蒋烽烽 鲍翔 刘晓波 徐渭 余丹枫 童民锋 周格知

[摘要] 目的 探討单时相CTA良好侧支代偿急性前循环大血管闭塞延期血管内再通治疗患者的临床特点。 方法 回顾性收集2016年1月～2019年12月我院神经外科收治的急性缺血性脑卒中接受血管内治疗249例患者的临床资料。选取其中年龄>18岁;CTA证实急性前循环大血管闭塞且原始CTA侧支循环评估等级为充足（3分）;初始NIHSS评分≥6分，入卒中单元前NIHSS评分<6分，伴或不伴静脉溶栓;首次入院未接受血管内治疗，内科治疗期间NIHSS评分再次升高并接受急诊血管内治疗，且发病至血管内治疗时间6 h～3 d的患者。共确认16例（6.4%），分析这部分患者的病因、治疗以及预后特点。 结果 16例患者发病中位NIHSS评分16（9，23）分，入卒中单元时中位NIHSS评分3（1，5）分。入卒中单元至出现NIHSS评分升高平均时间为（725±35）min。术前复查头颅CT有13例患者（81.3%）未出现ASPECT评分变化，比较首次ASPECT评分无统计学差异（P>0.05）。62.5%（10/16）的患者TOAST分型为ICAD。DSA侧支代偿良好率同单时相CTA比较无统计学差异（P>0.05）。87.5%（14/16）的患者术中实现成功再通（mTICI 2b～3级）。术后7 d中位NIHSS评分与发病即刻比较显著降低（P<0.01），但比较入卒中单元时无显著差异（P>0.05）。术后3个月87.5%患者预后良好（mRS评分0～2分），无死亡病例。 结论 单时相CTA良好侧支代偿急性前循环大血管闭塞患者，以动脉粥样硬化性病变为主，且呈现低龄的特点。延期血管内再通治疗安全性和有效性良好，大部分患者可取得良好预后，但较一期血管内治疗其长期良好预后率下降，最佳治疗策略需要更多的前瞻性随机对照研究进一步探索。

[关键词] 缺血性脑卒中;侧支循环;机械取栓;血管内治疗;延期

[中图分类号] R743.3          [文献标识码] B          [文章编号] 1673-9701（2020）17-0052-05

Observation on the clinical efficacy of delayed intravascular recanalization in the treatment of acute anterior circulation large vessel occlusion with single-phase CTA good collateral circulation compensation

JIANG Fengfeng   BAO Xiang   LIU Xiaobo   XU Wei   YU Danfeng   TONG Minfeng   ZHOU Gezhi

Department of Neurosurgery， Jinhua Municipal Central Hospital in Zhejiang Province， Jinhua   321000， China

[Abstract] Objective To explore the clinical characteristics of delayed intravascular recanalization in the treatment of patients with acute anterior circulation large vessel occlusion with single-phase CTA good collateral compensation. Methods The clinical data of 249 patients undergoing endovascular treatment for acute ischemic stroke who were admitted to the department of neurosurgery in our hospital from January 2016 to December 2019 were retrospectively collected. The selected patients were of the age>18 years old; they were confirmed of acute anterior circulation large vessel occlusion by CTA and the original CTA collateral circulation assessment level was sufficient（3 points）; they were with initial NIHSS score≥6 points， NIHSS score<6 points before admission to the stroke unit， and complicated or not with intravenous thrombolysis; they did not receive intravascular treatment upon the first admission; during medical treatment， their NIHSS score increased again and they received emergency endovascular treatment， and the time from onset to endovascular treatment was 6 h～3 d. A total of 16 cases（6.4%） were confirmed， and the etiology， treatment， and prognosis characteristics of these patients were analyzed. Results The median NIHSS score of the 16 patients was 16（9， 23）， and the median NIHSS score was 3（1， 5） upon admission to the stroke unit. The average time from admission to the stroke unit to the increase of the NIHSS score was（725±35） min. There were 13 patients（81.3%） who did not have any change in ASPECT score by reexamination of cranial CT before surgery. There was no statistical difference between the first ASPECT scores（P>0.05）. 62.5%（10/16） of patients were with TOAST classification as ICAD， and there was no statistically significant difference between DSA good collateral compensation rate and single-phase CTA（P>0.05）. 87.5%（14/16） of patients were given successful recanalization during surgery （mTICI grade 2b-3）. The median NIHSS score at 7 d after surgery was significantly lower than that immediate onset（P<0.01）， but there was no significant difference compared to that upon admission to the stroke unit（P>0.05）. 87.5% of patients had a good prognosis（mRS score 0-2） at 3 months after surgery， and there were no cases of death. Conclusion The patients with acute anterior circulation large vessel occlusion with single-phase CTA good collateral compensation are mainly characterized by atherosclerotic lesions， and have the characteristics of young age. Delayed intravascular recanalization has a good safety and efficacy， and most patients can achieve a good prognosis. However， the long-term good prognosis rate is lower than that of first-stage endovascular treatment. The optimal treatment strategy requires more prospective randomized controlled studies for further exploration.

[Key words] Ischemic cerebral stroke; Collateral circulation; Mechanical thrombectomy; Endovascular treatment; Delayed

脑侧支循环是指当大脑的供血动脉严重狭窄或闭塞时，血流通过其他血管（侧支或新形成的血管吻合）到达缺血区，从而使缺血组织得到不同程度的灌注代偿[1]。几项荟萃分析显示较差的侧支循环是急性缺血性脑卒中（acute ischemic stroke，AIS）血管内治疗功能预后的强预测因子，充分的侧支循环有助于在没有血管再通的情况下维持缺血脑组织的活力，侧支代偿同临床预后呈正相关[2]。颅内大血……