摘要：

目的 对比症状性椎-基底动脉颅内段重度狭窄伴认知功能障碍患者支架联合药物治疗与积极药物治疗方式对患者认知功能的影响。方法 选择2016年10月至2019年3月53例症状性椎-基底动脉颅内段狭窄患者，分为支架联合药物治疗组（联合组，31例）和积极药物治疗组（单药组，22例），分析联合组围手术期情况以及两组累计不良事件发生情况；比较两种治疗方式在患者住院期间、出院后1个月、出院后6个月蒙特利尔认知评价量表（MoCA）评分，评价患者认知功能改善情况，同时针对联合组术前不同侧支循环状态进行亚组分析。结果 联合组围手术期有2例发生手术相关并发症，两组累计不良事件发生率和缺血性卒中发生率差异均无统计学意义（P>0.05）。对比两种不同治疗方式，仅延迟回忆两组比较差异有统计学意义（P=0.005），提示联合组在改善延迟回忆上较单药组有优势。MoCA总分（P=0.000）、交替连线（P=0.028）、画钟试验（P=0.006）、注意力（P=0.001）以及延迟回忆（P=0.000）在不同随访时间点之间差异均有统计学意义，联合组中上述各评分均可见提高，其中MoCA总分（P=0.000，0.000，0.009）和注意力评分（P=0.000，0.000，0.030）在住院期间、出院后1个月、出院后6个月评分逐步提高，而延迟回忆（P=0.000，0.000）、画钟试验（P=0.006，0.000）和交替连线评分（P=0.001，0.000）提高主要集中在出院后1个月。比较两种不同侧支循环状态MoCA评分，仅语言重复两组比较差异有统计学意义（P=0.021）。MoCA总分（P=0.000）、交替连线（P=0.000）、画钟试验（P=0.002）、注意力（P=0.000）以及延迟回忆（P=0.000）在不同随访时间点比较差异均有统计学意义。进一步比较两组各时间点MoCA评分变化，侧支良好组中MoCA总分（P=0.006，0.006）和注意力评分（P=0.005，0.002）在出院后6个月较出院后1个月和住院期间均提高，提示上述评分提高主要集中在出院后1~6个月之间，延迟回忆评分出院后6个月评分较住院期间提高（P=0.012）；侧支不良组中MoCA总分（P=0.000，0.000）、交替连线（P=0.003，0.001）、画钟试验（P=0.004，0.001）、注意力（P=0.000，0.000）和延迟回忆评分（P=0.000，0.000）在出院后6个月和出院后1个月均较住院期间提高，提示上述评分提高主要集中在出院后1个月。结论 对于症状性椎-基底动脉颅内段重度狭窄伴认知功能障碍患者，支架联合药物治疗能够改善多项认知功能，同时在延迟回忆方面较积极药物治疗存在优势，同时术前侧支循环不良患者认知功能获益的时间更早。

关键词: 椎底动脉供血不足, 动脉粥样硬化, 认知障碍, 支架, 血小板聚集抑制剂, 侧支循环

Abstract:

Objective To compare the effects of stent combined with drug therapy and aggressive drug therapy alone on cognitive function for patients with symptomatic severe intracranial vertebrobasilar artery stenosis and cognitive dysfunction. Methods A total of 53 patients from October 2016 to March 2019 with symptomatic severe intracranial vertebrobasilar artery stenosis and cognitive dysfunction were collected. Patients were divided into 2 groups[stent combined with drugs group (n=31) and aggressive drugs alone group (n=22)] based on patients' informed consent. Perioperative status of stent combined with drugs group and incidence of adverse events in both groups were analyzed. Montreal Congnitive Assessment (MoCA) scores were compared in hospitalization period, 1 month and 6 months at follow-up in order to evaluate the improvement of cognition. Then subgroup analysis of different collateral circulation status before stent combined with drugs group was conducted. Results There were 2 cases of perioperative complication in stent combined with drugs group, and there was no statistical difference in cumulative incidence of adverse events and ischemic stroke between 2 groups. According to the comparion that MoCA scores in hospitalization, 1 month and 6 months at follow-up in two different therapy groups, the score of delayed recall had statistical significance (P=0.005), which indicted stent group had advantages in delayed recall over drugs group. The scores of total MoCA (P=0.000), line connection test (P=0.028), drawing clock (P=0.006), attention (P=0.001) and delayed recall (P=0.000) had statistical significance in different follow-up time points and were significantly improved in stent group. In stent group, the scores of total MoCA (P=0.000, 0.000, 0.009) and attention (P=0.000, 0.000, 0.030) improved in succession in the time of before treatment, 1 month and 6 months at follow-up. However, the scores of line connection test (P=0.001, 0.000), drawing clock (P=0.006, 0.000), and delayed recall (P=0.000, 0.000) improved mainly within first month at discharge. As to the scores of MoCA in different preoperative collateral circulation status groups, sentence repetition only had statistical significance (P=0.021). The scores of total MoCA (P=0.000), line connection test (P=0.000), drawing clock (P=0.002), attention (P=0.000) and delayed recall (P=0.000) had statistical significance in different follow-up time points. In further comparion of changes of MoCA scores at different time points in 2 preoperative collateral circulation status groups, scores of total MoCA (P=0.006, 0.006) and attention (P=0.005, 0.002) were higher at follow-up of 6 month than these in hospitalization and 1 month follow-up in good collateral group, which suggested the scores above improved mainly between 1 month and 6 month at discharge. The score of delayed recall at discharge after 6 month was higher than it in hospitalization. The scores of total MoCA (P=0.000, 0.000), line connection test (P=0.003, 0.001), drawing clock (P=0.004, 0.001), attention (P=0.000, 0.000) and delayed recall (P=0.000, 0.000) were higher at follow-up of 1 month and 6 month than these in hospitalization in poor collateral group, which suggested the scores above improved mainly within first month at discharge. Conclusions As to the patients with symptomatic severe vertebrobasilar artery stenosis and cognitive dysfunction, the improvement in multiple cognitive domains of stent combined with drugs therapy and the advantage over aggressive drugs alone group were observed. Meanwhile, the time of cognitive benefit was earlier in poor preoperative collateral circulation status groups than in good collateral group.

Key words: Vertebrobasilar insufficiency, Atherosclerosis, Cognition disorders, Stents, Platelet aggregation inhibitors, Collateral circulation