摘要：

目的 探讨血管内机械取栓治疗大血管闭塞致急性缺血性卒中的有效性和安全性。方法 共41 例大血管闭塞致急性缺血性卒中患者采用血管内机械取栓治疗，记录发病至入院时间、入院至股动脉穿刺时间、发病至血管再通时间，术后即刻采用改良脑梗死溶栓血流分级（mTICI）评价血管再通情况，术后24 h 采用美国国立卫生研究院卒中量表（NIHSS）评价神经功能，术后90 d 采用改良Rankin量表（mRS）评价临床预后；记录围手术期血管内机械取栓相关并发症，术后90 d 症状性颅内出血发生率和病死率；采用美国介入和治疗性神经放射学学会/美国介入放射学学会侧支循环分级系统评价前循环侧支代偿，BATMAN 评分标准评价后循环侧支代偿。结果 41 例患者中12 例（29.27%）行静脉溶栓桥接血管内机械取栓。32 例（78.05%）术后即刻实现血管再通（mTICI 2b ~ 3 级），前循环再通20 例（80%，20/25）、后循环再通12 例（12/16），组间差异无统计学意义（校正χ² = 1.424，P = 0.706）；28 例（68.29%）术后24 h 神经功能改善（NIHSS 评分下降≥ 4 分），前循环闭塞18 例（72%，18/25）、后循环闭塞10 例（10/16），组间差异无统计学意义（χ² = 0.407，P = 0.524）；11 例（26.83%）术后90 d 内死亡，前循环闭塞4 例（16%，4/25）、后循环闭塞7 例（7/16），组间差异无统计学意义（校正χ² = 2.130，P = 0.144），3 例死于并发肺部感染和呼吸功能衰竭、8 例死于缺血性卒中；14 例（34.15%）预后良好（mRS 评分≤ 2 分），前循环闭塞10 例（47.62%，10/21）、后循环闭塞4 例（4/9），组间差异无统计学意义（校正χ² = 0.493，P = 0.483）；6 例（14.63%）发生症状性颅内出血，前循环闭塞4 例（16%，4/25）、后循环闭塞2 例（2/16），组间差异无统计学意义（校正χ² = 3.303，P = 0.856）。33 例行侧支代偿评价，20 例前循环闭塞患者中14 例（70%）侧支代偿良好，其中9 例（9/14）术后90 d 预后良好，6 例（30%）侧支代偿欠佳均预后不良，组间差异有统计学意义（Fisher确切概率法：P = 0.014）；13 例后循环闭塞患者中3 例（3/13）侧支代偿良好，术后90 d 均预后良好，10 例（10/13）侧支代偿欠佳，仅1 例（1/10）预后良好，组间差异有统计学意义（Fisher 确切概率法：P = 0.014）。结论 血管内机械取栓用于治疗大血管闭塞致急性缺血性卒中安全、有效，严格把握手术适应证、充分进行术前评估、完善脑卒中救治流程可以提高血管内机械取栓疗效。

关键词: 卒中, 脑缺血, 血栓切除术, 血管造影术, 数字减影

Abstract:

Objective  To evaluate the efficiency and safety of endovascular thrombectomy for acute ischemic stroke caused by acute large vessel occulsion.  Methods  A total of 41 patients with acute ischemic stroke caused by acute large vessel occulsion were treated with endovascular thrombectomy. Time from onset to admission, from admission to femoral artery puncture, from onset to recanalization were recorded. Modified Thrombolysis in Cerebral Infarction (mTICI) was used to assess the recanalization immediately after operation. National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the neurological function at 24 h after operation. Modified Rankin Scale (mRS) was used to evaluate clinical prognosis at 90 d after operation. Perioperative procedure-related complications and occurrence rate of symptomatic intracranial hemorrhage within at 90 d after operation were recorded. American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) Collateral Flow Grading System (ACG) was used to assess collateral compensation of anterior circulation. BATMAN score was used to assess collateral compensation of posterior circulation.  Results  Among 41 patients, 12 (29.27%) were treated with recombinant tissue-type plasminogen activator (rt-PA) intravenous thrombolysis. There were 32 patients (78.05%) achieved successful recanalization, including 20 patients (80%, 20/25) in anterior circulation and 12 (12/16) in posterior circulation, and no significant difference was seen between them (adjusted χ² = 1.424, P = 0.706). At 24 h after operation, 28 patients (68.29%) had better neurological function than preoperation (NIHSS decreasing ≥ 4 score), including 18 patients (72%, 18/25) with anterior circulation occlusion and 10 (10/16) with posterior circulation occlusion, and there was no significant difference between them (χ² = 0.407, P = 0.524). Eleven patients (26.83%) died within 90 d after operation, including 4 patients (16%, 4/25) with anterior circulation occlusion and 7 (7/16) with posterior circulation occlusion, and there was no significant difference between them (adjusted χ² = 2.130, P = 0.144). Among the 11 dead, 3 died of complicated pulmonary infection and respiratory failure, and 8 died of ischemic stroke.  The other 30 patients were followed up for 3 months to one year, average (231.92 ± 95.36) d. At 90 d after operation, 14 patients (34.15%) had good outcome (mRS ≤ 2 score), including 10 patients (47.62%, 10/21) with anterior circulation occlusion and 4 (4/9) with posterior circulation occlusion, and there was no significant difference between them (adjusted χ² = 0.493, P = 0.483). Among 41 patients, 6 patients (14.63% ) had symptomatic intracranial hemorrhage, including 4 patients (16% , 4/25) with anterior circulation occlusion and 2 (2/16) with posterior circulation occlusion, and no significant difference was seen between them (adjusted χ² = 3.303, P = 0.856). Collateral compensation was evaluated in 33 patients (20 with anterior circulation occlusion and 13 with posterior patients circulation occlusion). In 20 patients with anterior circulation occlusion, 14 patients (70%) had good collateral compensation, in whom 9 (9/14) had good outcome 90 d after operation, while the other 6 patients (30%) had poor collateral compensation and then had good outcome 90 d after operation, and significant difference was seen between them (Fisher exact probability: P = 0.014). Among 13 patients with posterior circulation occlusion, 3 patients (3/13) had good collateral compensation and had good outcome 90 d after operation, while the other 10 (10/13) had poor collateral compensation, in whom one (1/10) had good outcome 90 d after operation, and significant difference was seen between them (Fisher exact probability: P = 0.014).  Conclusions Endovascular thrombectomy is an efficient and safe method for acute ischemic stroke caused by acute large vessel occlusion. Rigorously master the indication and preoperative evaluation, and perfect acute rescue procedure and treatment for stroke may increase the efficacy of endovascular thrombectomy.

Key words: Stroke, Brain ischemia, Thrombectomy, Angiography, digital subtraction