Therapeutic effect analysis of mechanical thrombectomy for acute middle cerebral artery M2 segment occlusion
-
摘要:
目的 探讨大脑中动脉M2段急性闭塞机械取栓治疗的疗效和安全性。 方法 回顾性收集2019年9月—2020年10月中国科学技术大学附属第一医院大脑中动脉M2段闭塞进行机械取栓的急性脑梗死患者20例。患者中男性8例,女性12例;年龄为32~84(62.5±14.4)岁;入院时美国国立卫生研究院卒中量表(NIHSS)评分(14±3)分;术前ASPECTS评分为8.0(7.0,9.0)分;病因分型采用TOAST分型,其中大动脉粥样硬化型2例,心源性栓塞10例,其他原因5例,不明原因3例;机械取栓前静脉溶栓6例,其中5例使用重组组织型纤溶酶原激活剂,1例使用尿激酶;优势M2患者14例;分析其手术方式、血管再通、颅内出血情况,并分析术后90 d预后。mTICI分级2b~3级为血管成功再通;mRS评分0~2分为临床预后良好。 结果 20例患者平均发病到股动脉穿刺时间为200~582 min,中位时间为370(277,483)min,发病到再通时间为(481.3±121.4)min;6例患者仅使用支架取栓,8例患者仅使用直接抽吸取栓,6例患者使用支架联合抽吸技术取栓,取栓次数为2(1,2)次;成功再通率为95.0%(19/20),4例患者发生颅内出血,其中2例为症状性颅内出血。90 d随访,20例患者中死亡1例,预后良好患者13例(65.0%)。单因素分析显示,联合静脉溶栓、不合并sICH与90 d良好预后相关。 结论 对大脑中动脉M2段闭塞急性缺血性卒中患者行机械取栓治疗具有安全性和有效性,联合静脉溶栓、不合并sICH与90 d良好预后相关。 Abstract:Objective To explore the efficacy and safety of mechanical thrombectomy for acute occlusion of the M2 segment of the middle cerebral artery. Methods Twenty patients with acute cerebral infarction who were subjected to mechanical thrombectomy for M2 segment middle cerebral artery occlusion in the First Affiliated Hospital of the University of Science and Technology of China from September 2019 to October 2020 were retrospectively collected. Amongst them, 8 were males, and 12 were females. Their ages ranged from 32 to 84 (62.5±14.4) years. The National Institutes of Health Stroke Scale score was (14±3) on admission. The preoperative ASPECTS score was 8.0 (7.0, 9.0) points. The aetiology classification adopted was TOAST classification, including 2 cases of aortic atherosclerosis, 10 cases of cardiogenic embolism, 5 cases of other causes, 3 cases of unknown cause. Before mechanical thrombectomy, intravenous thrombolysis was performed in 6 cases, of which 5 cases were treated with recombinant tissue plasminogen activator and 1 case with urokinase. There were 14 patients with dominant M2. The operation mode, recanalization and intracranial hemorrhage were analyzed, and the prognosis 90 days after operation was analyzed. An mTICI grade 2b-3 indicated successful recanalisation of blood vessels, and an mRS score of 0-2 meant good clinical prognosis. Results The average time from onset to femoral artery puncture in 20 patients was 200-582 min, the median time was 370 (277, 483) min, and the time from onset to recanalisation was (481.3±121.4) min. Stents were only used in 6 patients to remove the thrombus, direct aspiration was only used in 8 patients to remove the embolus, and stent combined with aspiration technology was used in 6 patients to remove the embolus. The number of emboli removed was 2 (1, 2). The successful recanalisation rate was 95%. Four patients had intracranial haemorrhage, and two of them had symptomatic intracranial haemorrhage. At 90-day follow-up, 1 patient died, the good prognosis rate was 65%. Univariate analysis showed that combined intravenous thrombolysis, without sICH were associated with good 90-day prognosis. Conclusion Mechanical thrombectomy for acute ischemic stroke patients with middle cerebral artery M2 occlusion is safe and effective. Combined intravenous thrombolysis, without sICH are associated with good prognosis at 90 days. -
Key words:
- Mechanical thrombectomy /
- Middle cerebral artery M2 segment /
- Safety /
- Effectiveness
-
表 1 影响大脑中动脉M2段急性闭塞行机械取栓的脑梗死患者临床预后的单因素分析
组别 例数 年龄(x ±s,岁) 性别[例(%)] 高血压[例(%)] 糖尿病[例(%)] 心房颤动[例(%)] 吸烟[例(%)] 饮酒[例(%)] 术前ASPECTS评分[M(P25,P75),分] 男性 女性 mRS≤2分 13 55.9±14.2 5(38.0) 8(62.0) 5(38.0) 1(8.0) 4(31.0) 1(8.0) 3(23.0) 8.0(7.0,9.0) mRS>2分 7 67.1±14.5 3(43.0) 4(57.0) 5(71.0) 0(0.0) 4(57.0) 1(14.0) 3(43.0) 8.0(7.5,8.5) 统计量 1.073a 0.182b 1.406b -0.725b 1.127b 0.447b 0.893b -0.631c P值 0.297 0.858 0.177 0.478 0.274 0.66 0.384 0.528 组别 例数 入院NIHSS评分[M(P25,P75),分] 优势M2 [例(%)] 发病到股动脉穿刺时间(x ±s,min) 发病到血管再通时间(x ±s,min) 联合静脉溶栓[例(%)] 取栓次数[M(P25,P75),分] 血管成功再通[例(%)] sICH [例(%)] mRS≤2分 13 13.0(12.5,15.0) 9(69.0) 387.5±129.2 489.7±134.9 6(46.2) 1(1,2) 12(92.0) 0(0.0) mRS>2分 7 15.0(11.0,17.0) 5(71.0) 354.9±94.5 465.6±99.4 0(0.0) 2(1,2) 7(100.0) 2(29.0) 统计量 -0.644c 0.097b -0.587a -0.414a 4.615b -0.805c < 0.001b 2.163b P值 0.519 0.924 0.564 0.684 0.032 0.421 0.999 0.042 注:a为t值,b为χ2值,c为Z值。 -
[1] GOYAL M, MENON B K, VAN ZWAM W H, et al. Endovascular thrombectomy after large-vessel ischaemic stroke: A meta-analysis of individual patient data from five randomised trials[J]. Lancet, 2016, 387(10029): 1723-1731. doi: 10.1016/S0140-6736(16)00163-X [2] POWERS W J, RABINSTEIN A A, ACKERSON T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke, 2019, 50(12): e344-e418. http://www.researchgate.net/publication/336901575_Guidelines_for_the_Early_Management_of_Patients_With_Acute_Ischemic_Stroke_2019_Update_to_the_2018_Guidelines_for_the_Early_Management_of_Acute_Ischemic_Stroke [3] 中华医学会神经病学分会, 中华医学会神经病学分会脑血管病学组. 中国急性缺血性脑卒中诊治指南2018[J]. 中华神经科杂志, 2018, 51(9): 666-682. doi: 10.3760/cma.j.issn.1006-7876.2018.09.004 [4] RAHME R, YEATTS S D, ABRUZZO T A, et al. Early reperfusion and clinical outcomes in patients with M2 occlusion: Pooled analysis of the PROACT Ⅱ, IMS, and IMS Ⅱ studies[J]. J Neurosurg, 2014, 121: 1354-1358. doi: 10.3171/2014.7.JNS131430 [5] BHOGAL P, BVCKE P, ALMATTER M, et al. A comparison of mechanical thrombectomy in the M1 and M2 segments of the middle cerebral artery: A review of 585 consecutive patients[J]. Interv Neurol, 2017, 6: 191-198. doi: 10.1159/000475535 [6] MENON B K, HILL M D, DAVALOS A, et al. Efficacy of endovascular thrombectomy in patients with M2 segment middle cerebral artery occlusions: Meta-analysis of data from the HERMES Collaboration[J]. J Neurointerv Surg, 2019, 11(11): 1065-1069. doi: 10.1136/neurintsurg-2018-014678 [7] MIURA M, YOSHIMURA S, SAKAI N, et al. Endovascular therapy for middle cerebral artery M2 segment occlusion: Subanalyses of RESCUE-Japan Registry 2[J]. J Neurointerv Surg, 2019, 11(10): 964-969. doi: 10.1136/neurintsurg-2018-014627 [8] SILLANPÄÄ N, PROTTO S, SAARINEN J T, et al. Internal carotid artery and the proximal M1 segment are optimal targets for mechanical thrombectomy[J]. Interv Neurol, 2017, 6(3-4): 207-218. doi: 10.1159/000475606 [9] SABER H, NARAYANAN S, PALLA M, et al. Mechanical thrombectomy for acute ischemic stroke with occlusion of the M2 segment of the middle cerebral artery: A meta-analysis[J]. J Neurointerv Surg, 2018, 10(7): 620-624. doi: 10.1136/neurintsurg-2017-013515 [10] GOEBEL J, STENZEL E, WANKE I, et al. Effectiveness of endovascular recanalization treatment for M2 Segment Occlusion: Comparison between intracranial ICA, M1, and M2 segment thrombectomy[J]. Acad Radiol, 2019, 26(10): e298-e304. doi: 10.1016/j.acra.2018.11.019 [11] NAKANO T, SHIGETA K, OTA T, et al. Efficacy and safety of mechanical thrombectomy for occlusion of the second segment of the middle cerebral artery: Retrospective Analysis of the Tama-REgistry of acute endovascular thrombectomy (TREAT)[J]. Clin Neuroradiol, 2020, 30(3): 481-487. doi: 10.1007/s00062-019-00810-3 [12] CHEN C J, WANG C, BUELL T J, et al. Endovascular mechanical thrombectomy for acute middle cerebral artery M2 Segment Occlusion: A systematic review[J]. World Neurosurg, 2017, 107: 684-691. doi: 10.1016/j.wneu.2017.08.108 [13] DORN F, LOCKAU H, STETEFELD H, et al. Mechanical thrombectomy of M2-Occlusion[J]. J Stroke Cerebrovasc Dis, 2015, 24(7): 1465-1470. doi: 10.1016/j.jstrokecerebrovasdis.2015.04.013 [14] DE HAVENON A, NARATA A P, AMELOT A, et al. Benefit of endovascular thrombectomy for M2 middle cerebral artery occlusion in the ARISE Ⅱ study[J]. J Neurointerv Surg, 2020. DOI: 10.1136/neurintsurg-2020-016427. [15] IVAN V L, RUBBERT C, CASPERS J, et al. Mechanical thrombectomy in acute middle cerebral artery M2 segment occlusion with regard to vessel involvement[J]. Neurol Sci, 2020, 41(11): 3165-3173. doi: 10.1007/s10072-020-04430-5 [16] FLORES A, TOMASELLO A, CARDONA P, et al. Endovascular treatment for M2 Occlusions in the era of stentrievers: A descriptive multicenter experience[J]. J Neurointerv Surg, 2015, 7(4): 234-237. doi: 10.1136/neurintsurg-2014-011100 [17] 李瑞, 郭玲玲, 王黎, 等. 急性缺血性脑卒中患者机械取栓的预后因素分析[J]. 中华全科医学, 2020, 18(9): 1455-1457. https://www.cnki.com.cn/Article/CJFDTOTAL-SYQY202009008.htm [18] SARRAJ A, SANGHA N, HUSSAIN M S, et al. Endovascular therapy for acute ischemic stroke with occlusion of the middle cerebral artery M2 segment[J]. JAMA Neurol, 2016, 73(11): 1291-1296. doi: 10.1001/jamaneurol.2016.2773 [19] JIANG L, XIA W Q, HUANG H, et al. Mechanical thrombectomy outcome predictors in stroke patients with M2 Occlusion: A single-center retrospective study[J]. World Neurosurg, 2019, 127: e155-e161. doi: 10.1016/j.wneu.2019.03.013 [20] FERRIGNO M, BRICOUT N, LEYS D, et al. Intravenous recombinant tissue-type plasminogen activator: Influence on outcome in anterior circulation ischemic stroke treated by mechanical thrombectomy[J]. Stroke, 2018, 49(6): 1377-1385. doi: 10.1161/STROKEAHA.118.020490 [21] YANG P, ZHANG Y, ZHANG L, et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke[J]. N Engl J Med, 2020, 382(21): 1981-1993. doi: 10.1056/NEJMoa2001123 [22] NOGUEIRA R G, GUPTA R, JOVIN T G, et al. Predictors and clinical relevance of hemorrhagic transformation after endovascular therapy for anterior circulation large vessel occlusion strokes: A multicenter retrospective analysis of 1122 patients[J]. J Neurointerv Surg, 2015, 7(1): 16-21. doi: 10.1136/neurintsurg-2013-010743