Fahed Robert, Redjem Hocine, Blanc Raphaël, Labreuche Julien, Robert Thomas, Ciccio Gabriele, Smadja Didier, Smajda Stanislas, Piotin Michel
Department of Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France.
Cerebrovasc Dis. 2016;41(5-6):298-305. doi: 10.1159/000444068. Epub 2016 Feb 12.
Ischemic strokes with tandem occlusions are associated with a poor prognosis. Recent studies demonstrating the effectiveness of endovascular treatment for large vessel occlusions have shown less impressive results in patients with tandem occlusions than in those with isolated intracranial occlusions. Also, the indications and effects of carotid stenting remain unclear.
From a prospectively gathered registry, we analyzed data of 70 consecutive patients who underwent mechanical endovascular treatment for acute stroke with tandem occlusions from November 2011 to August 2014. Clinical (including demographics, National Institutes of Health Stroke Scale (NIHSS), and stroke etiology), imaging (including diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Score), and endovascular treatment data were assessed and reviewed in consensus by 2 observers. Good clinical outcome was defined as a modified Rankin Scale of ≤2 at 3-month follow-up.
At 3-month follow-up, 50.8% had a poor clinical outcome, including death in 13.4%. Lower NIHSS (initial, at day 1, and at discharge) and successful recanalization (thrombolysis in cerebral infarction 2b-3) were associated with a good clinical outcome (p < 0.05). There were no statistically significant differences between patients with a good or poor clinical outcome in terms of intravenous (IV) tissue plasminogen activator use, delay between symptom onset and recanalization, and endovascular technique including the carotid stenting.
Despite the recent randomized control trials demonstrating the effectiveness of thrombectomy, there is still a research gap about tandem occlusions. This subtype of stroke, which usually responds poorly to IV thrombolysis, is also difficult to treat by endovascular means. Guidelines for the endovascular management of tandem occlusions are needed.
伴有串联闭塞的缺血性卒中预后较差。近期研究表明血管内治疗对大血管闭塞有效，但在伴有串联闭塞的患者中，其效果不如单纯颅内闭塞患者显著。此外，颈动脉支架置入术的适应证和效果仍不明确。
从一个前瞻性收集的登记处，我们分析了2011年11月至2014年8月期间连续70例接受机械血管内治疗急性串联闭塞性卒中患者的数据。2名观察者对临床（包括人口统计学、美国国立卫生研究院卒中量表（NIHSS）和卒中病因）、影像学（包括弥散加权成像-阿尔伯塔卒中项目早期计算机断层扫描评分）和血管内治疗数据进行了评估并达成共识。良好的临床结局定义为3个月随访时改良Rankin量表评分≤2。
在3个月随访时，50.8%的患者临床结局较差，其中13.4%死亡。较低的NIHSS评分（初始、第1天和出院时）和成功再通（脑梗死溶栓2b-3级）与良好的临床结局相关（p<0.05）。在静脉使用组织纤溶酶原激活剂、症状发作至再通的延迟以及包括颈动脉支架置入术在内的血管内技术方面，临床结局良好或较差的患者之间无统计学显著差异。
尽管近期的随机对照试验证明了血栓切除术的有效性，但关于串联闭塞仍存在研究空白。这种卒中亚型通常对静脉溶栓反应不佳，通过血管内手段治疗也很困难。需要制定串联闭塞血管内治疗的指南。
