Solitaire系列支架机械取栓治疗急性基底动脉闭塞研究

发布时间：2018-03-11 02:25

  本文选题：机械取栓　切入点：基底动脉闭塞　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景与目的急性基底动脉闭塞目前仍是缺血性脑卒中中最具致命性的亚型之一,如不能实现早期再通,临床功能预后极差。如急性缺血性脑卒中患者距离症状开始出现的时间在4.5小时以内,应用静脉内药物溶栓是公认的标准治疗方案,但由于其诊治窗口期短、血管再通效率低,一定程度上制约了其在临床实践中的应用。虽然已有充分数据证实,相比于静、动脉溶栓,支架样取栓装置在治疗前循环大血管闭塞时具有更佳的血管再通率及良好功能预后。但对于后循环尤其是基底动脉闭塞的作用仍不甚明确。因此,本研究的目的是评估应用Solitaire系列支架机械取栓治疗急性基底动脉闭塞的有效性及安全性,其次明确影响神经功能预后的因素。方法回顾性分析2015年6月份-2016年12月份在大连市中心医院和沈阳军区总医院神经外科两中心应用Solitaire系列支架取栓治疗的14例急性基底动脉闭塞患者的临床及影像学资料,所有患者的发病时间均在24小时以内。通过改良脑梗死溶栓分级标准(modified Thrombolysis in Cerebral Infarction scale,mTICI)评估是否再通,成功再通定义为mTICI2b或3级。良好临床预后定义为术后90天改良Rankin量表评分(modified Rankin Scale,mRS)≤2分。另外,使用单因素方差法分析基于全脑血管造影的侧支循环分级、术前NIHSS评分、入院到再通时间及取栓次数与临床预后的相关性。记录手术操作过程及设备相关并发症,包括症状性颅内出血、栓子脱落致远端梗塞、血管壁穿孔、动脉夹层、责任血管痉挛。结果 患者年龄平均值为(66.5±6.3)岁,其中男性数量占71%。发病到入院时间中位数为6.0(5.0,8.3)小时。取栓前造影侧支血流分级中,3例被评估后仅为0级,3例评估后达到2级,2例为1级。入院到股动脉穿刺时间中位数为119.5(108.8,130.3)分钟。术后美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分明显低于术前(20.0(18.3-22.8)vs.8.5(3.5-12.8);P=0.002)。从股动脉穿刺到实现成功再通(mTICI≥2b级)时间中位数为58.0(50.0,77.0)分钟。取栓次数中位数为2(1,3)次。14例患者中有2例在机械取栓前联合了静脉溶栓治疗,3例联合使用了球囊扩张技术,1例患者在取栓后原位释放Solitaire支架,4例联合使用了动脉溶栓。13例患者获得成功再通(mTICI2b或3级),占所有患者的93%。1例患者发生症状性颅内出血,占7%。2例在术中发生血管痉挛,未出现其他设备相关并发症。在术后90天随访中,有4例(28.6%)患者获得良好临床预后(mRS≤2分),2例(14.3%)死亡。在单因素方差分析中,发现全脑血管造影的侧支循环分级与临床预后明显相关,且高的侧支循环分级往往预示着良好预后。术前NIHSS评分(P=0.956)、入院到再通时间(P=0.227)及取栓次数(P=0.713)与临床预后无显著相关性。结论 对于急性基底动脉闭塞致后循环缺血的病人,应用Solitaire系列支架行血管内介入(即机械取栓)治疗,可以明显提高再通率,同时改善功能预后。基于全脑血管造影的侧支循环分级是重要的神经功能预后影响因子。
[Abstract]:Background and objective acute basilar artery occlusion is still one of the subtypes of ischemic stroke in the most deadly, if not early recanalization, poor clinical prognosis. Functions such as distance symptoms of acute ischemic stroke patients begin time within 4.5 hours of intravenous thrombolytic therapy is the standard treatment for recognized, but the diagnosis and treatment of short window period, recanalization of low efficiency, to a certain extent restrict its application in clinical practice. Although there are sufficient data confirm that compared to static, intra-arterial thrombolysis, thrombectomy device stent like circulation vascular occlusion before treatment has better recanalization rate and good functional outcome. But for posterior circulation especially the basilar artery occlusion effect is still unclear. Therefore, the purpose of this study is to evaluate the application of Solitaire series mechanical thrombectomy for acute basilar artery occlusion Effectiveness and safety, secondly the influence factors of neurological outcome. Methods a retrospective analysis of 14 cases of acute basilar artery in 2015 June -2016 year in December in Dalian Central Hospital and General Hospital of Shenyang Command Center Department of Neurosurgery two application of Solitaire series of stent thrombectomy for occlusion of the clinical and imaging data were all, the onset time of patients in less than 24 hours. By improving the cerebral infarction classification standard (modified Thrombolysis in Cerebral Infarction scale, mTICI) to assess whether successful recanalization, recanalization was defined as mTICI2b or 3. Good clinical outcome was defined as 90 days after the modified Rankin scale (modified Rankin Scale, mRS = 2). In addition, the use of single factor variance analysis method based on the cerebral collateral circulation classification, preoperative NIHSS score, admission to recanalization time and thrombectomy times and the pre clinical phase Close. Records of operation process and equipment related complications, including symptomatic intracranial hemorrhage, emboli caused by distal infarction, vascular wall perforation, artery dissection, liability of vasospasm. Results patients average age is (66.5 + 6.3) years old, male accounted for 71%. incidence to hospital admission time was 6 hours (5.0,8.3). Thrombectomy before angiography collateral blood flow grading, 3 cases were assessed after only 0 grade, 3 cases after the evaluation reaches level 2, 2 cases of grade 1. Admission to the femoral artery puncture time was 119.5 minutes (108.8130.3). The National Institutes of Health Stroke Scale (National Institutes of Health after Stroke Scale, NIHSS) were significantly lower than preoperative (20 (18.3-22.8) vs.8.5 (3.5-12.8); P=0.002). From the femoral artery puncture to achieve successful recanalization (mTICI = 2b) time was 58 minutes (50.0,77.0). The number of thrombectomy for a median of 2 (1,3).14 patients In 2 cases in mechanical thrombectomy before combined intravenous thrombolytic therapy, 3 cases of combined use of balloon angioplasty, 1 patients with Solitaire stent in situ release after thrombectomy, 4 cases of combined use of intra-arterial thrombolysis in.13 patients received successful recanalization (mTICI2b or 3), accounting for symptomatic intracranial hemorrhage all cases of 93%.1 patients, 7%.2 patients accounted for vasospasm during operation, no other equipment related complications. In the 90 day postoperative follow-up, 4 cases (28.6%) patients got good prognosis (mRS = 2 points), 2 cases (14.3%) died. The single factor analysis of variance. That was obviously related to collateral grading and prognosis of cerebral angiography, collateral circulation and high grade often indicates a good prognosis. The preoperative NIHSS score (P=0.956), admission to reperfusion time (P=0.227) and thrombectomy times (P=0.713) had no significant correlation with the clinical prognosis. Conclusion for the treatment of acute Basilar artery occlusion caused by posterior circulation ischemia patients, interventional endovascular stent application of Solitaire series (i.e. mechanical thrombectomy) treatment, can significantly improve the recanalization rate, and improve the function of collateral grading prognosis. Cerebral angiography is based on the effect of nerve function of important prognostic factors.

【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3
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本文编号：1596187