伴大核心梗死的前循环串联闭塞的急性期同期血管内治疗研究

目的 评价伴大核心梗死的前循环串联病变急性期同期血管内治疗的安全性及有效性。方法 回顾性分析2018年3月-2020年5月收治的伴大核心梗死的前循环串联病变患者的临床及影像资料，对患者的术前评估、手术方式、手术要点及术中不同处理方式、围手术期的管理及手术结果和预后进行总结分析。结果 5例患者中男性4例，女性1例；年龄61～71岁，颈内动脉（internal carotid artery，ICA）起始段闭塞合并远端C7段闭塞1例，合并同侧大脑中动脉（middle cerebral artery，MCA）M1段闭塞4例。5例患者均采用取栓支架半释放保护（solitaire stent-retriever half-release protection，Sharp）技术先处理远端病变、后处理近端病变。2例患者MCA再通后即刻行同侧ICA支架置入；2例患者MCA再通后予以较长时间观察，等待颅内灌注得到一定恢复后再予以ICA支架置入；1例患者MCA再通后仅行颈动脉球囊扩张治疗。5例患者的闭塞血管均成功再通，且未出现症状性颅内出血及远端血栓事件。患者从发病到再通时间为637.2±172.2（451～814）min，再通至颈ICA支架置入时间为152.5±92.2（59～270）min。2例患者术后发生高灌注损伤导致死亡，其余3例患者术后90 d预后良好（mRS均为3分）。结论 伴大核心梗死的前循环串联病变进行急性血管内治疗可使部分患者获益，为降低术后的高灌注损伤风险，予以适当的“再灌注预适应”时间再同期处理颅外病变可能降低术后的高灌注损伤风险，但最佳的预适应时间仍需进一步探讨与实践。

Emergent Management of Anterior Circulation Tandem Occlusion with Large Core Infarction

Objective To evaluate the safety and efficacy of endovascular of in treating anterior circulation tandem occlusion with large core infarction. Methods The clinical and imaging data of the patients with anterior circulation tandem occlusion and large core infarction who were admitted to Daping Hospital, Army Military Medical University from March 2018 to May 2020 were retrospectively analyzed. The preoperative evaluation, surgical approach, operation technique, perioperative management, surgical outcomes and prognosis of the patients were analyzed. Results A total of five patients were included, with 4 males and age range 61-71 years old. Of the 5 cases, the initial and terminal segment occlusion of internal carotid artery (ICA) was in one patient, and ICA initial segment occlusion combined with ipsilateral middle cerebral artery (MCA) occlusion was in four patients. All of them underwent distal-to-proximal revascularization by applying the Solitaire stent-retriever half-release protection (Sharp) technique. Two patients underwent ipsilateral ICA stenting immediately after MCA recanalization; in the other two patients, ICA stenting was performed after MCA recanalization and a long time of reperfusion observation; and one patient only underwent balloon dilation of carotid artery after recanalization. All 5 patients got successful recanalization of the occluded vessels without symptomatic intracranial hemorrhage or distal thrombotic events. The time from stroke onset to recanalization was 637.2±172.2 (451-814) minutes, and the time from recanalization to ICA stent implantation was 152.5±92.2 (59-270) minutes. Two patients died from postoperative hyperperfusion (edema), and the other three patients all had a good prognosis (mRS 3) at 90 days after surgery. Conclusions Patients with anterior circulation tandem occlusion and large core infarction may benefit from acute endovascular treatment. To reduce the risk of postoperative hyperperfusion, appropriate "reperfusion precondition" time is necessary, then dealing with intracranial lesion, while the optimal precondition time is still uncertain.