Hui Ferdinand K, Narayanan Sandra, Cawley C Michael
Department of Radiology, Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
World Neurosurg. 2010 Jan;73(1):17-21. doi: 10.1016/j.surneu.2009.05.020. Epub 2009 Jul 29.
Mechanical thrombectomy devices rely on the ability of an operator to directly access a thrombus with the device. The authors demonstrate the first reported posterior-to-anterior circulation approach using the Penumbra Stroke System (Penumbra, Inc, Alameda, CA) for thrombectomy in acute stroke.
A 53-year-old man presented 5 hours and 15 minutes after onset of left homonymous hemianopia, left facial droop, left upper extremity plegia, and left lower extremity paresis (NIHSS = 15). Computed tomography of the head revealed hyperdense material in the right M1 to M2 segments without loss of gray-white differentiation in the right cerebral hemisphere. Cerebral angiography at 6 hours and 50 minutes revealed occlusion of the right ICA at its origin. Injection of the left vertebral artery demonstrated clot in the right M1 segment with no anterograde flow. An Excelsior 1018 (Boston Scientific, Natick, MA) microcatheter was used to access the right PCOM and subsequently the right ICA and right MCA. A joint decision was made with the stroke neurology service to bury the microcatheter within the right MCA clot and administer 13 mg of tPA. A triaxial system using the Penumbra 041 catheter, Excelsior SL-10 microcatheter, and Synchro2 (Boston Scientific) guidewire was used to traverse the left vertebral and basilar arteries, the right PCOM, and the right ICA to the thrombosed right M1 segment. Aspiration using the Penumbra 41 catheter and 41 Separator was performed, resulting in a TIMI-2 result with minimal residual superior right M2 thrombus.
In patients with proximal vascular occlusion, mechanical thrombectomy with relatively stiff thrombectomy systems can be achieved through collateral pathways in the circle of Willis. Although the diameter mismatch between the Penumbra 41 catheter and a microguidewire may make sharp turns challenging, the use of an SL-10 microcatheter as a functional obturator may afford access.
机械取栓装置依赖于操作者使用该装置直接接触血栓的能力。作者展示了首例使用Penumbra卒中系统（Penumbra公司，阿拉米达，加利福尼亚州）从后循环到前循环的取栓方法用于急性卒中的治疗。
一名53岁男性在出现左侧同向性偏盲、左侧面部下垂、左侧上肢瘫痪和左侧下肢轻瘫（美国国立卫生研究院卒中量表[NIHSS]=15）5小时15分钟后就诊。头部计算机断层扫描显示右侧M1至M2段有高密度物质，右侧大脑半球灰白质分界未消失。6小时50分钟时的脑血管造影显示右侧颈内动脉起始处闭塞。左侧椎动脉造影显示右侧M1段有血栓，无顺行血流。使用一根Excelsior 1018（波士顿科学公司，纳蒂克，马萨诸塞州）微导管进入右侧后交通动脉，随后进入右侧颈内动脉和右侧大脑中动脉。与卒中神经科团队共同决定将微导管埋入右侧大脑中动脉血栓内并给予13毫克组织型纤溶酶原激活剂（tPA）。使用Penumbra 041导管、Excelsior SL-10微导管和Synchro2（波士顿科学公司）导丝组成的三轴系统穿过左侧椎动脉和基底动脉、右侧后交通动脉以及右侧颈内动脉到达血栓形成的右侧M1段。使用Penumbra 41导管和41分离器进行抽吸，结果达到心肌梗死溶栓（TIMI）2级，右侧M2段上方残留极少血栓。
在近端血管闭塞的患者中，使用相对较硬的取栓系统通过 Willis 环的侧支通路可实现机械取栓术。尽管Penumbra 41导管与微导丝之间的直径不匹配可能使急转弯具有挑战性，但使用SL-10微导管作为功能性闭塞器可能有助于进入。
