目的:急性和孤立的颅外颈内动脉(eICA)闭塞的治疗选择仍然存在,到目前为止,有争议。虽然建议静脉溶栓,其效力普遍较低。这项回顾性研究旨在评估因eICA急性闭塞而接受颈动脉内膜切除术(CEA)的有症状患者的临床结果和CT灌注的作用。
方法:所有21例患者均出现进展性卒中,颅内循环完全通畅,CT时没有出血转化的证据,最低ASPECTS为6。通过评估NIHSS和mRS的变化来评估临床改善。我们调查了NIHSS与手术时机之间的关系,ASPECT评分,和CT灌注时缺血半暗带的体积。
结果:入院时NIHSS中位数为9(范围1-24),在手术后24小时降至4(范围0-35),76.2%的患者有所改善。ASPECTS为6(3例)的患者表现出66.7%的改善,而以9分或10分开始的患者(11例)为81.8%。在21例患者中,有12例患者在3个月后达到了0到2之间的mRS。手术和症状发作之间的平均时间为410分钟(范围为70-1070分钟)。在症状发作后8小时内治疗的14例患者临床改善为85.7%,相比之下,接受后来手术的患者为57.1%。4例患者在CEA之前接受了溶栓治疗,显示术后临床改善且无颅内出血。在接受CT灌注的14例患者中,在临床改善的患者(10例)中,中位缺血半暗带体积为112cc,在临床结局较差的患者(4例)中,中位缺血半暗带体积为84cc.
结论:孤立性eICA闭塞的急诊CEA已被证明是选定患者的安全有效的治疗选择。CT灌注,对缺血半暗带成像并量化适合再灌注的组织,在诊断-治疗检查中提供有效的支持。的确,我们可以推断,缺血半暗带的面积与血运重建后临床改善的边缘成正比,假设适当的干预时机是尊重。
OBJECTIVE: The treatment of choice for acute and isolated extracranial internal carotid artery (eICA) occlusion remains, to date, controversial. Although intravenous thrombolysis is recommended, its effectiveness is generally low. This retrospective study aims to assess the clinical outcome and the role of CT perfusion in symptomatic patients who underwent carotid endarterectomy (CEA) for acute occlusion of the eICA.
METHODS: All the 21 patients presented with stroke-in-evolution, complete patency of intracranial circulation, no evidence of hemorrhagic transformation at CT and a minimum ASPECTS of 6. Clinical improvement was assessed by evaluating the variation of NIHSS and the mRS. We investigated the relationship between NIHSS and the timing of the surgery, the ASPECT score, and the volume of ischemic penumbra at CT perfusion.
RESULTS: Median NIHSS on admission was 9 (range 1-24) and it decreased to 4 (range 0-35) 24 h after surgery, improving in 76.2% of patients. Patients with an ASPECTS of 6 (3 patients) showed an improvement of 66.7%, while it was of 81.8% in those starting with a score of 9 or 10 (11 patients). A mRS between 0 and 2 after 3 months was achieved in 12 out of 21 patients. The average time elapsing between surgery and symptom onset was 410 min (range 70-1070 min). Fourteen patients treated within 8 h from symptoms onset showed a clinical improvement of 85.7%, compared to a 57.1% for those which underwent later surgery. Four patients underwent thrombolytic therapy before CEA showing postoperative clinical improvement and no intracranial hemorrhage. Among the 14 patients who underwent CT perfusion, the median ischemic penumbra volume was 112 cc in those with clinical improvement (10 patients) and only 84 cc in those with worse clinical outcomes (4 patients).
CONCLUSIONS: Emergency CEA in isolated eICA occlusion has proved to be a safe and effective treatment option in selected patients. CT perfusion, imaging the ischemic penumbra and quantifying the tissue suitable for reperfusion, offers a valid support in the diagnostic-therapeutic workup. Indeed, we can infer that the area of the ischemic penumbra is directly proportional to the margin of clinical improvement after revascularization, supposing that the appropriate intervention timing is respect.