颅内支架置入术治疗 emboTrap 装置取栓失败后的颅内血管狭窄
Intracranial Stenting after Failure of Thrombectomy with the emboTrap Device.
机构信息
University hospitals Leuven, Leuven, Belgium.
Department of Clinical Neuroscience, Karolinska Institutet and Department of Neuroradiology, Karolinska University Hospital, Solnavägen 1, 171 77, Stockholm, Solna, Sweden.
出版信息
Clin Neuroradiol. 2019 Dec;29(4):677-683. doi: 10.1007/s00062-018-0697-x. Epub 2018 May 29.
BACKGROUND
Approved alternatives in the guidelines for acute ischemic stroke patients who have failed intracranial thrombectomy are lacking. Primary permanent intracranial stenting was initially used in the era before thrombectomy and might still be a useful rescue treatment in acute stroke patients suffering from ongoing large vessel occlusion refractory to thrombectomy.
METHODS
The prospectively collected registry of patients with acute stroke caused by large vessel occlusions and treated with the emboTrap® device in Karolinska Hospital from October 2013 through March 2017 were retrospectively reviewed. Clinical outcome of non-recanalized patients with a thrombolysis in cerebral infarction (TICI) score of 0-1 after failed thrombectomy were compared with those who were treated with permanent intracranial stenting as rescue therapy. Favorable outcome was defined as modified Rankin scale 0-2.
RESULTS
The emboTrap® device was used in 201 patients. Persistent re-occlusions on withdrawal of the thrombectomy device were seen in 26 patients (13%) and of those, 12 individuals (46%) were treated with intracranial stenting. Baseline National Institutes of Health stroke scale (NIHSS), occlusion site, and onset-to-puncture time did not differ between the stenting group and the non-recanalized group. During the procedure half dose (5/12 patients) or full dose abciximab (6/12 patients), or aspirin (1/12 patient) was given intravenously immediately after stent placement. In 2 patients (17%) multiple stents were implanted. The stenting group had better functional outcomes at 3 months compared to the non-stenting group with 8/12 (66%) vs. 3/14 (21.4%, p < 0.05). Of the patients 5 (36%) in the non-stented group had died at 3 months follow-up, whereas mortality in the stenting cohort was 0% (p < 0.05) and no symptomatic intracranial hemorrhage (ICH) occurred in either group.
CONCLUSION
Intracranial stenting after failure of recanalization with thrombectomy led to a better rate of clinical outcome than leaving the patient non-recanalized. The required antiplatelet therapy, predominantly abciximab, did not lead to additional ICH.
背景
在颅内血栓切除术失败的急性缺血性脑卒中患者的指南中，缺乏可替代的治疗方法。原发性永久性颅内支架置入术最初用于血栓切除术之前的时代，对于正在接受经皮血管内治疗的大血管闭塞且对血栓切除术有抵抗的急性脑卒中患者，可能仍然是一种有用的挽救性治疗方法。
方法
回顾性分析了 2013 年 10 月至 2017 年 3 月期间在卡罗林斯卡医院使用 emboTrap®装置治疗的由大血管闭塞引起的急性脑卒中患者的前瞻性登记资料。比较了血栓切除术失败后血栓再通率（TICI）评分 0-1 的非再通患者与接受永久性颅内支架作为挽救性治疗的患者的临床结局。良好的临床结局定义为改良 Rankin 量表评分 0-2。
结果
该装置共应用于 201 例患者。26 例（13%）患者在撤出血栓切除术装置时出现持续性再闭塞，其中 12 例（46%）患者接受了颅内支架置入术。支架置入组和非再通组的基线国立卫生研究院卒中量表（NIHSS）评分、闭塞部位和发病至穿刺时间无差异。术中半剂量（5/12 例）或全剂量阿昔单抗（6/12 例）或阿司匹林（1/12 例）在支架置入后立即静脉内给予。2 例（17%）患者植入了多个支架。与非支架组相比，支架组在 3 个月时的功能结局更好，8/12 例（66%）与 3/14 例（21.4%）相比，差异有统计学意义（p < 0.05）。在非支架组中，5 例（36%）患者在 3 个月随访时死亡，而支架组的死亡率为 0%（p < 0.05），两组均未发生症状性颅内出血（ICH）。
结论
与不进行再通相比，经血栓切除术再通失败后行颅内支架置入可获得更好的临床结局。主要为阿昔单抗的抗血小板治疗并未导致额外的 ICH。
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