挽救性支架植入对取栓困难的脑动脉栓塞开通效果

Recanalization efficiency of rescue stenting for embolic cerebral artery occlusion with difficulty in thrombectomy

摘要:

目的 探究急性脑栓塞取栓失败和神经介入术中发生医源性脑动脉栓塞后补救性支架植入术的开通效果。方法 回顾性分析2020年1月至2021年11月上海交通大学医学院附属第九人民医院6例脑栓塞取栓失败和4例医源性颅内中远端动脉栓塞、接受补救性支架植入术的患者临床信息，总结患者术后血管开通情况、术后24 h 支架内血流通畅情况、出血转化和预后等情况。结果 6例急性脑栓塞取栓失败，补救性支架植入后闭塞血管全部开通（modified thrombosis in cerebral infarction score，mTICI 2b~3），术后3例出血转化（1例PH2型，2例HI2型），术后24 h支架内血流通畅5例（83%），1例未行血管造影复查；3例患者住院期间死亡。4例医源性中远端动脉闭塞中，1例为原发病为椎基底动脉高度狭窄，支架置入术中发生右侧小脑前下动脉闭塞，补救性支架置入后完全开通，术后24 h复查所有支架通畅，无脑出血，3个月预后良好，改良Rankin量表（modified Rankin score，mRS）评分1分；3例原发病为大脑中动脉栓塞，取栓术中出现同侧大脑前动脉分支闭塞，补救性支架植入后完全开通，其中1例术后24 h头颅计算机体层血管成像（computed tomography angiography，CTA）可见支架通畅，合并片状出血转化（HI2型），2例因为病重未行血管复查。结论 补救性支架植入可以快速开通取栓失败以及医源性中远端动脉的栓塞，但是疗效和安全性需进一步研究。

Abstract:

Objective To explore whether rescue stenting can efficiently recanalize embolic cerebral artery occlusion after failed thrombectomy or iatrogenic cerebral artery embolism in nerve intervention.Methods The clinical data of 6 patients with failed thrombectomy and 4 patients with iatrogenic cerebral middle and distal artery embolism received rescue stenting in Shanghai Ninth People's Hospital，Shanghai Jiaotong University School of Medicine from January 2020 to November 2021 were analyzed retrospectively. The preoperative National Institutes of Health Stroke Scale（NIHSS），the NIHSS score at 24 h after procedure，the postoperative stent patency，the type of hemorrhagic transformation and prognosis were recorded.Results There were 6 cases receiving rescue stenting after failed thrombectomy for embolic occlusion of middle cerebral artery. All of them（100%） had modified thrombosis in cerebral infarction score（mTICI 2b-3），3 cases had hemorrhagic transformation after the surgery （1 case of PH2 type，and 2 cases of HI2 type），5 cases （83%） had patent bleeding at 24 h after operation，one did not undergo repeated angiography examination，and 3 cases（50%） died during hospitalization. Among the 4 cases of iatrogenic cerbral middle and distal artery occlusion，one was primarily high vertebrobasilar artery stenosis，and had right anterior inferior cerebellar artery embolism during the stenting. The recanalization occurred after the rescue stenting. At 24 h after operation，all stents were unobstructed，no patients had no cerebral hemorrhage，and the prognosis was good after 3 months （modified Rankin score，mRS： 1 point）. Three cases had iatrogenic ipsilateral anterior cerebral artery embolism during thrombectomy for middle cerebral artery embolism，the blood flow recovered immediately after direct stent implantation，among which，one case underwent cerebral computed tomography angiography（CTA） at 24 h after operation showing the patent stent and hemorrhagic transformation（type HI2）. The other 2 cases did not have repeated examination because of disease severity.Conclusion Rescue stenting can rapidly and efficiently recanalize embolic occlusion of cerebral artery due to failed thrombectomy or iatrogenic middle and distal embolism，but its effectiveness and safety need to be further studied.