支架样取栓装置对急性缺血性卒中血管再通治疗临床效果观察

目的 探讨应用支架样取栓装置对前循环大动脉闭塞所致急性缺血性卒中患者机械取栓治疗的临 床效果。 方法 连续纳入采用支架样取栓装置治疗的前循环急性颅内大动脉近端闭塞患者。分析纳入患 者的临床特征、影像学资料、治疗及术后90 d临床随访结果。以术后90 d改良Rankin量表（modified Rankin Scale,mRS）评分为主要指标评估治疗有效性,以症状性颅内出血率、术后90 d死亡率评估治疗 的安全性。 结果 共纳入30例患者,29例应用Solitaire,1例应用Trevo。平均年龄（65.97±11.67）岁。入院时美国 国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分中位数13.50（9.75, 18.00）。包括颈内动脉闭塞9例,大脑中动脉M1段闭塞20例,大脑前动脉A1段闭塞1例。术后90 d随访, 56.7%（17/30）患者预后良好（mRS评分0～2分）。术后发生症状性颅内出血率13.3%（4/30）,术后 90 d死亡率20%（6/30）。 结论 支架样取栓装置在前循环大动脉闭塞性急性缺血性卒中取栓治疗中临床效果较好,其有效 性、安全性能够在真实世界中得到体现,是治疗急性颅内大动脉闭塞的有效方法。     

急性缺血性卒中动脉溶栓和取栓治疗的研究进展

发病时间窗内采用静脉溶栓是治疗急性缺血性卒中的首选方法。然而对于大血管闭塞性 脑梗死,静脉溶栓血管再通率偏低,血管内治疗可提高血管再通率。本文主要对动脉溶栓及机械取 栓的研究进展进行综述,旨在指导未来的临床工作。     

Mechanical Thrombectomy for Acute Ischemic Stroke in Pregnancy

Intravenous recombinant tissue-plasminogen-activator (rtPA) and mechanical-thrombectomy (MT) are currently the only approved treatments for acute ischemic stroke. Their effectiveness was demonstrated in several clinical trials, and is therefore standard of care. Pregnant women were not included in these studies and consequently the effectiveness and safety in this group are unclear. We present a rare case of a patient in the third-trimester of pregnancy that underwent MT. A 29-year-old woman of 39 weeks’ gestation presented with left facial-paresis, hemiparesis, and neglect. Her CT-Angiogram showed a large occlusive thrombus within the right M1-M2 segments. During pregnancy she had developed thrombocytopenia. There was initial treatment decision dilemma. In view of her history of thrombocytopenia, there was concern about administering rtPA due to the risk of bleeding. As the thrombus was large, rtPA may also be ineffective. MT was proposed by the Stroke Physician as the preferred treatment option. A concern from the Interventional-Radiologist was the risk of exposure to radiation and contrast agents. As the patient had a disabling stroke at a young age, decision was made to proceed with MT which started 141 minutes after symptom onset. The clot was aspirated without complications. Final check angiogram showed complete resolution of flow within the right middle cerebral artery territory. The patient underwent elective uncomplicated Caesarean-section 5 days later delivering a healthy new born. Severe stroke in pregnancy is rare, but has grave consequences for both mother and infant. Timely decision-making is crucial. Our case demonstrates that MT can be provided safely and effectively in the third trimester of pregnancy.     

Prestroke Conditions of Acute Ischemic Stroke Patients are Associated with Functional Outcome after Mechanical Thrombectomy

Background and AimMechanical thrombectomy was demonstrated to be useful for acute ischemic stroke. However, whether it is beneficial for patients with poor prestroke conditions, such as older adults and those with low activity of daily living, is unclear.MethodsA total of 134 patients who underwent mechanical thrombectomy in our hospital between April 2015 and January 2019 were retrospectively evaluated. Good outcome was defined as modified Rankin scale score of 0-2 at 90 days after stroke onset. Several factors were analyzed to assess their effects on clinical outcomes.ResultsAt 90 days after stroke onset, 37.3% (50 of 134) of patients had a good outcome. Prestroke modified Rankin scale score was independently associated with a good outcome (odds ratio .39, 95% confidence interval .22-.67, P < .001). In patients with prestroke modified Rankin scale score 0-1, 55.4% (46 of 83) had a good outcome, and no significant difference in prognosis was found between patients aged less than 80 years and those aged greater than or equal to 80 years (P = .64). More than half the patients with prestroke modified Rankin scale score greater than or equal to 2 were graded as modified Rankin scale score 5-6 at 90 days regardless of age, which was significantly higher than those with prestroke modified Rankin scale score 0-1 (P < .001).ConclusionsPatients with prestroke modified Rankin scale score 0-1 are expected to have a good prognosis after mechanical thrombectomy even if aged greater than or equal to 80 years. Patients with prestroke modified Rankin scale score greater than or equal to 2 might have an extremely poor prognosis, and we should be more careful in selecting candidates for mechanical thrombectomy.     

High Stress Hyperglycemia Ratio Predicts Poor Outcome after Mechanical Thrombectomy for Ischemic Stroke

Objective: The present study aimed to evaluate the association between stress hyperglycemia ratio (SHR) and outcome at 3 months after mechanical thrombectomy (MT) for acute occlusion in the anterior circulation. Methods: Data from 160 consecutive patients with large vessel occlusion in the anterior circulation who underwent MT from May 2013 to March 2018 were retrospectively reviewed. SHR was calculated as the fasting glucose concentration divided by the estimated average glucose concentration (derived from the glycosylated hemoglobin level). Patients were dichotomized into 2 groups in accordance with the median SHR. Univariate and multivariate analyses were used to identify predictors of functional outcome. Good and poor outcomes were defined as modified Rankin Scale scores of 0-2 and 3-6, respectively. Results: patients with unfavorable outcome had significantly higher levels of SHR than those with favorable outcome (median in SHR = 1.02 versus .84, P = .000). The median SHR was .96. Univariate analysis showed that significantly more patients with a poor outcome had SHR ≥ .96 compared with those with a good outcome (65.2% versus 31.0%, P = .000). After adjusting for potential covariates, Increased SHR (odds ratio [OR] 6.97, 95% confidence intervals [CI] 1.22-39.65, P = .029, for continuous SHR levels) and SHR ≥ .96 (OR 3.12, 95% CI 1.39-6.96, P = .006) remained independent predictors of poor outcome. Conclusions: Increased SHR is strongly correlated with poor outcome at 3 months after MT for proximal artery occlusion in the anterior circulation.     

急性缺血性卒中出血转化的研究进展

出血转化是急性缺血性卒中再灌注治疗后的主要并发症之一,与缺血性卒中预后不良密 切相关。急性缺血性卒中的主要治疗方案,包括阿替普酶静脉溶栓、血管内治疗及抗血小板聚集药 物治疗等均可能导致出血转化。目前临床上尚无对缺血性卒中出血转化有效的预测方法,本文对缺 血性卒中出血转化的病因以及影像学和生物学标志物进展进行综述,旨在为出血转化的预防和治疗 提供参考。     

Recurrent Cardioembolic Stroke Treated Successfully with Repeated Mechanical Thrombectomy within the Acute Index Stroke Period

Background

The safety of repeated mechanical thrombectomy within the acute stroke period has not yet been clearly demonstrated. We describe herein a patient who was successfully treated with repeated mechanical thrombectomy within the acute index stroke period.

Case Report

A 50-year-old woman with atrial fibrillation presented with left-sided weakness caused by occlusion of the right middle cerebral artery (MCA). Emergent mechanical thrombectomy with the Solitaire device achieved complete recanalization. The left MCA occlusion redeveloped at 6 days after the first treatment, at which time her international normalized ratio (INR) was 2.3. Endovascular thrombectomy was reattempted rapidly and complete recanalization was achieved again. Her neurologic symptoms resolved after the thrombectomy.

Conclusions

This case demonstrates that repeated mechanical thrombectomy can be safely and successfully performed even in a patient with a high INR and a recurrent stroke during the acute period after the index stroke.     

急性缺血性脑卒中出血性转化的发生率

急性缺血性脑卒中按发生原因分为自发性出血性转化和继发性出血性转化。自发性出血性转化即出血性脑梗死,发生率为5%~10%(文献报告)或1.4%~7.3%(多项研究证实)或0~3.4%(汇总分析),溶栓后自发性出血性转化发生率为9%~12%(头颅CT证实)或10.0%~19.8%(多项研究证实),血管介入治疗后自发性出血性转化发生率为8.1%~37.0%,抗血小板聚集治疗和抗凝治疗后自发性出血性转化的发生率分别为4.0%~5.3%,和1.4%~13.0%。     

Predictors and Dynamic Nomogram to Determine the Individual Risk of Malignant Brain Edema After Endovascular Thrombectomy in Acute Ischemic Stroke

Background and PurposeThis study aimed to construct an optimal dynamic nomogram for predicting malignant brain edema (MBE) in acute ischemic stroke (AIS) patients after endovascular thrombectomy (ET).MethodsWe enrolled AIS patients after ET from May 2017 to April 2021. MBE was defined as a midline shift of >5 mm at the septum pellucidum or pineal gland based on follow-up computed tomography within 5 days after ET. Multivariate logistic regression and LASSO (least absolute shrinkage and selection operator) regression were used to construct the nomogram. The area under the receiver operating characteristic curve (AUC) and decision-curve analysis were used to compare our nomogram with two previous risk models for predicting brain edema after ET.ResultsMBE developed in 72 (21.9%) of the 329 eligible patients. Our dynamic web-based nomogram (https://successful.shinyapps.io/DynNomapp/) consisted of five parameters: basal cistern effacement, postoperative National Institutes of Health Stroke Scale (NIHSS) score, brain atrophy, hypoattenuation area, and stroke etiology. The nomogram showed good discrimination ability, with a C-index (Harrell’s concordance index) of 0.925 (95% confidence interval=0.890–0.961), and good calibration (Hosmer-Lemeshow test, p=0.386). All variables had variance inflation factors of <1.5 and tolerances of >0.7, suggesting no significant collinearity among them. The AUC of our nomogram (0.925) was superior to those of Xiang-liang Chen and colleagues (0.843) and Ming-yang Du and colleagues (0.728).ConclusionsOur web-based dynamic nomogram reliably predicted the risk of MBE in AIS patients after ET, and hence is worthy of further evaluation.