Department of Interventional Neuroradiology, Beijing Tiantan Hospital, The Capital Medical University, Beijing, China.
J Neurointerv Surg. 2010 Jun;2(2):99-103. doi: 10.1136/jnis.2009.001669. Epub 2010 Apr 21.
Intracranial vertebrobasilar artery (VBA) stenosis portends a stroke and death rate of 8.5-22.8% annually despite medical therapy. Stenting has emerged as a treatment option but also carries substantial risk. Awake stenting under local anesthesia to minimize major procedural complication was investigated.
Between January 2007 and December 2008, 43 of 46 consecutive patients with severe symptomatic intracranial VBA stenosis underwent elective angioplasty assisted with self-expanding Wingspan stent under local anesthesia at our institute. All data were collected prospectively.
All 43 patients tolerated the stenting procedure under local anesthesia well. Forty-two patients (97.7%) were stented successfully. Within 30 days, there were three periprocedural strokes, including thromboembolic infarct, pontine perforator infarct and intracranial hemorrhage, without fatality. In addition, five patients had intraoperative brainstem transient ischemic attacks (TIAs) seconds after the deployment of the stent delivery system across the tortuous VBA. The symptoms and signs included impaired consciousness (n=5), dysarthria (n=3), convulsion (n=2), conjugate horizontal gaze palsy (n=2), nystagmus (n=2) and pinpoint pupils (n=1). There was angiographic evidence of VBA straightening without thromboembolism. The TIAs resolved within minutes of prompt removal of the delivery catheter.
VBA stenting under local anesthesia is feasible with a 7% periprocedural stroke risk. Awake stenting allows timely detection of intraoperative TIAs. The mechanism of intraoperative TIA appears to be stent delivery system induced VBA straightening and distortion of its vascular tree. A devastating stroke may ensue if the TIA is not detected and distortion of VBA perforators is not reversed promptly.
尽管进行了药物治疗，颅内椎基底动脉（VBA）狭窄每年仍有 8.5-22.8%的卒中发生率和死亡率。支架置入术已成为一种治疗选择，但也存在较大风险。本研究旨在探讨在局部麻醉下进行清醒支架置入术以最小化主要手术并发症。
2007 年 1 月至 2008 年 12 月，我院 46 例连续的严重症状性颅内 VBA 狭窄患者，在局部麻醉下进行血管成形术，术中使用自膨式 Wingspan 支架辅助治疗。所有数据均前瞻性收集。
43 例患者均能很好地耐受局部麻醉下的支架置入术。42 例（97.7%）患者成功置入支架。在 30 天内，有 3 例围手术期卒中，包括血栓栓塞性梗死、脑桥穿支梗死和颅内出血，但无死亡。此外，5 例患者在支架输送系统穿过迂曲的 VBA 时，术中有脑干短暂性脑缺血发作（TIA）。症状和体征包括意识障碍（n=5）、构音障碍（n=3）、抽搐（n=2）、共轭水平凝视麻痹（n=2）、眼球震颤（n=2）和针尖样瞳孔（n=1）。血管造影显示 VBA 变直而无血栓栓塞。在迅速取出输送导管后，TIA 在数分钟内缓解。
局部麻醉下进行 VBA 支架置入术是可行的，围手术期卒中风险为 7%。清醒支架置入术可及时发现术中 TIA。术中 TIA 的机制似乎是支架输送系统引起的 VBA 变直和血管树扭曲。如果 TIA 未被发现且 VBA 穿支未被及时纠正，可能会导致灾难性的卒中。
