支架辅助弹簧圈栓塞治疗颅内动脉瘤后迟发性缺血性卒中：预防性双联抗血小板治疗的特征和最佳持续时间。
Delayed ischemic stroke after stent-assisted coil placement in cerebral aneurysm: characteristics and optimal duration of preventative dual antiplatelet therapy.
机构信息
From the Department of Neurosurgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bungdang-gu, Seongnam, Gyeonggi 463-707, Korea (G.H., N.M.P., S.J.P., E.A.J., O.K.K.); Department of Neurosurgery, New Korea Hospital, Gimpo, Korea (J.G.K., K.S.S.); Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea (Y.J.L.); Department of Neuroscience, Section of Neurosurgery, Makati Medical Center, Makati, Philippines (J.B.V.); and Department of Neurosurgery, Airlangga University, Dr Sutomo General Hospital, Surabaya, Indonesia (N.S.S.).
出版信息
Radiology. 2014 Oct;273(1):194-201. doi: 10.1148/radiol.14140070. Epub 2014 Jun 11.
PURPOSE
To evaluate characteristics of delayed ischemic stroke after stent-assisted coil placement in cerebral aneurysms and to determine the optimal duration of dual antiplatelet therapy for its prevention.
MATERIALS AND METHODS
This retrospective study was approved by the institutional review board, and the requirement to obtain written informed consent was waived. Of 1579 patients with 1661 aneurysms, 395 patients (25.0%) with 403 aneurysms (24.3%) treated with stent-assisted coil placement were included and assigned to groups stratified as early (126 patients [31.9%]; 3 months of coil placement), midterm (160 patients [40.5%]; 6 months), or late (109 patients [27.6%]; ≥ 9 months), according to the time points of switching dual antiplatelet therapy to monotherapy from coil placement. Cumulative rates of delayed ischemic stroke in each group were calculated by using Kaplan-Meier estimates that were compared with log-rank tests. Risk factors of delayed ischemic stroke were identified by using Cox proportional hazard analysis.
RESULTS
Delayed ischemic stroke occurred in 3.5% of all cases (embolism, 3.0%; thrombotic occlusion, 0.5%) within 2 months following the switch. Late switch yielded no delayed ischemic stroke, unlike early (seven of 126 patients [5.6%]; P = .013) or midterm (seven of 160 patients [4.4%]; P = .028) switch. Incomplete occlusion (hazard ratio, 6.68 [95% confidence interval: 1.490, 29.900]) was identified as a risk factor.
CONCLUSION
Delayed ischemic stroke after stent-assisted coil placement is caused by embolism from or thrombotic occlusion of stent-containing vessels after switching from dual antiplatelet therapy to monotherapy. The stent-containing vessel with incomplete aneurysm occlusion presents as a long-term thromboembolic source. Therefore, dual antiplatelet therapy for more than 9 months and late switch to monotherapy are recommended for its prevention.
目的
评估支架辅助线圈置入治疗颅内动脉瘤后迟发性缺血性卒中的特点，并确定预防迟发性缺血性卒中的最佳双联抗血小板治疗持续时间。
材料与方法
本回顾性研究经机构审查委员会批准，并豁免了获得书面知情同意的要求。在 1579 例 1661 个动脉瘤患者中，纳入了 395 例（25.0%）403 个动脉瘤（24.3%）接受支架辅助线圈置入治疗的患者，并根据从线圈置入到双联抗血小板治疗转换为单药治疗的时间点分为早期（126 例[31.9%]；3 个月）、中期（160 例[40.5%]；6 个月）和晚期（109 例[27.6%]；≥9 个月）组。通过 Kaplan-Meier 估计计算每组的迟发性缺血性卒中累积发生率，并通过对数秩检验进行比较。采用 Cox 比例风险分析确定迟发性缺血性卒中的危险因素。
结果
在支架辅助线圈置入后 2 个月内，所有病例中有 3.5%（栓塞 3.0%；血栓闭塞 0.5%）发生迟发性缺血性卒中。与早期（126 例中的 7 例[5.6%]；P=.013）或中期（160 例中的 7 例[4.4%]；P=.028）转换相比，晚期转换无迟发性缺血性卒中。不完全闭塞（危险比，6.68[95%置信区间：1.490，29.900]）被确定为危险因素。
结论
支架辅助线圈置入后迟发性缺血性卒中是由于从双联抗血小板治疗转换为单药治疗后支架内血管的栓塞或血栓闭塞引起的。支架内含有不完全闭塞的动脉瘤的血管呈现为长期的血栓栓塞源。因此，建议双联抗血小板治疗超过 9 个月，并在晚期转为单药治疗，以预防迟发性缺血性卒中。
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