Department of Neurosurgery, Fuji Brain Institute and Hospital, 270-12 Sugita, Fujinomiya-shi, Shizuoka, 418-0021, Japan.
Acta Neurochir (Wien). 2012 Aug;154(8):1455-61; discussion 1461. doi: 10.1007/s00701-012-1398-x. Epub 2012 Jun 9.
Acute vertebrobasilar artery (VBA) occlusion is catastrophic. For embolic occlusion, thrombolysis is reasonable. However, if the occlusion is atherosclerotic, the best therapeutic approach remains unclear. The aim of this study was to characterize the clinical course, case selection, techniques and complications associated with acute to subacute surgical revascularization in atherosclerotic vertebrobasilar occlusion under appropriate patient selection based on diffusion-weighted imaging (DWI) combined with careful evaluation of progressive neurological symptoms.
We retrospectively reviewed nine consecutive patients who were scheduled to undergo acute to subacute surgical revascularization for progressing stroke in atherosclerotic VBA occlusion consisting of a relatively small DWI lesion. Clinical characteristics, radiological findings, results of revascularization, and 3-month outcomes (mRS) were assessed.
Seven patients underwent surgical revascularization (superficial temporal artery [STA]-superior cerebellar artery [SCA] bypass, n = 5; occipital artery [OA]-posterior inferior cerebellar artery [PICA] bypass, n = 1; vertebral endarterectomy, n = 1). Revascularization distal to the occlusion was successful in all seven patients. Two patients scheduled for STA-SCA bypass sustained irreversible confluent brainstem infarction before surgical intervention and died. The median time between admission and surgical treatment or irreversible coma was 20 h (range, 4-72 h). The modified Rankin Scale (mRS) at 3 months of seven patients who underwent surgical revascularization was good (mRS 0-2) in four patients, poor (mRS 3-6) in three patients. Mid- to long-term bypass patency was confirmed by magnetic resonance angiography (MRA) in the surviving five patients at a median follow-up of 7 months (range, 1-25 months).
Atherosclerotic vertebrobasilar artery (VBA) occlusion presented with stuttering onset of symptoms and patients developed worsening symptoms of vertebrobasilar insufficiency over hours to days. DWI was a useful modality to help guide the appropriate selection of patients for acute to subacute surgical revascularization for progressing stroke in atherosclerotic VBA occlusion. The surgical methods themselves were feasible. Poor outcomes were related to delay of treatment rather than surgical or technical failure.
急性椎基底动脉（VBA）闭塞是灾难性的。对于栓塞性闭塞，溶栓是合理的。然而，如果闭塞是动脉粥样硬化性的，最佳治疗方法仍不清楚。本研究的目的是描述基于弥散加权成像（DWI）结合对进行性神经症状的仔细评估，在适当的患者选择下，对急性至亚急性手术再血管化治疗动脉粥样硬化性 VBA 闭塞的临床过程、病例选择、技术和并发症进行特征描述。
我们回顾性分析了 9 例因进展性卒中而接受急性至亚急性手术再血管化治疗的连续患者，这些患者的 DWI 病变相对较小，存在动脉粥样硬化性 VBA 闭塞。评估了临床特征、影像学表现、再血管化结果和 3 个月的结果（mRS）。
7 例患者接受了手术再血管化治疗（颞浅动脉[SCA]-小脑上动脉[SCA]旁路，n=5；枕动脉[OA]-小脑后下动脉[PICA]旁路，n=1；椎动脉内膜切除术，n=1）。7 例患者的闭塞远端再血管化均成功。2 例计划进行 SCA-SCA 旁路的患者在手术干预前发生不可逆转的脑桥融合性梗死并死亡。从入院到手术治疗或不可逆昏迷的中位时间为 20 小时（范围 4-72 小时）。7 例接受手术再血管化治疗的患者的改良 Rankin 量表（mRS）在 3 个月时为 4 例良好（mRS 0-2），3 例较差（mRS 3-6）。在中位随访 7 个月（范围 1-25 个月）时，5 例存活患者的磁共振血管造影（MRA）证实了中至长期旁路通畅。
动脉粥样硬化性 VBA 闭塞表现为症状的间歇性发作，患者在数小时至数天内出现椎基底动脉功能不全的症状恶化。DWI 是一种有用的方法，可以帮助指导对急性至亚急性手术再血管化治疗进展性动脉粥样硬化性 VBA 闭塞的患者进行适当选择。手术方法本身是可行的。不良结局与治疗延迟有关，而与手术或技术失败无关。
