Department of Neuroradiology, Frenchay Hospital, North Bristol NHS Trust, Bristol, UK.
J Neurointerv Surg. 2012 Jul;4(4):266-73. doi: 10.1136/neurintsurg-2011-010090. Epub 2011 Jul 23.
Basilar artery occlusion is an infrequent form of acute stroke; clinical outcomes are heterogeneous, but the condition can be fatal. There is a lack of randomized controlled trial data in this field. Case series suggest that patients who are recanalized have much better outcomes than those who are not, and it is generally accepted that intra-arterial techniques achieve high rates of recanalization. Controversially, several studies, including a meta-analysis and registry-based investigation, that have compared intravenous thrombolysis (IVT) and intra-arterial treatment suggest similar outcomes. However, there are many potential sources of bias in each of these studies, precluding a firm conclusion. Indeed, there are many confounding factors that can influence the outcome including severity of presentation, site of occlusion, clot load, degree of collateral flow, timing of therapy, agent used for recanalization and dose of thrombolytic agent. Additionally, pretreatment infarct core imaging using diffusion-weighted imaging and the posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) scoring systems have been shown to predict outcome and therefore may be useful in selecting patients for aggressive therapy. Protocols combining intravenous agents such as glycoprotein IIb/IIIa receptor antagonists or thombolytics agents with intra-arterial techniques ('bridging' therapy) have shown encouraging improvements in neurological outcome and survival. Furthermore, initial case series describing the use of mechanical clot extraction devices or aspiration catheters suggest high rates of recanalization. What would be useful is a randomized trial comparing IVT, endovascular approaches and a combined IVT/endovascular approach. However, the small numbers of patients and multiple confounding factors are barriers to the development of such a trial.
基底动脉闭塞是一种罕见的急性脑卒中形式；临床结局各异，但该病症可能致命。该领域缺乏随机对照试验数据。病例系列研究表明，再通的患者比未再通的患者预后要好得多，而且一般认为动脉内技术可实现较高的再通率。有争议的是，包括一项荟萃分析和基于注册的研究在内的几项研究表明，静脉内溶栓（IVT）和动脉内治疗的结果相似。然而，这些研究中的每一项都存在许多潜在的偏倚来源，无法得出明确的结论。事实上，有许多混杂因素会影响结果，包括发病时的严重程度、闭塞部位、血栓负荷、侧支循环程度、治疗时机、再通药物以及溶栓药物剂量。此外，使用弥散加权成像和后循环急性脑卒中预后早期 CT 评分（pc-ASPECTS）评分系统对梗塞核心进行预处理成像，已被证明可预测结局，因此可能有助于选择接受积极治疗的患者。联合应用静脉内药物（如糖蛋白 IIb/IIIa 受体拮抗剂或溶栓药物）与动脉内技术（“桥接”治疗）的方案已显示出在神经功能结局和生存率方面的可喜改善。此外，最初描述使用机械性血栓清除装置或抽吸导管的病例系列研究表明再通率较高。有用的是一项比较 IVT、血管内方法和 IVT/血管内联合方法的随机试验。然而，患者数量少和多种混杂因素是开展此类试验的障碍。
