 years (range 47 to 81 years) underwent treatment with percutaneous endovascular balloon angioplasty and stent placement. Sixteen patients (76.2%) had evidence of contralateral involvement, and 9 (42.8%) demonstrated severe anterior-circulation atherosclerosis. Nine patients had a previous infarct in the occipital lobe, cerebellum, or pons before treatment. Follow-up was available for all patients. RESULTS: Balloon angioplasty with intravascular stent placement was performed in 13 vertebral artery lesions (10 at the origin, 3 in the cervical segment) and in 8 subclavian lesions. The prestenting stenosis was 75% (50% to 100%) and was reduced to 4.5% (0% to 20%) after stenting. Six of the patients with proximal subclavian stenosis demonstrated angiographic evidence of subclavian steal, which resolved in all cases after treatment. All patients showed improvement in symptoms after the procedure except for 1 who developed a hemispheric stroke after thrombotic occlusion of an untreated cavernous carotid artery stenosis (rate of major stroke and mortality=4.8%). One patient (4.8%) had a periprocedural transient ischemic attack (TIA), and none had minor stroke. At long-term follow-up (mean=20.7+/-3.6 months) of the surviving 20 patients, 12 (57.1%) remained symptom-free, 4 (19%) had at most 1 TIA over a 3-month period, 2 (9.5%) had at most 1 TIA per month, and 2 (9.5%) had persistent symptoms. There were no clinically evident infarcts during the follow-up period. CONCLUSIONS: Endovascular treatment using balloon angioplasty with intravascular stent placement for symptomatic stenotic lesions resulting in VBI that is unresponsive to medical therapy appears to be of benefit in this high-risk subset of patients with poor collateral flow.     

Clinical significance of the ophthalmic artery in carotid artery disease

A total of 141 subjects with tight stenosis (≥75%) or occlusion of internal carotid artery were followed up at intervals 3–6 months regularly for 40 ± 16 months. The direction of ophthalmic artery flow was used as a parameter of risk indicator on cerebral ischemic events. Eleven patients with bilateral carotid tight stenosis/occlusion were excluded in the analysis. Thus, the 130 carotid arteries were divided into three groups: (1) carotid artery with ipsilateral hemispheric TIA or stroke (85 patients), (2) carotid arteries with contralateral hemispheric TIA/stroke or VBI (15 patients), and (3) carotid arteries of asymptomatic patients (30 patients). The symptomatic carotid artery group (group 1) had significantly more often reversed ophthalmic flow than the other two groups (group 2 and 3, p < 0.001). During follow-up prospectively for four years, 41 patients had cerebral ischemic events, three had cardiac ischemic events and six died of malignancy. Patients with reversed OA flow had more often subsequent cerebral ischemic events than those with forward flow (27 vs 14, p = 0.010). However, the difference remained significant only in the asymptomatic patients (group 3, 4 vs 0, P < 0.001), not for groups 1 and 2, after further analysis. Our work supported that the clinical role of ophthalmic artery collateral varied between asymptomatic and symptomatic patients.     

Feasibility of percutaneous transluminal angioplasty for carotid artery stenosis.

Percutaneous transluminal balloon angioplasty was attempted in seven patients with internal carotid artery stenosis, including one patient who had two procedures. All had recurrent, carotid territory, neurological symptoms considered haemodynamic in origin. Six had occlusion of the contralateral internal carotid artery. Cerebral blood flow studies confirmed diminished cerebrovascular reserve in six patients studied. In five patients (six procedures) angioplasty of the stenosed internal carotid artery was carried out successfully. With two patients technical difficulty in crossing the stenosis prevented angioplasty and in one patient with bilateral stenosis the procedure was not attempted on the second side because of the severity of the stenosis. In two patients transient aphasia developed during cannulation of the carotid artery and in another a transient monoparesis developed during the procedure. Both these haemodynamic complications recovered within ten minutes. No other complications occurred. Our experience suggests that balloon angioplasty is technically feasible in the management of stenotic carotid disease associated with haemodynamic stroke. It is a technically simple procedure requiring only a brief admission to hospital. However, its general application to patients with thromboembolic carotid-territory stroke will depend on the risk/benefit ratio compared to carotid endarterectomy or to conventional medical treatment.     

Outcome of surgical treatment of 110 patients with transient ischemic attack

Between 1980 and 1982, 227 consecutive patients with transient ischemic attack (TIA) or ischemic brain infarction (IBI) were evaluated as possible candidates for carotid surgery in the Department of Neurology, University of Helsinki. One hundred and ten patients (mean age 58, range 41-72 years) were selected for surgery; 82 of them had had TIA and 28 IBI as the presenting symptom. After a total of 128 operations (84 unilateral and 18 bilateral endarterectomies, and 8 arterial reconstructions), 16 patients (14.5%) developed neurological deficits. In 7 patients (6.4%), the deficit was severe and 4 of them (3.6%) died within the first four days after surgery. Ten patients had occlusion of the contralateral internal carotid artery and/or severe hypertension. Five of them suffered ischemic brain infarction after the operation and two died. Operation on an occluded internal carotid artery in 7 patients was complicated by hemiparesis in two patients, one of whom died. Patients with surgical complications more often had severe hypertension (p less than .001), total occlusion of the contralateral internal carotid artery, (n.s.) and severe angiographic changes (n.s.) compared with patients without complications. During the follow-up the annual rate for IBI was 3.3% and for acute myocardial infarction (AMI) 4.4%. Vascular death occurred with a frequency of 1.7% per year. The results emphasize that patients with TIA or IBI should be carefully evaluated before recommending surgical treatment for prevention of threatened stroke. Patients with severe risk factors may fare better on medical treatment than with surgical intervention.     

颈动脉支架成形术与药物治疗颈动脉狭窄的对比研究

目的 分析颈动脉支架成形术（CAS）与药物治疗颈动脉狭窄的疗效，并评价其安全性。方法 2003年11月至2006年3月采用颈动脉支架成形术治疗颈内动脉狭窄（狭窄率≥50％）21例,于围手术期进行抗血小板治疗及控制危险因素。单纯药物治疗组53例，药物治疗方案同治疗组。临床随访6～28个月。结果 21例手术操作完全成功，术后残余狭窄＜30％，术中3例患者出现一过性心率减慢、血压下降，2例出现颈内动脉远端血管痉挛，治疗后好转；术后未发生新的卒中，颈动脉超声未显示再狭窄。药物治疗组随访期间，5例患者再发卒中，颈动脉超声检查发现14例患者狭窄程度加重，其中2例血管造影证实颈内动脉完全闭塞。结论 与药物治疗组比较，CAS治疗颈内动脉狭窄可以提高患者的生活质量，而且比较安全，短期疗效较好，但有待大样本研究结果证实     

Changes in cerebral hemodynamics after carotid stenting: evaluation with CT perfusion studies

PURPOSE: To determine changes in cerebral perfusion parameters, based on CT perfusion imaging, in patients after unilateral transluminal angioplasty and stent placement. MATERIAL AND METHODS: 74 patients with symptomatic high - grade internal carotid artery stenosis (>70%) were studied with CT perfusion imaging before and - on average - 70 hours and 172 days after carotid stent placement. There were 50 patients with unilateral carotid artery stenosis and 24 with stenosis and accompanying contralateral internal carotid artery occlusion. CT examination was performed using a multidetector helical CT scanner (Light Speed Ultra Advantage, GE Healthcare, USA). Maps showing the absolute values of cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were generated. RESULTS: In a group with unilateral carotid artery stenosis perfusion deficits were present in 84% of patients, ipsilaterally to stenosis. MTT elongation was noted (6.2-6.8s) together with decreased values of CBF (40-46ml/100g/min) and slightly increased CBV (3.2ml/100g). In this group, 3 days after stenting, 30% of patients had perfusion deficits, and after 6 months only 6%. In a group with carotid artery stenosis and contralateral artery occlusion severe perfusion deficits were noted in both hemispheres and they were present in 100% of patients. 6 months after stenting hypoperfusion was observed only in 17% of patients. CONCLUSIONS: Brain perfusion deficits, observed in a majority of patients with carotid artery stenosis tend to improve considerably after carotid artery stenting, in long - term follow up.