血管成形术论文：症状性大脑中动脉狭窄血管腔内支架成形治疗的临床研究

血管成形术论文：症状性大脑中动脉狭窄血管腔内支架成形治疗的临床研究 血管成形术论文:症状性大脑中动脉狭窄血管腔内支架成形治疗的临床研究 【中文摘要】背景与颅内动脉粥样硬化性狭窄尤其是症状性大脑中动脉狭窄(middle cerebral artery stenosis, MCAS)是引起缺血性卒中的一个重要原因,年卒中发生率为7.0%-17.7%。大脑中动脉是颈内动脉的直接延续,主干分出许多皮质支分布于大脑半球外侧面的大部分,即除枕叶及额极以外的额叶、岛叶、颞叶、顶叶和基底节区等多个区域。各种因素造成大脑中动脉狭窄或闭塞,通常能造成相应供血部位血流动力学障碍,脑卒中发生的危险性增高,急性主干闭塞更能带来同侧大脑半球的灾难性大面积脑梗死,甚至死亡。近年来,随着无创性医学影像技术日新月异的发展,使复杂的脑血管病检出率得到提高,特别是颅内血管狭窄的诊断检出率增加尤其明显,为脑血管病的临床诊断和治疗提供了可靠的依据。临床上大脑中动脉狭窄的治疗方法主要有三种:药物治疗、外科血管搭桥再通术、血管内治疗(球囊扩张成形术和支架植入术)。其中近年来腔内支架成形术逐渐成为治疗症状性MCAS的有效手段,国内外开展迅速。本研究收集了2011年1月-2012年2月在河南省人民医院脑血管病中心住院的53例短暂性脑缺血发作(TIA)或脑梗死的症状性大脑中动脉狭窄患(MCAS)者。详细记录其临床资料、影像资料(MRI、CTPI、DSA、HRMRI)、手术记录、及术后随访资料。比较分析:患者术前、术后狭窄改善情况; 术前、后MCA-M1段狭窄血管供血区灌注改变情况;HRMRI评价MCA-M1 段管腔狭窄程度的准确性和可靠度;术前、术后、围手术期及随访 NIHSS、MRS评分;再狭窄的发生情况。结果53例症状性MCAS患者 接受了腔内支架成形治疗。应用的支架系统为:球囊扩张式支架 (Apollo)支架和自膨式(Wingspan)支架。1例手术失败,手术成功率 达98.1%(52/53)。MCA-M1段支架置入术后狭窄血管供血区rCBV、rTTP 与术前相比改善明显,差异有统计学意义,而rCBF的变化无统计学意 义;CTPI定性分析与MRI梗塞灶不具有相关性;DSA测量的狭窄率与 HRMRI测量的狭窄率具有中度一致性;MCA直径和狭窄率与术前比较 两者均有统计学意义;NIHSS评分和mRS评分手术前后无显著性差异; 围手术期并发症发生率为7.5%,30天内累计并发症发生率9.4%,平均 1年内累计并发症发生率11.3%(6/53);随访6-19月,8例出现再狭 窄,卒中率12.5%(5/32),平均狭窄率与手术前狭窄率相比有明显差异, 与手术后无统计学差异。结论腔内支架成形术治疗症状性大脑中动脉 狭窄是可行的,技术成功率高、围手术期并发症发生率低,血流动力学 改善明显,能降低再发卒中率。但腔内支架成形技术要求较高,准确的 疗效还有待前瞻性随机对照研究进一步评估。 【英文摘要】Background and PurposeIntracranial atherosclerotic stenosis, especially symptomatic middle cerebral artery stenosis is an important cause of ischemic stroke. The stroke rate is 7.0%-17.7%. Middle cerebral artery is a direct continuation of the internal carotid artery. There are many cortical branches supplying the outer side of the cerebral hemispheres including insula, temporal lobe, parietal lobe and basal ganglia district and other areas. Middle cerebral artery stenosis or occlusion due to various factors, usually cause corresponding hemodynamic disorders and stroke risk increases. Acute occlusion is more likely to lead to catastrophic large area infant of the ipsilateral cerebral hemisphere. In recent years, with the rapid development of non-invasive medical imaging technology, cerebrovascular disease detection rate is improved, especially intracranial vascular stenosis, which provide a reliable basis for the clinical diagnosis and treatment of the cerebrovascular diseaseTreatment means for symptomatic middle cerebral artery stenosis in clinical are including medication, surgical revascularization, endovascular balloon angioplasty and stent implantation. Among these, stenting being an effective way is carried out rapidly over the world. Fifty-three cases hospitalized suffering from transient ischemic attack (TIA) or cerebral infarction due to middle cerebral artery stenosis were collected between January 2011 and February,2012 in Henan Province People’s Hospital. Detailed clinical data, image data (MRI, CTPI, DSA, HRMRI), surgical records, and postoperative follow-up data were analyzed. Stenosis degree, perfusion parameter, NIHSS and mRS score were compared before, after and follow-up of the procedure.ResultsFifty-three cases of MCAS patients received stenting treatment using balloon-expandable stents (Apollo) or self-expanding stents (Wingspan). Technique success rate was 98.1%(52/53). Except rCBF, rCBV and rTTP improved significantly. There is no correlation between CTPI qualitative analysis and MRI infarct,Stenosis rate measured by the DSA and HRMR showed moderate consistency, The MCA diameter and stenosis degree changed significantly compared with those preoperative, No significant difference was found for NIHSS score and mRS score before surgery and after surgery, Perioperative complications were 7.5%, within 30 days of cumulative complication rate of 9.4 percent, one year cumulative incidence of complications were 11.3%(6/53), Following -up was done for 6-19 months, eight restenosis occurred, the stroke rate of 12.5%(5/32), there is significant difference for stenosis rate compared with the preoperative stenosis rate, but no significant difference with stenosis rate after surgery.ConclusionsThis study demonstrated that it is feasible that angioplasty and stenting for symptomatic middle cerebral artery stenosis. The technique success rate is high, perioperative complication is low, haemodynamics improved significantly and it can reduce the stroke rate. But the procedure is complex. The critical role still needs to be verified by prospective randomized controlled long-term follow-up studies. 【关键词】血管成形术 支架 症状性大脑中动脉狭窄 HRMRI CTPI 【英文关键词】Angioplasty Intracranial artery stenosis Stents HRMRI CTPI 【目录】症状性大脑中动脉狭窄血管腔内支架成形治疗的临床研 究 摘要 4-6 Abstract 6-7 前言 9-11 对象和 方法 11-17 结果 17-21 讨论 21-30 结论 30-31 附图 31-38 参考文献 38-43 综述 症状性 颅内动脉狭窄血管内支架成形术的术前评价及治疗进展 43-67 参考文献 61-67 英文缩略词 67-68 个人 简历 68-69 攻读硕士期间发的文章 69-70 致谢 70