Weis-Müller Barbara Theresia, Spivak-Dats Asya, Turowski Bernd, Siebler Mario, Balzer Kai Michael, Grabitz Klaus, Godehardt Erhard, Sandmann Wilhelm
Department for Vascular Surgery and Kidney Transplantation, University Hospital of Düsseldorf, Heinrich-Heine-University of Düsseldorf, Düsseldorf, Germany.
Ann Vasc Surg. 2013 May;27(4):424-32. doi: 10.1016/j.avsg.2012.05.023. Epub 2013 Feb 10.
Clinical outcome and surgical success rate of open surgical reconstruction for acute symptomatic internal carotid artery (ICA) occlusion up to 1 week after stroke onset were analyzed to determine a cutoff time, after which risk exceeds clinical benefit.
From November 1997 to March 2007, a total of 5369 patients were examined at the authors' stroke unit; 502 from this cohort underwent ICA reconstruction. A subgroup of 49 patients underwent surgical revascularization of acute ICA occlusion within 168 hr at a mean of 42.5±38.7 hr after stroke onset. Preoperative diagnostic measures consisted of extracranial/intracranial duplex sonography (n=49), cerebral computed tomography (n=31), magnetic resonance imaging and angiography (n=37), and digital subtraction angiography (n=24). All 49 patients experienced a complete ICA occlusion and an ipsilateral recent ischemic infarction. Modified Rankin scale score (mRS) before surgery was 0 to 3 in 20 patients (41%) and 4 to 5 in 29 patients (49%).
ICA patency could be restored in 38 patients (78%). The following clinical outcomes were noted: clinical improvement in mRS by at least 1 point in 23 of 49 of patients (47%), no change in 14 of 49 (28%), deterioration in mRS by at least 1 point in 6 of 49 (12%), and death within 30 days in 6 of 49 (12%). A total of 21 patients (43%) experienced perioperative cerebral events (new infarction, new intracranial hemorrhage or enlargement, or hemorrhagic transformation of the preexisting infarction). Univariate analysis showed that clinical improvement correlated significantly with success of recanalization and with early recanalization within 72 hr. Age, gender, and preoperative Rankin stage did not have influence. Clinical deterioration or death was only associated with perioperative cerebral events and seemed to be time-independent. Multivariate analysis did not have enough statistical power to analyze the impact of different risk factors on outcome after urgent revascularization.
In patients who undergo surgery after 72 hr from symptom onset, the risk seems to outweigh the benefit.
分析急性症状性颈内动脉（ICA）闭塞在卒中发作后1周内行开放手术重建的临床结局和手术成功率，以确定一个风险超过临床获益的截止时间。
1997年11月至2007年3月，作者所在的卒中单元共检查了5369例患者；该队列中有502例接受了ICA重建。其中49例患者在卒中发作后平均42.5±38.7小时内的168小时内行急性ICA闭塞的手术血运重建。术前诊断措施包括颅外/颅内双功超声检查（n = 49）、脑计算机断层扫描（n = 31）、磁共振成像和血管造影（n = 37）以及数字减影血管造影（n = 24）。所有49例患者均出现完全性ICA闭塞和同侧近期缺血性梗死。术前改良Rankin量表评分（mRS）为0至3分的患者有20例（41%），4至5分的患者有29例（49%）。
38例患者（78%）的ICA通畅得以恢复。观察到以下临床结局：49例患者中有23例（47%）的mRS临床改善至少1分，49例中有14例（28%）无变化，49例中有6例（12%）的mRS恶化至少1分，49例中有6例（12%）在30天内死亡。共有21例患者（43%）发生围手术期脑部事件（新发梗死、新发颅内出血或扩大，或既往梗死的出血性转化）。单因素分析显示，临床改善与再通成功以及72小时内的早期再通显著相关。年龄、性别和术前Rankin分期无影响。临床恶化或死亡仅与围手术期脑部事件相关，且似乎与时间无关。多因素分析没有足够的统计效力来分析不同危险因素对紧急血运重建后结局的影响。
在症状发作后72小时后接受手术的患者中，风险似乎超过获益。
