Zanaty Mario, Howard Susanna, Roa Jorge A, Alvarez Carlos M, Kung David K, McCarthy David J, Samaniego Edgar A, Nakagawa Daichi, Starke Robert M, Limaye Kaustubh, Al Kasab Sami, Chalouhi Nohra, Jabbour Pascal, Torner James, Tranel Daniel, Hasan David
Departments of1Neurosurgery.
2Department of Neurosurgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois.
J Neurosurg. 2019 Mar 29;132(4):1158-1166. doi: 10.3171/2019.1.JNS183337. Print 2020 Apr 1.
Revascularization of a symptomatic, medically refractory, cervical chronically occluded internal carotid artery (COICA) using endovascular techniques (ETs) has surfaced as a viable alternative to extracranial-intracranial bypass. The authors aimed to assess the safety, success, and neurocognitive outcomes of recanalization of COICA using ETs or hybrid treatment (ET plus carotid endarterectomy) and to identify candidate radiological markers that could predict success.
The authors performed a retrospective analysis of their prospectively collected institutional database and used their previously published COICA classification to assess the potential benefits of ETs or hybrid surgery to revascularize symptomatic patients with COICA. Subjects who had undergone CT perfusion (CTP) imaging and Montreal Cognitive Assessment (MoCA) testing, both pre- and postprocedure, were included. The authors then performed a review of the literature on patients with COICA to further evaluate the success and safety of these treatment alternatives.
The single-center study revealed 28 subjects who had undergone revascularization of symptomatic COICA. Five subjects had CTP imaging and MoCA testing pre- and postrevascularization and thus were included in the study. All 5 patients had very large penumbra involving the entire hemisphere supplied by the ipsilateral COICA, which resolved postoperatively. Significant improvement in neurocognitive outcome was demonstrated by MoCA testing after treatment (preprocedure: 19.8 ± 2.4, postprocedure: 27 ± 1.6; p = 0.0038). Moreover, successful revascularization of COICA led to full restoration of cerebral hemodynamics in all cases. Review of the literature identified a total of 333 patients with COICA. Of these, 232 (70%) showed successful recanalization after ETs or hybrid surgery, with low major and minor complication rates (3.9% and 2.7%, respectively).
ETs and hybrid surgery are safe and effective alternatives to revascularize patients with symptomatic COICA. CTP imaging could be used as a radiological marker to assess cerebral hemodynamics and predict the success of revascularization. Improvement in CTP parameters is associated with significant improvement in neurocognitive functions.
采用血管内技术（ETs）对有症状的、药物治疗无效的颈内动脉慢性闭塞（COICA）进行血运重建，已成为颅外 - 颅内旁路手术的一种可行替代方案。作者旨在评估使用ETs或杂交治疗（ETs加颈动脉内膜切除术）对COICA进行再通的安全性、成功率和神经认知结果，并确定可预测成功的候选放射学标志物。
作者对前瞻性收集的机构数据库进行了回顾性分析，并使用他们先前发表的COICA分类法来评估ETs或杂交手术对有症状的COICA患者进行血运重建的潜在益处。纳入术前和术后均进行了CT灌注（CTP）成像和蒙特利尔认知评估（MoCA）测试的受试者。作者随后对COICA患者的文献进行了综述，以进一步评估这些治疗方案的成功率和安全性。
单中心研究发现28例有症状的COICA患者接受了血运重建。5例患者在血运重建术前和术后进行了CTP成像和MoCA测试，因此被纳入研究。所有5例患者均有非常大的半暗带，累及同侧COICA供血的整个半球，术后消失。治疗后MoCA测试显示神经认知结果有显著改善（术前：19.8±2.4，术后：27±1.6；p = 0.0038）。此外，COICA成功再通在所有病例中均导致脑血流动力学完全恢复。文献综述共确定了333例COICA患者。其中，232例（70%）在接受ETs或杂交手术后成功再通，主要和次要并发症发生率较低（分别为3.9%和2.7%）。
ETs和杂交手术是对有症状的COICA患者进行血运重建的安全有效的替代方案。CTP成像可作为一种放射学标志物，用于评估脑血流动力学并预测血运重建的成功。CTP参数的改善与神经认知功能的显著改善相关。
