缺血性脑血管病介入治疗的临床研究
发布时间：2018-07-22 13:26
【摘要】：背景及目的缺血性脑血管病是临床常见的一种血管疾病,主要发生在老年人。随着我国人口进入老龄化,缺血性脑血管病的发病率越来越高,且有年轻化的趋势。动脉粥样硬化引起的血管狭窄是引起脑缺血发作和卒中的重要原因。近年来,对于缺血性脑血管病的治疗研究突飞猛进,无论是传统的药物治疗还是新开展的介入治疗都取得了巨大进步,尤其是介入治疗方面,人们吸取了冠脉缺血性病变、外周血管病变以及出血性脑血管介入治疗的经验,在很短时间内无论在技术的可行性方面,还是临床疗效方面都取得了突破性进展。随着神经影像学、导管技术和材料、计算机等学科的迅速发展,神经介入技术日臻成熟,目前已成为脑血管病的重要治疗方法,并逐渐发展成为一门独立的学科。缺血性脑血管病介入治疗是指研究利用血管内导管操作技术,在计算机控制的数字减影血管造影(digital subtraction angiography, DSA)系统的支持下,对累及人体神经系统血管的病变进行诊断和治疗,达到栓塞、溶解、扩张、成形等治疗目的的一种临床医学科学。缺血性脑血管病的神经介入诊断及治疗,能够大大减少患者痛苦及致残率,减轻家庭及社会负担,摆脱缺血性脑血管病发病率高、反复发病的怪圈,以及单一用药物治疗缺血性脑血管病的历史。缺血性脑血管病介入治疗技术是近二十多年迅速发展起来的新兴学科。虽然这一技术在脑血管病中的应用时间较短,发展却非常迅速。从治疗方式、患者筛选、术中术后用药、并发症防治等诸多方面对血管内介入技术在脑血管病中的临床应用进行了系统规范。在放射影像引导下,借助导管、导丝、扩张球囊、支架等卓越材料进行的血管内微创手术,可使过去认为难治、不能治的闭塞或重度狭窄的脑供血动脉管腔重塑并基本恢复正常,为缺血性脑血管病的治疗开辟了新的治疗途径。由于创伤小、安全性高、疗效好,已经成为医学界一颗璀璨的明星,越来越引起人们的重视。目前缺血性脑血管病介入手术有：急性脑梗死超选择接触性动脉内溶栓术、颅内静脉窦血栓介入溶栓术、颅内动脉狭窄支架成形术、颅外脑供血动脉(颈总动脉、颈内动脉、椎动脉、锁骨下动脉、无名动脉)狭窄支架成形术。而目前DSA已经成为缺血性脑血管病早期诊断中最重要的方法,在PTAS术前指导和术后评价中具有重要的价值；PTAS是治疗缺血性脑血管病颅内外脑供血动脉狭窄或闭塞新的有效治疗方法,微创、安全、有效,近期疗效肯定。熟练而规范的操作是支架置入技术成功的关键,在严格掌握适应症和有经验的医生操作下治疗是安全的。目前状况,1、在颅外段颈动脉粥样硬化性狭窄,常用的治疗方法有药物治疗、手术治疗及血管内介入治疗,其中,手术治疗包括动脉内膜剥脱术(carotid endarterectomy, CEA)、颅内外血管搭桥术等,血管内介入治疗包括血管成形和支架置入术(carotid artery stenting, CAS)、血管内膜旋切术、机械辅助的血管再通术等。虽在外科手术治疗颈动脉粥样硬化性狭窄的方法中,动脉内膜剥脱术操作相对简单,疗效已被50多年的临床实践所验证,但我国CEA由于种种原因在各级医院神经外科开展非常有限,且目前几项大的临床随机研究都没有显示出CAS比CEA风险更高,因此CAS可以成为颈动脉粥样硬化性狭窄治疗的主要方法之一；2、在颅外段椎动脉粥样硬化性狭窄,规范内科药物治疗疗效并不明确,而外科手术治疗并发症发生率较高,其远期效果也远不如内膜切除术治疗颈动脉狭窄,虽现阶段支持颅外段椎动脉狭窄血管成形术治疗的循证医学证据尚不充分,但由于药物治疗及外科手术的局限性,药物治疗后仍有缺血事件发生的患者可考虑施行血管内介入治疗,且椎动脉动脉粥样硬化性狭窄血管成形术及支架植入术正在成为研究的热点；3、在无名动脉或锁骨下动脉狭窄,目前对于药物治疗无效的症状性动脉粥样硬化性狭窄或闭塞的患者,随着血管内介入治疗技术和材料的发展,通过血管内介入方法治疗无名动脉或锁骨下动脉狭窄或闭塞性病变具有创伤小、术后恢复快、临床疗效满意等优点,已逐步取代动脉旁路移植术,成为首选的治疗手段；4、在颅内动脉粥样硬化性狭窄的治疗,目前的观点认为对于症状性颅内动脉粥样硬化性狭窄患者,首先应积极进行优化的药物治疗,对于药物治疗无效的患者,如临床状况允许、侧支循环差、狭窄程度≥70%,可以考虑血管内介入治疗；5、在急性缺血性卒中救治方面,目前唯一被循证医学证实有效的治疗方法就是静脉溶栓,但静脉溶栓具有时间窗短、溶通率低、再闭塞率高、有一定出血风险等缺点,而血管内动脉溶栓、机械取栓装置以及动脉溶栓联合机械取栓方法的临床应用,进一步扩展了急性缺血性卒中的治疗时间窗、再通率、减少出血风险；6、颅内静脉窦血栓介入治疗,目前缺乏有力的循证医学证据表明颅内静脉窦血栓患者需采用血管内介入治疗,但经规范抗凝及静脉溶栓无效的患者,可考虑血管内治疗,包括静脉窦内接触性溶栓、机械性碎栓、静脉窦内支架植入术。在国际上,有关缺血性脑血管病介入治疗的指南每年都有较大的更新,每年都有新技术、新材料、新疗法和新的大型临床研究报道,而中国拥有世界上最庞大的脑血管病患者群体,但我们目前还没有开展缺血性脑血管病介入治疗的大型临床对照研究,缺乏针对中国人缺血性脑血管病介入治疗的循证医学Ⅰ、Ⅱ级证据。同时,我国在制定缺血性脑血管病介入治疗的指南时,还只能参考国外研究的结果。但需要注意的是,由于生活方式、经济文化和人种的不同,脑血管病的发病特点、危险因素和远期预后可能会存在差异,颅内外动脉粥样硬化发生的部位、病理特点也可能会存在差异,最终可能影响患者血管内介入治疗的获益性不同。此外,患者的社会经济状况还可能会影响介入器材的选择和术后是否能坚持用药。因此开展脑血管病介入治疗时,要充分考虑这些因素,不能完全照搬西方的研究结果。到目前为止,血管内介入技术在西方国家经历了多年的发展,已建立了系统的介入技术培训机制,形成了比较完善的介入医师资质认证体系,加上医疗保险系统的监督和制衡作用,使血管内介入技术步入了良性发展的轨道。而在我国,尽管神经血管介入技术的研发和临床应用取得了长足进展,某些领域可能还处于世界领先的地位,但由于技术整体开展时间短,缺乏完善的规章制度,没有系统的人员培训和资质认证机制,因此,这一技术往往成为行业内外争论的焦点。要解决这一问题,需要不同的从业人员联合起来,建立规范的脑血管病介入技术培训机制,制定可行的介入医师资格认证体系,使我国的神经血管介入技术朝着合理、有序的方向发展,造福广大患者。本文探讨数字减影血管造影(digital subtraction angiography, DSA)对缺血性脑血管病的病因早期确诊的优越性及诊断价值。同时探讨经皮腔内支架成形术(percutaneous transluminal angioplasty and stenting, PTAS)在缺血性脑血管病治疗中的适应症的选择、技术操作、疗效和并发症,对比分析手术前患者临床症状的改变、脑血流灌注的改善程度,初步探讨PTAS术的安全性和有效性；总结PTAS治疗100例患者的疗效及并发症的发生与防治。方法回顾性分析我院神经内外科2012年8月至2013年5月开展缺血性脑血管病介入治疗期间住院的缺血性脑血管病患者125例,所有患者均进行颈部彩色多普勒血流显像(color Doppler flow imaging, CDFI)、经颅多普勒超声(transcranial Doppler, TCD)、电子计算机体层扫描(computerized tomography,CT)、CT血管造影(computed tomography angiography, CTA)、CT灌注成像(computed tomography Perfusion, CTP)、核磁共振成像magnetic resonance imaging, MRI)、弥散加权成像(diffusion weighted imaging, D WI)、核磁共振血管造影(magnetic resonance angiography, MRA)、DSA检查,对比不同方法对患者的诊断价值。明确弓上头颈部大血管(无名动脉、锁骨下动脉、颈动脉及椎动脉颅外段)和颅内血管狭窄部位、程度并进行术前评价,依据缺血性脑血管病介入治疗的适应证和禁忌证筛选了100例患者的118支血管进行PTAS治疗,均成功完成支架置入；共置入支架119枚。术后即刻造影评价并随访6个月-1年,对DSA的检查结果、介入治疗的疗效和并发症进行临床分析。结果125例患者通过DSA检查1250条血管发现121例患者有血管狭窄,查出病变血管共有301支。其中颈内动脉C1段73支,椎动脉V1段64支,锁骨下动脉38支,无名动脉4支,大脑中动脉43支、基底动脉33支、椎动脉V4段20支、颈内动脉C4段9支、C6段11支、C7段6支。血管闭塞18支,狭窄在70%、99%之间的142支,狭窄程度在50-69%之间的57支,狭窄程度低于50%的84支。血管病变程度：使用DSA发现患者的病变血管支数最多,与多层螺旋CTA及MRA检查比较有统计学差异,p0.05；最终经过严格筛选出100例症状性动脉粥样硬化性重度动脉狭窄的患者,均符合介入手术适应症,共有118支病变血管,共植入支架119枚。手术成功率100%。患者术后血管狭窄改善明显；症状明显缓解或消失；神经功能状况改善；前向血流及脑灌注明显改善。围手术期,13例TIA患者和8例表现有明显头昏的患者症状即刻消失或好转；12例行颈内动脉支架植入术后原来难以控制的高血压病明显改善。1例患者颈内动脉C1段及椎动脉V1段同时狭窄,支架置入后出现灌注突破后脑出血,1例基底动脉支架植入后支架发生穿支事件,1例大脑中动脉支架植入后发生血管破裂,1例椎动脉V4段支架植入后出现支架内急性血栓形成。100例患者术后随访6个月-1年,术后发生并发症的4例,1例预后不良,其余3例经过临床处理后基本恢复正常,残留轻度神经系统症状及体征；其余96均未出现再狭窄及与所治疗血管相关的神经系统症状和体征。结论本研究显示,脑血管造影对缺血性脑血管病早期病因的诊断优于头颈部CTA及MRA；经过严格的术前评估,尤其是脑灌注和侧支循环的评估、术中选择合适的材料、术中术后规范用药、防治并发症等方面进行系统规范后,PTAS是治疗缺血性脑血管病新的有效治疗方法,微创、安全、有效,近期疗效肯定,可使过去认为难治、不能治的闭塞或重度狭窄的颅内外动脉管腔重塑并基本恢复正常。
[Abstract]:Background and objective ischemic cerebrovascular disease is a common clinical vascular disease, which mainly occurs in the elderly. With the aging of the population in China, the incidence of ischemic cerebrovascular disease is becoming more and more high and has a trend of youth. Atherosclerosis caused by vascular stenosis is an important cause of cerebral ischemic attack and stroke in recent years. As for the treatment of ischemic cerebrovascular disease, great progress has been made in both traditional and new interventional therapy, especially for interventional therapy. People have learned from the experience of coronary artery disease, peripheral vascular disease and hemorrhagic cerebrovascular interventional therapy in a very short time. With the rapid development of neuroimaging, catheter technology, materials, computer and other disciplines, neural interventional technology is becoming more and more mature, and it has become an important treatment for cerebrovascular disease and has gradually developed into an independent subject. Ischemic cerebrovascular disease. Interventional therapy is a clinical medical department that studies the use of intravascular catheter manipulation, with the support of the computer controlled digital subtraction angiography (DSA) system, to diagnose and treat the vascular lesions involved in the human nervous system, and to achieve the purpose of embolization, dissolution, dilation, and forming. The diagnosis and treatment of ischemic cerebrovascular disease can greatly reduce the pain and disability rate of the patients, reduce the family and social burden, get rid of the high incidence of ischemic cerebrovascular disease, the cycle of recurrent disease, and the history of the single drug treatment of ischemic cerebrovascular disease. The interventional therapy of ischemic cerebrovascular disease is nearly twenty. Although the application of this technology in cerebrovascular disease is short and the development is very rapid, the application of intravascular interventional technique in cerebrovascular disease is systematically standardized in the aspects of treatment, screening, postoperative drug use, prevention and treatment of complications. At the same time, intravascular minimally invasive surgery, such as catheter, guide wire, dilated balloon and stent, can make the intracerebral occlusion or severe stenosis of the brain remolded and basically restored to normal in the past. It opens a new way for the treatment of ischemic cerebrovascular disease. It has become a resplendent star in the medical field, which has attracted more and more attention. At present, the interventional operation of ischemic cerebrovascular disease is: transcatheter thrombolysis in acute cerebral infarction, interventional thrombolysis of intracranial venous sinus thrombosis, stent angioplasty for intracranial artery stenosis, and cranial cerebral blood supply artery (common carotid artery, internal carotid artery, and vertebral artery) DSA has become the most important method in the early diagnosis of ischemic cerebrovascular disease, and it is of great value in the preoperative guidance and postoperative evaluation of PTAS; PTAS is a new effective treatment method for the treatment of ischemic cerebrovascular disease with intracranial and intracerebral artery stenosis or occlusion. Safe, effective, recent curative effect. Skilled and standardized operation is the key to the success of stent implantation. Treatment is safe under the strict control of indications and experienced doctors. Current status, 1, carotid atherosclerotic stenosis in the extracranial segment, commonly used therapy, surgical treatment, and intravascular interventional therapy, Among them, the surgical treatment includes carotid endarterectomy (CEA), intracranial and extracranial bypass, and intravascular interventional therapy including angioplasty and stent implantation (carotid artery stenting, CAS), endovascular endovascular resection, mechanically assisted hemangioplasty, and so on. Although surgical treatment of carotid atherosclerotic narrowing is performed. In the narrow method, the operation of endarterectomy is relatively simple, the curative effect has been verified by 50 years of clinical practice, but the CEA in our country has been very limited in the Department of Neurosurgery at all levels for various reasons, and the present several large clinical randomized studies have not shown that CAS is higher than the risk of CEA, so CAS can become carotid atherosclerosis. One of the main methods for the treatment of sexual stenosis; 2, in the atherosclerotic stenosis of the extracranial segment, the standard medical treatment is not clear, and the surgical treatment has a high incidence of complications, and its long-term effect is far less than endarterectomy for carotid stenosis. Although the present stage supports the treatment of extracranial vertebral artery stenosis by angioplasty Evidence based evidence-based medicine is not sufficient, but due to the limitations of drug treatment and surgical operations, intravascular interventional therapy can be considered in patients with ischemic events after medication, and atherosclerotic stenosis of vertebral artery and stent implantation are becoming the focus of research. 3, innominate artery or clavicle. At present, the patients with symptomatic atherosclerotic stenosis or occlusion that are not effective at present, with the development of intravascular interventional therapy and material, the treatment of innominate artery or subclavian artery stenosis or occlusive disease by intravascular interventional therapy has little trauma, quick recovery and satisfactory clinical efficacy. Point, gradually replace arterial bypass grafting and become the preferred treatment. 4, in the treatment of intracranial atherosclerotic stenosis, the present point of view is that for patients with symptomatic intracranial atherosclerotic stenosis, the first should be actively optimized for drug treatment, for patients who are not effective in the drug treatment, such as the clinical condition permitting, and the side. The poor circulation and the degree of stenosis more than 70% can consider intravascular interventional therapy. 5. In the treatment of acute ischemic stroke, the only effective treatment method proved by evidence-based medicine is venous thrombolysis, but venous thrombolysis has short time window, low dissolution rate, high reocclusion rate and a certain bleeding risk, and endovascular thrombolysis, The clinical application of mechanical thrombolytic device and arterial thrombolysis combined with mechanical embolectomy further expands the time window, repassage rate and reducing the risk of bleeding for acute ischemic stroke; 6, the interventional therapy of intracranial venous sinus thrombosis is lacking a strong evidence-based medical evidence that intravascular interventional therapy for patients with intracranial venous sinus thrombosis is lacking. Treatment, but intravascular therapy, including intravascular thrombolysis, mechanical thrombolysis, and intravascular stent implantation, can be considered in patients who have failed to regulate anticoagulant and venous thrombolysis. International guidelines for interventional therapy for ischemic cerebrovascular disease have been greatly updated every year. New techniques, new materials, new treatments and new treatments are available every year. Large clinical research reports, and China has the world's largest group of patients with cerebrovascular disease, but we have not yet carried out large clinical control studies on interventional therapy for ischemic cerebrovascular disease, and lack of evidence based evidence-based medicine for interventional therapy for ischemic cerebrovascular disease in China. However, it should be noted that there may be differences in the characteristics, risk factors and long-term prognosis of cerebrovascular diseases due to different lifestyles, economic and cultural differences, and the differences in the risk factors and long-term prognosis. There may be differences in the location and pathological characteristics of the intracranial and external atherosclerosis. In addition, the socioeconomic status of the patient may also affect the selection of the intervention equipment and the ability to adhere to the medication after the operation. Therefore, these factors should be taken into full consideration when the interventional therapy of cerebrovascular disease is carried out, and the results of the western study are not completely copied. So far, blood vessels The technology of internal intervention has been developed in western countries for many years. It has established a systematic training mechanism for interventional technology, formed a relatively perfect accreditation system for interventional physicians, combined with the supervision and balance of the medical insurance system, and made the intravascular interventional technology into a benign development track. In our country, although neurovascular intervention is involved. The development and clinical application of technology have made great progress, and some areas may still be in the leading position in the world. However, because of the short time, lack of perfect rules and regulations, no systematic personnel training and qualification authentication mechanism, this technology is often the focus of debate inside and outside the industry. It is necessary for different employees to join together to establish a standardized training mechanism for interventional technique for cerebrovascular disease and to establish a feasible accreditation system for interventional physicians to make the neurovascular interventional techniques in our country develop in a reasonable and orderly direction and benefit the majority of patients. This paper discusses the digital subtraction angiography (DSA). The superiority and diagnostic value of the early diagnosis of the etiology of ischemic cerebrovascular disease. At the same time, the selection, technical operation, efficacy and complications of percutaneous transluminal angioplasty and stenting (PTAS) in the treatment of ischemic cerebrovascular disease, and the comparison and analysis of the clinical symptoms of the patients before the operation are compared. Change, the improvement of cerebral blood flow perfusion, preliminarily discuss the safety and effectiveness of PTAS, summarize the curative effect of 100 patients with PTAS and the occurrence and prevention of complications. Method retrospective analysis of the ischemic cerebrovascular disease hospitalized during the treatment of ischemic cerebrovascular disease during the treatment of ischemic cerebrovascular disease from August 2012 to May 2013 in our hospital. In 125 cases, all patients underwent neck color Doppler flow imaging (color Doppler flow imaging, CDFI), transcranial Doppler (transcranial Doppler, TCD), computer tomography (computerized tomography, CT), CT angiography. On, CTP), nuclear magnetic resonance imaging magnetic resonance imaging, MRI), diffusion weighted imaging (diffusion weighted imaging, D WI), nuclear magnetic resonance angiography (magnetic), compared to the diagnostic value of different methods for patients. And the position of the extracranial segment of the vertebral artery and the intracranial vascular stenosis, the degree and preoperative evaluation, according to the indications and contraindications of the interventional therapy of ischemic cerebrovascular disease, 118 vessels of 100 patients were selected for PTAS treatment, and the stent implantation was successfully completed; 119 stents were implanted. The immediate postoperative angiography was evaluated and followed up for 6 months -1 years, DSA Results and clinical analysis of the curative effect and complications of interventional therapy. Results 125 cases of 1250 vascular stenosis were found through DSA examination in 121 cases, and 301 vessels were found in 121 cases, including 73 branches of C1 segment of internal carotid artery, 64 V1 segment of vertebral artery, 38 subclavian artery, 4 innominate artery, 43 branch of middle cerebral artery and basilar artery. 33 branches of V4 segment of vertebral artery, 9 branches of C4 segment of internal carotid artery, 11 branches of C6 segment, 6 branches of C7 segment, 18 vascular occlusion, 142 stenosis between 70% and 99%, 57 branches between 50-69% and 84 branches of stenosis less than 50%. The degree of vascular lesions was found to be the most supported by DSA, and compared with multi-layer spiral CTA and MRA examination. There were 100 patients with severe atherosclerotic severe arterial stenosis, which were all in accordance with the indications of interventional surgery, with a total of 118 vessels and a total of 119 stent implantation. The success rate of 100%. patients was obviously improved after operation; the symptoms were obviously relieved or disappeared, and the nerve function status was observed. Improvement. The anterior blood flow and cerebral perfusion improved obviously. In the perioperative period, 13 TIA patients and 8 patients with obvious dizziness disappeared or improved immediately. 12 cases of intractable hypertension after internal carotid artery stent implantation improved the C1 segment of the internal carotid artery and the V1 segment of the vertebral artery at the same time, and the stent was placed after the stent implantation. After cerebral hemorrhage, there were 1 cases of perforating events after stent placement, and 1 cases of middle cerebral artery stenting.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R743
本文编号：2137607
[Abstract]:Background and objective ischemic cerebrovascular disease is a common clinical vascular disease, which mainly occurs in the elderly. With the aging of the population in China, the incidence of ischemic cerebrovascular disease is becoming more and more high and has a trend of youth. Atherosclerosis caused by vascular stenosis is an important cause of cerebral ischemic attack and stroke in recent years. As for the treatment of ischemic cerebrovascular disease, great progress has been made in both traditional and new interventional therapy, especially for interventional therapy. People have learned from the experience of coronary artery disease, peripheral vascular disease and hemorrhagic cerebrovascular interventional therapy in a very short time. With the rapid development of neuroimaging, catheter technology, materials, computer and other disciplines, neural interventional technology is becoming more and more mature, and it has become an important treatment for cerebrovascular disease and has gradually developed into an independent subject. Ischemic cerebrovascular disease. Interventional therapy is a clinical medical department that studies the use of intravascular catheter manipulation, with the support of the computer controlled digital subtraction angiography (DSA) system, to diagnose and treat the vascular lesions involved in the human nervous system, and to achieve the purpose of embolization, dissolution, dilation, and forming. The diagnosis and treatment of ischemic cerebrovascular disease can greatly reduce the pain and disability rate of the patients, reduce the family and social burden, get rid of the high incidence of ischemic cerebrovascular disease, the cycle of recurrent disease, and the history of the single drug treatment of ischemic cerebrovascular disease. The interventional therapy of ischemic cerebrovascular disease is nearly twenty. Although the application of this technology in cerebrovascular disease is short and the development is very rapid, the application of intravascular interventional technique in cerebrovascular disease is systematically standardized in the aspects of treatment, screening, postoperative drug use, prevention and treatment of complications. At the same time, intravascular minimally invasive surgery, such as catheter, guide wire, dilated balloon and stent, can make the intracerebral occlusion or severe stenosis of the brain remolded and basically restored to normal in the past. It opens a new way for the treatment of ischemic cerebrovascular disease. It has become a resplendent star in the medical field, which has attracted more and more attention. At present, the interventional operation of ischemic cerebrovascular disease is: transcatheter thrombolysis in acute cerebral infarction, interventional thrombolysis of intracranial venous sinus thrombosis, stent angioplasty for intracranial artery stenosis, and cranial cerebral blood supply artery (common carotid artery, internal carotid artery, and vertebral artery) DSA has become the most important method in the early diagnosis of ischemic cerebrovascular disease, and it is of great value in the preoperative guidance and postoperative evaluation of PTAS; PTAS is a new effective treatment method for the treatment of ischemic cerebrovascular disease with intracranial and intracerebral artery stenosis or occlusion. Safe, effective, recent curative effect. Skilled and standardized operation is the key to the success of stent implantation. Treatment is safe under the strict control of indications and experienced doctors. Current status, 1, carotid atherosclerotic stenosis in the extracranial segment, commonly used therapy, surgical treatment, and intravascular interventional therapy, Among them, the surgical treatment includes carotid endarterectomy (CEA), intracranial and extracranial bypass, and intravascular interventional therapy including angioplasty and stent implantation (carotid artery stenting, CAS), endovascular endovascular resection, mechanically assisted hemangioplasty, and so on. Although surgical treatment of carotid atherosclerotic narrowing is performed. In the narrow method, the operation of endarterectomy is relatively simple, the curative effect has been verified by 50 years of clinical practice, but the CEA in our country has been very limited in the Department of Neurosurgery at all levels for various reasons, and the present several large clinical randomized studies have not shown that CAS is higher than the risk of CEA, so CAS can become carotid atherosclerosis. One of the main methods for the treatment of sexual stenosis; 2, in the atherosclerotic stenosis of the extracranial segment, the standard medical treatment is not clear, and the surgical treatment has a high incidence of complications, and its long-term effect is far less than endarterectomy for carotid stenosis. Although the present stage supports the treatment of extracranial vertebral artery stenosis by angioplasty Evidence based evidence-based medicine is not sufficient, but due to the limitations of drug treatment and surgical operations, intravascular interventional therapy can be considered in patients with ischemic events after medication, and atherosclerotic stenosis of vertebral artery and stent implantation are becoming the focus of research. 3, innominate artery or clavicle. At present, the patients with symptomatic atherosclerotic stenosis or occlusion that are not effective at present, with the development of intravascular interventional therapy and material, the treatment of innominate artery or subclavian artery stenosis or occlusive disease by intravascular interventional therapy has little trauma, quick recovery and satisfactory clinical efficacy. Point, gradually replace arterial bypass grafting and become the preferred treatment. 4, in the treatment of intracranial atherosclerotic stenosis, the present point of view is that for patients with symptomatic intracranial atherosclerotic stenosis, the first should be actively optimized for drug treatment, for patients who are not effective in the drug treatment, such as the clinical condition permitting, and the side. The poor circulation and the degree of stenosis more than 70% can consider intravascular interventional therapy. 5. In the treatment of acute ischemic stroke, the only effective treatment method proved by evidence-based medicine is venous thrombolysis, but venous thrombolysis has short time window, low dissolution rate, high reocclusion rate and a certain bleeding risk, and endovascular thrombolysis, The clinical application of mechanical thrombolytic device and arterial thrombolysis combined with mechanical embolectomy further expands the time window, repassage rate and reducing the risk of bleeding for acute ischemic stroke; 6, the interventional therapy of intracranial venous sinus thrombosis is lacking a strong evidence-based medical evidence that intravascular interventional therapy for patients with intracranial venous sinus thrombosis is lacking. Treatment, but intravascular therapy, including intravascular thrombolysis, mechanical thrombolysis, and intravascular stent implantation, can be considered in patients who have failed to regulate anticoagulant and venous thrombolysis. International guidelines for interventional therapy for ischemic cerebrovascular disease have been greatly updated every year. New techniques, new materials, new treatments and new treatments are available every year. Large clinical research reports, and China has the world's largest group of patients with cerebrovascular disease, but we have not yet carried out large clinical control studies on interventional therapy for ischemic cerebrovascular disease, and lack of evidence based evidence-based medicine for interventional therapy for ischemic cerebrovascular disease in China. However, it should be noted that there may be differences in the characteristics, risk factors and long-term prognosis of cerebrovascular diseases due to different lifestyles, economic and cultural differences, and the differences in the risk factors and long-term prognosis. There may be differences in the location and pathological characteristics of the intracranial and external atherosclerosis. In addition, the socioeconomic status of the patient may also affect the selection of the intervention equipment and the ability to adhere to the medication after the operation. Therefore, these factors should be taken into full consideration when the interventional therapy of cerebrovascular disease is carried out, and the results of the western study are not completely copied. So far, blood vessels The technology of internal intervention has been developed in western countries for many years. It has established a systematic training mechanism for interventional technology, formed a relatively perfect accreditation system for interventional physicians, combined with the supervision and balance of the medical insurance system, and made the intravascular interventional technology into a benign development track. In our country, although neurovascular intervention is involved. The development and clinical application of technology have made great progress, and some areas may still be in the leading position in the world. However, because of the short time, lack of perfect rules and regulations, no systematic personnel training and qualification authentication mechanism, this technology is often the focus of debate inside and outside the industry. It is necessary for different employees to join together to establish a standardized training mechanism for interventional technique for cerebrovascular disease and to establish a feasible accreditation system for interventional physicians to make the neurovascular interventional techniques in our country develop in a reasonable and orderly direction and benefit the majority of patients. This paper discusses the digital subtraction angiography (DSA). The superiority and diagnostic value of the early diagnosis of the etiology of ischemic cerebrovascular disease. At the same time, the selection, technical operation, efficacy and complications of percutaneous transluminal angioplasty and stenting (PTAS) in the treatment of ischemic cerebrovascular disease, and the comparison and analysis of the clinical symptoms of the patients before the operation are compared. Change, the improvement of cerebral blood flow perfusion, preliminarily discuss the safety and effectiveness of PTAS, summarize the curative effect of 100 patients with PTAS and the occurrence and prevention of complications. Method retrospective analysis of the ischemic cerebrovascular disease hospitalized during the treatment of ischemic cerebrovascular disease during the treatment of ischemic cerebrovascular disease from August 2012 to May 2013 in our hospital. In 125 cases, all patients underwent neck color Doppler flow imaging (color Doppler flow imaging, CDFI), transcranial Doppler (transcranial Doppler, TCD), computer tomography (computerized tomography, CT), CT angiography. On, CTP), nuclear magnetic resonance imaging magnetic resonance imaging, MRI), diffusion weighted imaging (diffusion weighted imaging, D WI), nuclear magnetic resonance angiography (magnetic), compared to the diagnostic value of different methods for patients. And the position of the extracranial segment of the vertebral artery and the intracranial vascular stenosis, the degree and preoperative evaluation, according to the indications and contraindications of the interventional therapy of ischemic cerebrovascular disease, 118 vessels of 100 patients were selected for PTAS treatment, and the stent implantation was successfully completed; 119 stents were implanted. The immediate postoperative angiography was evaluated and followed up for 6 months -1 years, DSA Results and clinical analysis of the curative effect and complications of interventional therapy. Results 125 cases of 1250 vascular stenosis were found through DSA examination in 121 cases, and 301 vessels were found in 121 cases, including 73 branches of C1 segment of internal carotid artery, 64 V1 segment of vertebral artery, 38 subclavian artery, 4 innominate artery, 43 branch of middle cerebral artery and basilar artery. 33 branches of V4 segment of vertebral artery, 9 branches of C4 segment of internal carotid artery, 11 branches of C6 segment, 6 branches of C7 segment, 18 vascular occlusion, 142 stenosis between 70% and 99%, 57 branches between 50-69% and 84 branches of stenosis less than 50%. The degree of vascular lesions was found to be the most supported by DSA, and compared with multi-layer spiral CTA and MRA examination. There were 100 patients with severe atherosclerotic severe arterial stenosis, which were all in accordance with the indications of interventional surgery, with a total of 118 vessels and a total of 119 stent implantation. The success rate of 100%. patients was obviously improved after operation; the symptoms were obviously relieved or disappeared, and the nerve function status was observed. Improvement. The anterior blood flow and cerebral perfusion improved obviously. In the perioperative period, 13 TIA patients and 8 patients with obvious dizziness disappeared or improved immediately. 12 cases of intractable hypertension after internal carotid artery stent implantation improved the C1 segment of the internal carotid artery and the V1 segment of the vertebral artery at the same time, and the stent was placed after the stent implantation. After cerebral hemorrhage, there were 1 cases of perforating events after stent placement, and 1 cases of middle cerebral artery stenting.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R743
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