Qureshi Adnan I, Siddiqui Amir M, Kim Stanley H, Hanel Ricardo A, Xavier Andrew R, Kirmani Jawad F, Suri M Fareed K, Boulos Alan S, Hopkins L Nelson
Department of Neurosurgery and Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.
AJNR Am J Neuroradiol. 2004 Feb;25(2):322-8.
Early reocclusion of recanalized arteries has been observed after thrombolysis for acute coronary occlusion and has been attributed to platelet activation after exposure to thrombolytic agents. We conducted a retrospective study to determine the rate of reocclusion during intra-arterial thrombolysis for acute ischemic stroke and the effect of reocclusion on functional outcome.
Patients treated for acute ischemic stroke at our center between September 2000 and May 2002 received a maximum total dose of 4 U of reteplase intra-arterially in 1-U increments via superselective catheterization. Pharmacologic thrombolysis was supplemented by mechanical thrombolysis with balloon angioplasty or snare manipulation at the occlusion site. Angiography was performed after each unit of reteplase or mechanical maneuver, and the images were interpreted by a blinded reviewer. Reocclusion was defined as partial or complete initial recanalization with occlusion recurring at the same site as documented by angiography during the endovascular treatment. Reocclusions were treated by further pharmacologic and/or mechanical thrombolysis according to the discretion of the treating physician. Clinical evaluations were performed before and 24 hr, 7 to 10 days, and 1 to 3 months after treatment.
Forty-six consecutive patients underwent intra-arterial thrombolysis. Reocclusion was observed in eight (17%). Among these patients, initial sites of occlusion were in the following arteries: intracranial internal carotid artery (n = 2), M1 segment of the middle cerebral artery (n = 3), M1 and M2 segments of the middle cerebral artery (n = 2), and basilar artery (n = 1). The mean initial National Institutes of Health Scale score for these eight patients was 23.3 +/- 6.2; mean time from symptom onset to treatment was 4.4 +/- 1.2 hr. The reocclusions were treated by using additional doses of reteplase alone (n = 1), reteplase with snare maneuver and/or angioplasty (n = 5), reteplase with angioplasty or snare and then stent placement (n = 1), and angioplasty with stent placement (n = 1). The reocclusions resolved in six of eight patients after further treatment. Six patients died and two survived but were severely disabled at 1 month (modified Rankin Scale scores of 4 and 5, respectively). Independent functional outcome scores (modified Rankin Scale scores of 0-2) were significantly lower among patients with angiographically shown reocclusion than in those without (0 of 8 versus 17 of 38, P =.02).
Reocclusion occurs relatively frequently during intra-arterial thrombolysis for ischemic stroke and seems to be associated with poor clinical outcomes.
急性冠状动脉闭塞溶栓治疗后，已观察到再通动脉的早期再闭塞，这被归因于接触溶栓剂后血小板的激活。我们进行了一项回顾性研究，以确定急性缺血性卒中动脉内溶栓期间的再闭塞率以及再闭塞对功能结局的影响。
2000年9月至2002年5月在我们中心接受急性缺血性卒中治疗的患者，通过超选择性导管插入术以1单位递增的方式动脉内给予最大总量4单位的瑞替普酶。在闭塞部位进行球囊血管成形术或圈套器操作等机械溶栓辅助药物溶栓。每给予1单位瑞替普酶或进行一次机械操作后均行血管造影，图像由一位不知情的阅片者解读。再闭塞定义为血管内治疗期间血管造影显示在同一部位出现的部分或完全初始再通后再次闭塞。根据治疗医师的判断，对再闭塞采用进一步的药物和/或机械溶栓治疗。在治疗前、治疗后24小时、7至10天以及1至3个月进行临床评估。
46例连续患者接受了动脉内溶栓治疗。8例（17%）观察到再闭塞。在这些患者中，初始闭塞部位位于以下动脉：颅内颈内动脉（n = 2）、大脑中动脉M1段（n = 3）、大脑中动脉M1和M2段（n = 2）以及基底动脉（n = 1）。这8例患者的初始美国国立卫生研究院卒中量表平均评分为23.3±6.2；从症状发作到治疗的平均时间为4.4±1.2小时。再闭塞的治疗采用单独额外给予瑞替普酶（n = 1）、瑞替普酶联合圈套器操作和/或血管成形术（n = 5）、瑞替普酶联合血管成形术或圈套器然后置入支架（n = 1）以及血管成形术联合置入支架（n = 1）。8例患者中有6例在进一步治疗后再闭塞得到缓解。6例患者死亡，2例存活但在1个月时严重残疾（改良Rankin量表评分分别为4分和5分）。血管造影显示有再闭塞的患者中独立功能结局评分（改良Rankin量表评分0 - 2分）显著低于无再闭塞的患者（8例中的0例与38例中的17例，P = 0.02）。
缺血性卒中动脉内溶栓期间再闭塞相对频繁发生，且似乎与不良临床结局相关。
