Natarajan Sabareesh K, Snyder Kenneth V, Siddiqui Adnan H, Ionita Catalina C, Hopkins L Nelson, Levy Elad I
Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University New York, Buffalo, NY 14209, USA.
Stroke. 2009 Oct;40(10):3269-74. doi: 10.1161/STROKEAHA.109.555102. Epub 2009 Jul 23.
This is a retrospective review of patients who underwent endovascular recanalization > or = 8 hours after acute ischemic stroke symptom onset, including wake-up strokes, between June 2005 and June 2008.
Thirty patients with a premorbid modified Rankin score < or = 1 and NIHSS between 5 and 22 were included. All had admission CT, CTA, and CT perfusion scans to evaluate for salvageable brain tissue. Recanalization effectiveness was assessed by angiograms obtained within 30 hours after intervention. Patient, treatment characteristics, and immediate and 3-month outcomes were analyzed.
Mean NIHSS at presentation was 13 (median=12). Mean interval between time last-seen well and angiogram was 12.75 hours (median=10). Twenty-six patients (86.7%) presented with complete-to-near-complete vessel occlusion (thrombolysis in myocardial infarction [TIMI] 0/1); 4 had partial vessel occlusion (TIMI 2). Interventions included intra-arterial pharmacological thrombolysis (n=10), mechanical thrombectomy(n=21; Merci, 16; intracranial stent, 9; extracranial stent, 3), angioplasty (n=14; intracranial, 11; extracranial, 3). Nine patients received GPIIb/IIIa inhibitors (eptifibatide); all received heparin. Partial-to-complete recanalization (TIMI 2/3) was achieved in 20 patients (66.7%). Procedure-related complications included vascular perforations (n=3) and femoral access site complication (n=1). One patient had an embolic anterior cerebral artery infarct during intervention; another had progression of brain stem infarct. Symptomatic intracerebral hemorrhage occurred in 3 patients (10%), with 2 being primarily subarachnoid in location. Total in-hospital mortality including procedural mortality, disease progression, or other comorbidities was 23.3% (n=7). Mean discharge NIHSS was 9.5, representing an overall NIHSS 3.5-point improvement. Overall, mean modified Rankin score at death or last follow-up (mean=10.6 months) was 4.2. At 3 months, total mortality was 33.3% (n=10), 20% had modified Rankin score < or = 2, and 33% had modified Rankin score < or = 3. Among survivors, mean modified Rankin score at 3-month follow-up was 3.
Our data show that delayed endovascular revascularization of carefully selected patients is safe, effective, and improves clinical outcome.
这是一项对2005年6月至2008年6月期间急性缺血性卒中症状发作后8小时及以上接受血管内再通治疗的患者进行的回顾性研究，包括醒后卒中患者。
纳入30例病前改良Rankin量表评分≤1且美国国立卫生研究院卒中量表（NIHSS）评分在5至22分之间的患者。所有患者均进行了入院时的CT、CT血管造影（CTA）和CT灌注扫描，以评估可挽救的脑组织。通过干预后30小时内获得的血管造影评估再通效果。分析患者、治疗特征以及即刻和3个月的结局。
就诊时NIHSS评分的平均值为13分（中位数=12分）。最后一次情况良好至血管造影的平均间隔时间为12.75小时（中位数=10小时）。26例患者（86.7%）表现为完全至近乎完全的血管闭塞（心肌梗死溶栓分级[TIMI]0/1）；4例为部分血管闭塞（TIMI 2）。干预措施包括动脉内药物溶栓（n=10）、机械取栓（n=21；Merci取栓器，16例；颅内支架，9例；颅外支架，3例）、血管成形术（n=14；颅内，11例；颅外，3例）。9例患者接受了糖蛋白IIb/IIIa抑制剂（依替巴肽）治疗；所有患者均接受了肝素治疗。20例患者（66.7%）实现了部分至完全再通（TIMI 2/3）。与手术相关的并发症包括血管穿孔（n=3）和股动脉穿刺部位并发症（n=1）。1例患者在干预过程中发生栓塞性大脑前动脉梗死；另1例患者脑干梗死进展。3例患者（10%）发生有症状性脑出血，其中2例主要位于蛛网膜下腔。包括手术死亡率、疾病进展或其他合并症在内的院内总死亡率为23.3%（n=7）。出院时NIHSS评分的平均值为9.5分，总体NIHSS评分改善了3.5分。总体而言，死亡或最后一次随访时（平均=10.6个月）改良Rankin量表评分的平均值为4.2分。3个月时，总死亡率为33.3%（n=10），20%的患者改良Rankin量表评分≤2分，33%的患者改良Rankin量表评分≤3分。在幸存者中，3个月随访时改良Rankin量表评分的平均值为3分。
我们的数据表明，对精心挑选的患者进行延迟血管内血运重建是安全、有效的，并且可改善临床结局。
