Blassiau Alexandre, Gawlitza Matthias, Manceau Pierre-François, Bakchine Serge, Serre Isabelle, Soize Sébastien, Pierot Laurent
Department of Neuroradiology, Hôpital Maison-Blanche, Reims, France.
Department of Neurology, Hôpital Maison-Blanche, Reims, France.
Front Neurol. 2018 Nov 5;9:928. doi: 10.3389/fneur.2018.00928. eCollection 2018.
Mechanical thrombectomy (MT) is of clinical benefit for patients with extracranial-intracranial tandem lesions of anterior circulation. However, the optimal approach to the cervical lesion of the internal carotid artery (ICA) during MT has yet to be established. Data on a conservative approach for the proximal lesion during the acute phase are scarce. A retrospective study on an institutional, prospective database was conducted. We included patients with anterior circulation stroke presenting with a tandem lesion that was approached conservatively during MT. Thirty-five 35 patients were included, of whom 25 (71.4%) had an atheromatous ICA lesion and 10 (28.6%) a dissection. Despite implementing a conservative strategy, acute percutaneous transluminal angioplasty (PTA) and/or stenting was necessary in 8 (22.9%) and 3 patients (8.6%), respectively. Of 27 surviving patients, 7 (25.9%) underwent delayed treatment of the ICA lesion. No new embolic events occurred between MT and delayed treatment. A favorable clinical outcome (mRS ≤ 2) was achieved in 15/35 patients (45.7%) and was associated with higher baseline ASPECTS (OR 1.62, 95% CI 1.08-2.45, = 0.002) and successful recanalization (OR 9.39, 95% CI 1.92-45.80, = 0.0005). Successful recanalization (TICI ≥ 2B) itself was observed in 54.3% of patients and was more likely with acute treatment of the proximal ICA lesion (OR 6.3, 95% CI 11-35.67, = 0.03) and, more importantly, by the use of distal access catheters (OR 16.25, 95% CI 3.06-86.41, = 0.0001). A conservative approach for ICA lesions during MT is feasible and offers favorable outcomes and successful recanalization for a significant proportion of patients. However, acute treatment of the cervical lesion is often necessary (31.4%) to make the distal occlusion accessible. Clinical outcome is influenced by the size of the baseline ischemic core and by successful recanalization; the latter is strongly favored by the use of distal access catheters to pass the proximal lesion. The fact that acute treatment of the ICA lesion favored intracranial recanalization but had no effect on clinical outcome is probably due to sample size, emphasizing the need for large scale, randomized studies to determine the optimal treatment strategy for this pathology.
机械取栓术（MT）对前循环颅外 - 颅内串联病变患者具有临床益处。然而，MT期间处理颈内动脉（ICA）颈部病变的最佳方法尚未确立。关于急性期近端病变采用保守方法的数据很少。我们对一个机构前瞻性数据库进行了一项回顾性研究。我们纳入了在MT期间采用保守方法处理串联病变的前循环卒中患者。共纳入35例患者，其中25例（71.4%）有动脉粥样硬化性ICA病变，10例（28.6%）有夹层病变。尽管实施了保守策略，但分别有8例（22.9%）和3例（8.6%）患者仍需要进行急性经皮腔内血管成形术（PTA）和/或支架置入术。在27例存活患者中，7例（25.9%）接受了ICA病变的延迟治疗。MT与延迟治疗之间未发生新的栓塞事件。1 / 35例患者（45.7%）获得了良好的临床结局（改良Rankin量表评分≤2），这与较高的基线脑缺血评分（ASPECTS）（比值比1.62，95%置信区间1.08 - 2.45，P = 0.002）和成功再通（比值比9.39，95%置信区间1.92 - 45.80，P = 0.0005）相关。54.3%的患者实现了成功再通（脑梗死溶栓分级（TICI）≥2B），近端ICA病变的急性治疗（比值比6.3，95%置信区间1.11 - 35.67，P = 0.03）以及更重要的是使用远端通路导管（比值比16.25，95%置信区间3.06 - 86.41，P = 0.0001）更有利于成功再通。MT期间对ICA病变采用保守方法是可行的，并且对相当一部分患者可带来良好的结局和成功再通。然而，为了能够处理远端闭塞，通常需要对颈部病变进行急性治疗（31.4%）。临床结局受基线缺血核心大小和成功再通的影响；使用远端通路导管通过近端病变对成功再通非常有利。ICA病变的急性治疗有利于颅内再通但对临床结局无影响这一事实可能是由于样本量的原因，这强调了需要进行大规模随机研究以确定针对这种病理情况的最佳治疗策略。
