医学交流课件：急性缺血性卒中介入治疗机械拉栓或抽吸

1、急性缺血性卒中介入治疗机械拉栓或抽吸,1995 NINDS,2008ECASS III,静脉内治疗,有效的再通是AIS治疗的关键,2001 IMS I,1998PROACT II,2005IMS II,2003MERCI,1997PROACT,2006Multi Merci,动脉内治疗,2009Penumbra,2010/2011SWIFT/STAR,2013IMS III/MR RESCUE/SYNTHESIS,2014MR CLEAN,2007MELT,1998 ECASS,1995 ECASS,1999 ATLANTIS Part B,2000 ATLANTIS Part A,2004

2、Pooled analysis,2010 Pooled analysis,2013 IST-3,1999EMS,2015ESCAPE / EXTEND-IA / SWIFT PRIME/REVASCAT,急性脑梗死血管内治疗技术/材料进展,UCLA Stroke Center,Spiotta AM, et al. J NeuroIntervent Surg 2015;7:27,Spiotta AM, et al. J NeuroIntervent Surg 2015;7:27,Although the benefits are uncertain, the use of endovascula

3、r therapy with stent retrievers may be reasonable for carefully selected patients with acute ischemic stroke in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of vertebral arteries, basilar artery, or posterior cerebral arteries (Cla

4、ss IIb; Level of Evidence C).,支架取栓存在的技术问题,部分软膜代偿,Solitaire 4-20 反复5次取栓， rtpa 20mg补救,术前,Penumbra取栓导管,优点 1.快速实现再通 2.对于颈部大血管闭塞有优势 3.减少或不使用溶栓药物 4.延长治疗时间窗,缺点 1.对于小血管（2mm)闭塞不适合 2.费用较贵,中间导管：Navien、Neuron、Sofia,2020/12/8,R-CCA（2016-08-02支架前,R-CCA（2016-08-02支架后,R-CCA（2016-08-09,R-CCA（抽吸血栓后复查DSA,自8FGuiding尾端抽

5、出血栓及部分脂质成分,SOLUBRRA技术,急性缺血性卒中伴颅内动脉粥样硬化狭窄,Endovascular Therapy of Cerebral Arterial Occlusions: Intracranial Atherosclerosis versus Embolism. Lee JS, Hong JM, Lee KS, Suh HI, Demchuk AM, Hwang YH, Kim BM, Kim JS. J Stroke Cerebrovasc Dis. 2015 Sep;24(9):2074-80 Endovascular treatment and the outcomes

6、 of atherosclerotic intracranial stenosis in patients with hyperacute stroke. Yoon W, Kim SK, Park MS, Kim BC, Kang HK. Neurosurgery. 2015 Jun;76(6):680-6; discussion 686. 男性、危险因素、后循环缺血，需要急诊血管成形,12/8/2020,12/8/2020,31,RVA,LVA,47岁男性，发作性头晕一周，加重伴意识不清4小时。NIHSS:30,Solitaire FR 4.020mm取栓后,35,男性，53岁，突发意识障碍

7、5小时。GCS：7分,SOLITAIRE 4.0*15mm 支架,Penumbra 041,存在的问题和方向,工作流程持续改进 血管再通率仍偏低 病人选择优化 时间窗延长 影像学评估 缺血再灌注损伤 麻醉方式 围手术期抗栓治疗 神经保护药物或措施,Telestroke,国外部分正在进行的临床实验,BASICS: Basilar Artery International Cooperation Study, NCT01717755 DAWN: Trevo and Medical Management Versus Medical Management Alone in Wake Up and L

8、ate Presenting Strokes, NCT02142283 POSITIVE: Perfusion Imaging Selection of Ischemic Stroke Patients for Endovascular Therapy; NCT01852201 DEFUSE-3: Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution SIESTA: Sedation vs. Intubation for Endovascular Stroke Treatment; NCT02126085 主要为后循环大动脉闭塞、延长时间窗、影像学评估以及麻醉选择提供高级别循证学依据,与美国及PCI比较,美国,AIS