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中华脑科疾病与康复杂志(电子版)

中华脑科疾病与康复杂志(电子版) ›› 2022, Vol. 12 ›› Issue (03) : 171 -177. doi: 10.3877/cma.j.issn.2095-123X.2022.03.010

短篇论著

双支架取栓治疗难治性颅内大动脉分叉处急性闭塞的疗效观察
潘晓虎1, 朱发勇1,†(), 孙红艳2, 杨彩云3, 曹月洲3, 刘圣3   
  1. 1. 211700　江苏盱眙，盱眙县人民医院神经内科
    2. 264309　山东威海，石岛人民医院神经内科
    3. 210029　南京，南京医科大学第一附属医院介入放射科
  • 收稿日期:2022-01-11 出版日期:2022-06-15
  • 通信作者: 朱发勇

Efficacy of double stent-retriever thrombectomy in the treatment of refractory acute intracranial macrovascular occlusion at bifurcation

Xiaohu Pan1, Fayong Zhu1,†(), Hongyan Sun2, Caiyun Yang3, Yuezhou Cao3, Sheng Liu3   

  1. 1. Department of Neurology, Xuyi County People’s Hospital, Xuyi 211700, China
    2. Department of Neurology, Shidao People’s Hospital, Weihai 264309, China
    3. Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China
  • Received:2022-01-11 Published:2022-06-15
  • Corresponding author: Fayong Zhu
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潘晓虎, 朱发勇, 孙红艳, 杨彩云, 曹月洲, 刘圣. 双支架取栓治疗难治性颅内大动脉分叉处急性闭塞的疗效观察[J]. 中华脑科疾病与康复杂志(电子版), 2022, 12(03): 171-177.

Xiaohu Pan, Fayong Zhu, Hongyan Sun, Caiyun Yang, Yuezhou Cao, Sheng Liu. Efficacy of double stent-retriever thrombectomy in the treatment of refractory acute intracranial macrovascular occlusion at bifurcation[J]. Chinese Journal of Brain Diseases and Rehabilitation(Electronic Edition), 2022, 12(03): 171-177.

目的

探讨双支架取栓治疗难治性颅内大动脉分叉处急性闭塞的有效性及安全性。

方法

回顾性分析盱眙县人民医院神经内科和江苏省人民医院介入放射科自2019年5月至2021年10月行双支架取栓治疗难治性颅内大动脉分叉处急性闭塞患者的临床及影像学资料，评估患者的血管再通情况、手术并发症及临床预后。比较患者术前及出院时美国国立卫生研究院卒中量表（NIHSS）评分，采用改良Rankin评分（mRs）评价患者术后90 d的临床预后。

结果

本组共纳入11例患者，均为单支架取栓失败后改用双支架进行补救，9例（81.8%）患者成功再通（改良脑梗死溶栓分级为2b~3级），2例患者再通失败。4例患者术后发生症状性颅内出血。本组患者出院时NIHSS评分的中位数[12（2，20）分]较术前[16（8，21）分]明显降低，差异具有统计学意义（P=0.012）。术后随访90 d，2例患者死亡（mRs 6分），3例患者严重残疾（mRs 5分），1例患者重度残疾（mRs 4分），1例患者中等残疾（mRs 3分），4例患者良好（mRs≤2分）。

结论

双支架取栓技术治疗难治性颅内大血管分叉处急性闭塞安全、有效，血管再通率高，可以作为单支架取栓不成功的补救措施。

关键词: 急性缺血性脑卒中, 难治性栓塞, 双支架取栓
Objective

To investigate the effectiveness and safety of double stent-retriever thrombectomy in the treatment of acute intracranial macrovascular occlusion at bifurcation.

Methods

The clinical and imaging materials of patients with acute intracranial macrovascular occlusion at the bifurcation treated with double stent-retriever thrombectomy from May 2019 to October 2021 in the Neurology Department of Xuyi County People's Hospital and Interventional Radiology Department of Jiangsu Provincial People's Hospital were retrospectively analyzed. The recanalization rate and complications were determined and the clinical outcomes were assessed. Also, neurological functions of the patients before treatment and discharge from hospital, measured by National Institute of Health stroke scale (NIHSS) score, were compared via Wilcoxon test and the clinical outcomes were assessed by modified Rankin score (mRs) at 90 d after treatment.

Results

A total of 11 patients were treated with double stents after single stent thrombectomy failed, 9 patients resulted in successfully recanalization (modified thrombolysis in cerebrai infarction score of 2b to 3), and 2 patients failed. There were 4 patients with symptomatic intracranial hemorrhage occurred after operation. Compared with preoperative conditions, the NIHSS score discharge from hospital was markedly lower (12 vs 16, P=0.012). At 90 d, 2 patients died (mRs 6), 3 patients seriously disabled (mRs 5), 1 patient moderately seriously disabled (mRs 4), 1 patient resulted in moderate outcome (mRs 3) and the other 4 patients achieved good outcome (mRs 0-2).

Conclusion

Double stent-retriever thrombectomy is safe and effective in the treatment of acute intracranial macrovascular occlusion at bifurcation with high vascular recanalization rate. It can be used as a rescue strategy for the failure of single stent thrombectomy.

Key words: Acute ischemic stroke, Refractory embolism, Double stent-retriever thrombectomy
表1 11例双支架取栓患者的临床资料
序号 性别 年龄（岁） 既往病史 闭塞血管 发病时间（min） 术前/出院时NIHSS评分（分） 取栓次数 穿刺至再通时间（min） mTICI分级 sICH 90 d mRS评分（分）
1 男 75 房颤、糖尿病 右侧颈内动脉末端 136 21/12 8 194 3 无 4
2 男 72 房颤、心功能不全 基底动脉尖 323 35/35 2 45 2c 有 5
3 男 85 房颤 右侧大脑中动脉 286 21/14 4 39 0 无 5
4 女 67 糖尿病 右侧大脑中动脉 180 12/10 4 77 2b 有 3
5 男 72 房颤、高血压、糖尿病 基底动脉尖 140 38/38 7 67 2b 无 6
6 男 74 房颤、高血压 右侧颈内动脉末端 530 14/12 5 173 2c 有 5
7 男 75 房颤、高血压 左侧大脑中动脉 30 8/0 2 55 3 无 0
8 男 64 瓣膜置换 左侧大脑中动脉 258 8/2 5 167 3 无 0
9 男 38 房颤、心脏起搏器植入 右侧颈内动脉末端 300 8/2 2 65 2b 无 0
10 女 79 房颤 右侧颈内动脉末端 90 20/20 6 65 2a 有 6
11 男 66 前列腺癌 左侧颈内动脉末端 120 16/0 2 59 3 无 0
图1 典型病例1血管内治疗的影像学资料 A：术前DSA示右侧颈内动脉C1以上不显影(箭头示闭塞部位)；B：单支架(SWIM技术)取栓5次均失败(箭头示闭塞部位)；C：第6次取栓，行双支架取栓(箭头示打开的支架)；D：第6次取栓后右侧大脑中动脉起始部显影(箭头所示)；E：第7次取栓，采用"Y型"方式行双支架取栓(箭头示打开的支架)；F：第7次取栓后，右侧大脑前动脉完全显影，右侧大脑中动脉M1段部分显影（箭头所示）；G：第7次取栓取出的大负荷血栓；H：第8次取栓后，最终获得3级再通
图2 典型病例2血管内治疗的影像学资料 A：术前DSA示右侧大脑中动脉分叉部闭塞(箭头所示)；B：使用Solitaire AB 4 mm×20 mm支架置于上干取栓2次、下干取栓1次，均失败(箭头示闭塞部位)；C：第4次行双支架取栓(箭头示打开的支架)；D：第4次取栓后再通成功；E：双支架取出的血栓；F：术后次日头颅CT可见出血转化；G：术后1周头颅MRA示病变血管通畅；H：术后8 d头颅CT示出血基本吸收
图3 典型病例3血管内治疗的影像学资料 A：术前DSA示基底动脉尖分叉部闭塞(箭头)；B：使用Solitaire FR 4 mm×20 mm支架取栓置于右侧大脑后动脉取栓3次、左侧大脑后动脉取栓2次，均失败(箭头示闭塞部位)；C：第6、7次取栓，使用双支架取栓2次(箭头示打开的支架)；D：第7次取栓后显示病变血管基本通畅，基底动脉尖、右侧大脑后动脉少量血栓残留(箭头所示)；E：双支架取出的血栓；F：术后次日头颅CT示右侧中脑、岛叶出血转化
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