Department of Surgery, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
J Am Coll Surg. 2011 Apr;212(4):549-57; discussion 557-9. doi: 10.1016/j.jamcollsurg.2010.12.035.
Blunt cerebrovascular injuries (BCVI) once went unrecognized until cerebral ischemia or death occurred. We previously demonstrated that screening of high-risk asymptomatic patients and early treatment improved outcomes. However, major dissections, pseudoaneurysms, and fistulas rarely heal with antithrombotic therapy alone. Endovascular therapy in these lesions has increased without reports of outcomes. We sought to determine ischemic stroke and death rates after BCVI with and without endovascular treatment.
Patients with BCVI during a 53-month period ending May 2009 were identified. Antithrombotic therapy with heparin (goal partial thromboplastin time 40-60 s) or antiplatelets (aspirin and/or clopidogrel) was instituted after diagnosis of BCVI. Endovascular treatment was performed in patients with pseudoaneurysms, major dissections, and fistulas, whereas minor dissections and occluded vessels were treated with medical therapy alone. Outcomes evaluated were ischemic stroke and mortality, both in hospital and long term.
A total of 222 patients had 263 BCVI (115 carotid, 148 vertebral injuries); 22 patients had ischemic strokes before their angiographic diagnosis (17 present on arrival, 5 before angiography); 41% of patients underwent endovascular treatment for their BCVI, 50% were placed on heparin drips, and 76% and 52% were given aspirin and clopidogrel, respectively. Seven patients developed infarcts after BCVI diagnosis for a postdiagnosis rate of 4%. Follow-up was achieved in 85% of patients at a mean of 22 months. In-hospital mortality was 11%, and overall mortality rate was 16% at last follow-up.
Endovascular therapy of appropriate lesions in conjunction with medical therapy leads to the lowest ischemic stroke rates reported. Despite being used for more severe lesions with higher potential for ischemia, endovascular therapy had outcomes similar to medical therapy. Aggressive screening and treatment of BCVI leads to the lowest reported mortality and stroke rates.
直到出现脑缺血或死亡之前，钝性脑血管损伤（BCVI）一直未被识别。我们之前的研究表明，对高危无症状患者进行筛查并早期治疗可改善预后。然而，单纯抗血栓治疗很少能治愈大夹层、假性动脉瘤和动静脉瘘。这些病变的血管内治疗有所增加，但尚无相关疗效报告。我们旨在确定有或无血管内治疗的 BCVI 后缺血性卒中及死亡率。
在 2009 年 5 月结束的 53 个月期间，确定了患有 BCVI 的患者。在诊断出 BCVI 后，给予肝素（目标部分凝血活酶时间 40-60 秒）或抗血小板（阿司匹林和/或氯吡格雷）进行抗血栓治疗。对假性动脉瘤、大夹层和动静脉瘘患者进行血管内治疗，而对小夹层和闭塞血管仅采用药物治疗。评估的结局包括住院期间和长期的缺血性卒中和死亡率。
共有 222 名患者发生了 263 例 BCVI（115 例颈动脉，148 例椎动脉损伤）；22 名患者在血管造影诊断前发生缺血性卒中（17 例为入院时出现，5 例在血管造影前出现）；41%的患者接受了血管内治疗，50%的患者接受了肝素滴注，分别有 76%和 52%的患者接受了阿司匹林和氯吡格雷治疗。在诊断出 BCVI 后，有 7 名患者发生了梗死，因此诊断后的发生率为 4%。85%的患者在平均 22 个月时获得了随访。住院死亡率为 11%，最后一次随访时总死亡率为 16%。
对适当病变进行血管内治疗并联合药物治疗可使报道的缺血性卒中和发生率降至最低。尽管血管内治疗用于潜在缺血风险更高的更严重病变，但疗效与药物治疗相似。积极筛查和治疗 BCVI 可使报道的死亡率和卒中率降至最低。
Zotero 插件