摘要：

目的 探讨颅内动脉狭窄部位对支架成形术安全性的影响。方法 共73 例症状性颅内动脉粥样硬化性狭窄患者，根据颅内动脉狭窄部位分为颈内动脉颅内段组（18 例）、大脑中动脉M1 段组（11 例）、椎动脉颅内段组（27 例）和基底动脉组（17 例），均行颅内动脉支架成形术，记录颅内动脉狭窄改善情况，脑血管并发症（包括穿支事件、动脉夹层、支架内血栓形成、支架远端动脉栓塞和脑组织过度灌注等）和神经系统并发症（包括短暂性脑缺血发作、缺血性卒中和颅内出血），术后30 d 采用改良Rankin量表（mRS）评价临床预后。结果 73 例患者共植入支架73 个，包括Apollo 球囊扩张式支架35 例和Wingspan 自膨式支架38 例，其中，颈内动脉颅内段组应用Apollo 支架10 例（10/18），Wingspan 支架8 例（8/18）；大脑中动脉M1 段组应用Apollo 支架5 例（5/11），Wingspan 支架6 例（6/11）；椎动脉颅内段组应用Apollo 支架16 例（59.26%，16/27），Wingspan 支架11 例（40.74%，11/27）；基底动脉组应用Apollo 支架4 例（4/17），Wingspan 支架13 例（13/17），4 组患者术中应用支架类型差异无统计学意义（χ² = 7.422，P = 0.201）。治疗后颈内动脉颅内段组［（10.94 ± 1.99）%对（90.89 ± 7.71）%；t = 69.545，P = 0.000］、大脑中动脉M1 段组［（10.37 ± 2.14）%对（87.64 ± 9.46）%；t = 26.000，P = 0.000］、椎动脉颅内段组［（11.02 ± 1.99）%对（89.11 ± 7.97）%；t = 50.726，P = 0.000］和基底动脉组［（10.99 ± 3.39）%对（91.35 ± 5.62）%；t = 69.545，P = 0.000］血管狭窄率均较治疗前改善。73 例患者中11 例（15.07%）发生脑血管并发症，分别为穿支事件4 例、动脉夹层4 例、支架内血栓形成1 例、支架远端动脉栓塞2 例，其中，颈内动脉颅内段组3 例（3/18），为动脉夹层2 例、支架远端动脉栓塞1 例，基底动脉组8 例（8/17），为穿支事件4 例、动脉夹层2 例、支架内血栓形成1 例、支架远端动脉栓塞1 例，而大脑中动脉M1 段组和椎动脉颅内段组无一例发生脑血管并发症，组间差异有统计学意义（H = 63.134，P = 0.000）；6 例（8.22%）发生神经系统并发症，包括短暂性脑缺血发作4 例、缺血性卒中2 例，其中，颈内动脉颅内段组1 例（1/18），为缺血性卒中，基底动脉组5 例（5/17），包括短暂性脑缺血发作4 例、缺血性卒中1 例，而大脑中动脉M1 段组和椎动脉颅内段组无一例发生神经系统并发症，组间差异亦有统计学意义（H = 65.698，P = 0.003）。术后30 d颈内动脉颅内段组有1 例、基底动脉组有1 例mRS 评分1 分，预后良好率为97.26%（71/73）。结论 颅内动脉支架成形术围手术期脑血管和神经系统并发症风险与支架植入部位密切相关，且总体预后良好。

关键词: 颅内动脉硬化, 血管成形术, 支架, 手术后并发症, 血管造影术, 数字减影

Abstract:

Objective  To investigate the effect of location of intracranial arterial stenosis on the safety of intracranial stenting.  Methods  A total of 73 patients with symptomatic intracranial atherosclerotic stenosis (ICAS) were divided into intracranial internal carotid artery (IICA, N = 18), middle cerebral artery (MCA)-M1 segment (MCA-M1, N = 11), intracranial vertebral artery (IVA, N = 27) and basilar artery (BA, N = 17). All of them underwent intracranial stenting. The improvement of intracranial arterial stenosis, cerebrovascular complications including perforating events, artery dissection, in-stent thrombosis, distal stent arterial embolism and cerebral hyperperfusion, and neurological complications including transient ischemic attack (TIA), ischemic stroke and intracranial hemorrhage were recorded. Modified Rankin Scale (mRS) was used to evaluate the prognosis 30 d after operation.  Results  A total of 73 stents were implanted in 73 patients (35 Apollo balloon-expandable stents and 38 Wingspan self-expandable stents). Among them, 10 cases (10/18) were treated with Apollo stents and 8 cases (8/18) with Wingspan stents in IICA group, 5 cases (5/11) were treated with Apollo stents and 6 cases (6/11) with Wingspan stents in MCA-M1 group, 16 cases (59.26%, 16/27) were treated with Apollo stents and 11 cases (40.74%, 11/27) with Wingspan stents in IVA group, and 4 cases (4/17) were treated with Apollo stents and 13 cases (13/17) with Wingspan stents in BA group. No significant difference was seen in stent type among 4 groups (χ² = 7.422, P = 0.201). The stenosis rate of IICA group after treatment [(10.94 ± 1.99)%] was significantly improved than before treatment [(90.89 ± 7.71)%; t = 69.545, P = 0.000]. The stenosis rate of MCA-M1 group after treatment [(10.37 ± 2.14)%] was significantly improved than before treatment [(87.64 ± 9.46)%; t = 26.000, P = 0.000]. The stenosis rate of IVA group after treatment [(11.02 ± 1.99)% ] was significantly improved than before treatment [(89.11 ± 7.97)%; t = 50.726, P = 0.000]. The stenosis rate of BA group after treatment [(10.99 ± 3.39)%] was significantly improved than before treatment [(91.35 ± 5.62)%; t = 69.545, P = 0.000]. In 73 patients, cerebrovascular complications occurred in 11 cases (15.07%), including 4 cases of perforating events, 4 cases of artery dissection, one case of in-stent thrombosis and 2 cases of distal stent arterial embolism. There were 3 cases (3/18) in IICA group, including 2 cases of artery dissection and one case of distal stent arterial embolism, and 8 cases (8/17) in BA group, including 4 cases of perforating events, 2 cases of artery dissection, one case of in-stent thrombosis and one case of distal stent arterial embolism. No cerebrovascular complications occurred in MCA-M1 group and IVA group. The difference among 4 groups was statistically significant (H = 63.134, P = 0.000). Neurological complications occurred in 6 cases (8.22%), including 4 cases of TIA and 2 cases of ischemic stroke. There was one case (1/18) of ischemic stroke in IICA group, and 5 cases (5/17) in BA group, including 4 cases of TIA and one case of ischemic stroke. No neurological complications occurred in MCA-M1 group and IVA group. The difference among 4 groups was statistically significant (H = 65.698, P = 0.003). At 30 d after operation, there was one case with mRS 1 score in IICA group and one in BA group. The total rate of good prognosis 30 d after operation was 97.26% (71/73).  Conclusions  The location of intracranial arterial stenosis have a great influence on the risk of perioperative cerebrovascular and neurological complications in the intracranial stenting, and the overall prognosis is good.

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