本文選題：機(jī)械取栓　切入點(diǎn)：基底動(dòng)脈閉塞　出處：《大連醫(yī)科大學(xué)》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：背景與目的急性基底動(dòng)脈閉塞目前仍是缺血性腦卒中中最具致命性的亞型之一,如不能實(shí)現(xiàn)早期再通,臨床功能預(yù)后極差。如急性缺血性腦卒中患者距離癥狀開(kāi)始出現(xiàn)的時(shí)間在4.5小時(shí)以內(nèi),應(yīng)用靜脈內(nèi)藥物溶栓是公認(rèn)的標(biāo)準(zhǔn)治療方案,但由于其診治窗口期短、血管再通效率低,一定程度上制約了其在臨床實(shí)踐中的應(yīng)用。雖然已有充分?jǐn)?shù)據(jù)證實(shí),相比于靜、動(dòng)脈溶栓,支架樣取栓裝置在治療前循環(huán)大血管閉塞時(shí)具有更佳的血管再通率及良好功能預(yù)后。但對(duì)于后循環(huán)尤其是基底動(dòng)脈閉塞的作用仍不甚明確。因此,本研究的目的是評(píng)估應(yīng)用Solitaire系列支架機(jī)械取栓治療急性基底動(dòng)脈閉塞的有效性及安全性,其次明確影響神經(jīng)功能預(yù)后的因素。方法回顧性分析2015年6月份-2016年12月份在大連市中心醫(yī)院和沈陽(yáng)軍區(qū)總醫(yī)院神經(jīng)外科兩中心應(yīng)用Solitaire系列支架取栓治療的14例急性基底動(dòng)脈閉塞患者的臨床及影像學(xué)資料,所有患者的發(fā)病時(shí)間均在24小時(shí)以內(nèi)。通過(guò)改良腦梗死溶栓分級(jí)標(biāo)準(zhǔn)(modified Thrombolysis in Cerebral Infarction scale,mTICI)評(píng)估是否再通,成功再通定義為mTICI2b或3級(jí)。良好臨床預(yù)后定義為術(shù)后90天改良Rankin量表評(píng)分(modified Rankin Scale,mRS)≤2分。另外,使用單因素方差法分析基于全腦血管造影的側(cè)支循環(huán)分級(jí)、術(shù)前NIHSS評(píng)分、入院到再通時(shí)間及取栓次數(shù)與臨床預(yù)后的相關(guān)性。記錄手術(shù)操作過(guò)程及設(shè)備相關(guān)并發(fā)癥,包括癥狀性顱內(nèi)出血、栓子脫落致遠(yuǎn)端梗塞、血管壁穿孔、動(dòng)脈夾層、責(zé)任血管痙攣。結(jié)果 患者年齡平均值為(66.5±6.3)歲,其中男性數(shù)量占71%。發(fā)病到入院時(shí)間中位數(shù)為6.0(5.0,8.3)小時(shí)。取栓前造影側(cè)支血流分級(jí)中,3例被評(píng)估后僅為0級(jí),3例評(píng)估后達(dá)到2級(jí),2例為1級(jí)。入院到股動(dòng)脈穿刺時(shí)間中位數(shù)為119.5(108.8,130.3)分鐘。術(shù)后美國(guó)國(guó)立衛(wèi)生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)評(píng)分明顯低于術(shù)前(20.0(18.3-22.8)vs.8.5(3.5-12.8);P=0.002)。從股動(dòng)脈穿刺到實(shí)現(xiàn)成功再通(mTICI≥2b級(jí))時(shí)間中位數(shù)為58.0(50.0,77.0)分鐘。取栓次數(shù)中位數(shù)為2(1,3)次。14例患者中有2例在機(jī)械取栓前聯(lián)合了靜脈溶栓治療,3例聯(lián)合使用了球囊擴(kuò)張技術(shù),1例患者在取栓后原位釋放Solitaire支架,4例聯(lián)合使用了動(dòng)脈溶栓。13例患者獲得成功再通(mTICI2b或3級(jí)),占所有患者的93%。1例患者發(fā)生癥狀性顱內(nèi)出血,占7%。2例在術(shù)中發(fā)生血管痙攣,未出現(xiàn)其他設(shè)備相關(guān)并發(fā)癥。在術(shù)后90天隨訪中,有4例(28.6%)患者獲得良好臨床預(yù)后(mRS≤2分),2例(14.3%)死亡。在單因素方差分析中,發(fā)現(xiàn)全腦血管造影的側(cè)支循環(huán)分級(jí)與臨床預(yù)后明顯相關(guān),且高的側(cè)支循環(huán)分級(jí)往往預(yù)示著良好預(yù)后。術(shù)前NIHSS評(píng)分(P=0.956)、入院到再通時(shí)間(P=0.227)及取栓次數(shù)(P=0.713)與臨床預(yù)后無(wú)顯著相關(guān)性。結(jié)論 對(duì)于急性基底動(dòng)脈閉塞致后循環(huán)缺血的病人,應(yīng)用Solitaire系列支架行血管內(nèi)介入(即機(jī)械取栓)治療,可以明顯提高再通率,同時(shí)改善功能預(yù)后。基于全腦血管造影的側(cè)支循環(huán)分級(jí)是重要的神經(jīng)功能預(yù)后影響因子。
[Abstract]:Background and objective acute basilar artery occlusion is still one of the subtypes of ischemic stroke in the most deadly, if not early recanalization, poor clinical prognosis. Functions such as distance symptoms of acute ischemic stroke patients begin time within 4.5 hours of intravenous thrombolytic therapy is the standard treatment for recognized, but the diagnosis and treatment of short window period, recanalization of low efficiency, to a certain extent restrict its application in clinical practice. Although there are sufficient data confirm that compared to static, intra-arterial thrombolysis, thrombectomy device stent like circulation vascular occlusion before treatment has better recanalization rate and good functional outcome. But for posterior circulation especially the basilar artery occlusion effect is still unclear. Therefore, the purpose of this study is to evaluate the application of Solitaire series mechanical thrombectomy for acute basilar artery occlusion Effectiveness and safety, secondly the influence factors of neurological outcome. Methods a retrospective analysis of 14 cases of acute basilar artery in 2015 June -2016 year in December in Dalian Central Hospital and General Hospital of Shenyang Command Center Department of Neurosurgery two application of Solitaire series of stent thrombectomy for occlusion of the clinical and imaging data were all, the onset time of patients in less than 24 hours. By improving the cerebral infarction classification standard (modified Thrombolysis in Cerebral Infarction scale, mTICI) to assess whether successful recanalization, recanalization was defined as mTICI2b or 3. Good clinical outcome was defined as 90 days after the modified Rankin scale (modified Rankin Scale, mRS = 2). In addition, the use of single factor variance analysis method based on the cerebral collateral circulation classification, preoperative NIHSS score, admission to recanalization time and thrombectomy times and the pre clinical phase Close. Records of operation process and equipment related complications, including symptomatic intracranial hemorrhage, emboli caused by distal infarction, vascular wall perforation, artery dissection, liability of vasospasm. Results patients average age is (66.5 + 6.3) years old, male accounted for 71%. incidence to hospital admission time was 6 hours (5.0,8.3). Thrombectomy before angiography collateral blood flow grading, 3 cases were assessed after only 0 grade, 3 cases after the evaluation reaches level 2, 2 cases of grade 1. Admission to the femoral artery puncture time was 119.5 minutes (108.8130.3). The National Institutes of Health Stroke Scale (National Institutes of Health after Stroke Scale, NIHSS) were significantly lower than preoperative (20 (18.3-22.8) vs.8.5 (3.5-12.8); P=0.002). From the femoral artery puncture to achieve successful recanalization (mTICI = 2b) time was 58 minutes (50.0,77.0). The number of thrombectomy for a median of 2 (1,3).14 patients In 2 cases in mechanical thrombectomy before combined intravenous thrombolytic therapy, 3 cases of combined use of balloon angioplasty, 1 patients with Solitaire stent in situ release after thrombectomy, 4 cases of combined use of intra-arterial thrombolysis in.13 patients received successful recanalization (mTICI2b or 3), accounting for symptomatic intracranial hemorrhage all cases of 93%.1 patients, 7%.2 patients accounted for vasospasm during operation, no other equipment related complications. In the 90 day postoperative follow-up, 4 cases (28.6%) patients got good prognosis (mRS = 2 points), 2 cases (14.3%) died. The single factor analysis of variance. That was obviously related to collateral grading and prognosis of cerebral angiography, collateral circulation and high grade often indicates a good prognosis. The preoperative NIHSS score (P=0.956), admission to reperfusion time (P=0.227) and thrombectomy times (P=0.713) had no significant correlation with the clinical prognosis. Conclusion for the treatment of acute Basilar artery occlusion caused by posterior circulation ischemia patients, interventional endovascular stent application of Solitaire series (i.e. mechanical thrombectomy) treatment, can significantly improve the recanalization rate, and improve the function of collateral grading prognosis. Cerebral angiography is based on the effect of nerve function of important prognostic factors.

【學(xué)位授予單位】：大連醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R743.3
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本文編號(hào)：1596187