急性缺血性脑卒中机械取栓术中困难通路的处理策略

Management strategies for difficult access in mechanical thrombectomy for acute ischemic stroke

摘要:

目的 探讨在急性缺血性脑卒中机械取栓术中困难通路的处理策略。方法 回顾性分析2016年6月至2021年5月该院收治的42例急性缺血性脑卒中机械取栓术中困难通路患者的临床资料，男性24例，女性18例，年龄为56~82岁，平均年龄(70±12)岁。患者术前美国卫生研究院卒中量表(NHISS)评分为(17±2)分，取栓前闭塞动脉血流的改良脑梗死溶栓分级(mTICl分级)均为0级。术中采用Solitaire AB取栓支架动脉内取栓或抽吸导管直接抵近栓子抽栓。术中分别运用同轴技术、导丝交换技术、中间导管、球囊或支架锚定、直接桡动脉穿刺等技术处理困难通路。结果 困难通路中主动脉弓路径迂曲12例，颈动脉路径迂曲15例，大脑中动脉路径迂曲12例，双侧椎动脉闭塞2例，双侧股动脉闭塞1例。术后4例血管未开通，其余38例患者成功开通闭塞血管，血流达2b/3级，开通率达90%。术后90 d的改良Rankin评分良好(0~2级)24例，残疾(3~4级)14例，死亡4例。术中平均所用时间为(40±7.7)min。结论 困难通路是急性缺血性脑卒中机械取栓预后差的一个重要因素，正确识别与处理困难通路可以节省手术时间，改善患者临床结局。

Abstract:

Objective To investigate the management strategies for difficult access in mechanical thrombectomy for acute ischemic stroke.Methods A retrospective analysis was performed for the clinical data of 42 patients with acute ischemic stroke who were admitted to our hospital from June 2016 to May 2021 and had difficult access during mechanical thrombectomy. Among these patients， there were 24 male patients and 18 female patients， aged 56-82 years， with a mean age of 70±12 years. The patients had aNational Institutes of Health Stroke Scale （NHISS） score of 17±2 before surgery， with modified Thrombolysis in Cerebral Infarction （mTICI） grade 0 for occluded arterial blood flow. During surgery， Solitaire AB thrombectomy stent was used to remove the thrombus， or aspiration catheter directly approached the thrombus for aspiration. Difficult access during the surgery was managed by techniques such as coaxial technology， guide wire exchange， intermediate catheter， balloon or stent anchoring， and direct radial artery puncture.Results As for difficult access， 12 patients had tortuous path of the aortic arch， 15 had tortuous path of the carotid artery， 12 had tortuous path of the middle cerebral artery， 2 had occlusion of both vertebral arteries， and 1 had occlusion of both femoral arteries. Of all 42 patients， 4 had failed mechanical thrombectomy， and the remaining 38 patients had successful opening of the occluded blood vessels， with blood flow reaching 2b/3 level and an opening rate of 90%. Of all patients on day 90 after surgery， 24 had a good modified Rankin score （grade 0-2）， 14 had disability （grade 3-4）， and 4 died. The mean time of operation was 40±7.7 min.Conclusions Difficult access is an important factor for the poor prognosis of mechanical thrombectomy in acute ischemic stroke， and correct identification and management of difficult access can save time of operation and improve the clinical outcome of patients.