顱內(nèi)動脈支架

1、顱內(nèi)血管的特點 血管與其相應(yīng)供血區(qū)的關(guān)系 血管壁的結(jié)構(gòu) 穿支的問題 血管走行特點 TIA的病理生理 大動脈狹窄型 栓塞型 腔隙型 混合型 進展 自然病程 藥物治療 WASID 支架治療 首例 目前報道的小結(jié) 進展 第一例顱內(nèi)動脈支架（第一例顱內(nèi)動脈支架（1996年年7月）月） Cathet Cardiovasc Diagn. 1996 Jul;38(3):316- 9 Use of coronary Palmaz-Schatz stent in the percutaneous treatment of an intracranial carotid artery stenosis Feldm

2、an RL, Trigg L, Gaudier J, Galat J. Ocala Heart Institute, Florida, USA. A 69-yr-old man had chronic transient ischemia attacks due to severe stenosis of the intracranial portion of the right carotid artery. After failure of both antiplatelet and anticoagulant therapy, treatment was successful with

3、percutaneous transluminal angioplasty and a coronary Palmaz-Schatz stent. Use of the stent led to a better angiographic result than angioplasty alone. The patient is asymptomatic 4 mo later. 進展 進展 SSYLVIA Trial WINGSPAN Trial （prospective, multicenter study ） selfexpanding microstent 45 patients wit

4、h stenoses 50% ipsilateral stroke or death rate of 30-d 4.4% 6-m 7.1% 進展 多中心、隨機對照研究 進展 As technology and experience evolve, this procedure is becoming increasingly effective and safe for the treatment of intracranial atherosclerotic disease, and guidelines are being developed for its use. Hartmann M

5、, et al. Curr Op Neurol. 2005;18:3945. AJNR Am J Neuroradiol. 2005;26:23232327. 進展 Within peri-procedure Stroke and death 8.3% Annual stroke 3% - 5% Neurosurg Clin N Am. 2005;16:297308. AJNR Am J Neuroradiol. 2005;26:525530. 進展 This procedure, however, remains hazardous with up to 50% of patients sh

6、owing new, ipsilateral ischemic lesions on diffusion-weighted MR images. AJNR Am J Neuroradiol. 2005;26:385389. 進展 Intracranial angioplasty with or without stenting should be offered to symptomatic patients with intracranial stenoses who have failed medical therapy Similar to revascularization for e

7、xtracranial carotid artery stenosis, patient benefit from revascularization for symptomatic intracranial arterial stenosis is critically dependent on a low periprocedural stroke and death rate and should thus be performed by experienced neurointerventionists J Vasc Interv Radiol 2005; 16:12811285 進展

8、 Drug-eluting stents, although showing promise in coronary and canine vessels for the prevention of restenosis, are still not ready for human cerebral arteries because of differing histology and questions of drug neurotoxicity. Pelz D, Advances in Interventional Neuroradiology 2005. Stroke. 2006;37:

9、309-311.) 治療 手術(shù)適應(yīng)癥 TIAs or stroke attributed to intracranial stenoses of 50% diameter reduction Evidences of atherosclerotic risk factors or dissection Evidences of decreased perfusion distal to the stenosis 治療 狹窄率的測量 AJNR Am J Neuroradiol 21:643646, April 2000 治療 Determined by the following criteri

10、a First choice：The diameter of the proximal part of the artery at its widest, nontortuous, normal segment was chosen 治療 Second choice：If the proximal artery was diseased (eg, middle cerebral artery origin stenosis), the diameter of the distal portion of the artery at its widest, parallel, non- tortu

11、ous normal segment was substituted 治療 Third choice：If the entire intracranial artery was diseased, the most distal, parallel, non-tortuous normal segment of the feeding artery was measured 治療 技術(shù)成功標(biāo)準(zhǔn) Residual stenosis 30% 治療 術(shù)前評估 臨床 影像 腦實質(zhì) 腦血管 腦灌注 術(shù)前準(zhǔn)備 標(biāo)準(zhǔn)的顱內(nèi)支架置入技術(shù) Reduce related procedural complicati

12、ons 治療 術(shù)前評估 臨床 病史: 現(xiàn)病史、既往史、過敏史 物理檢查：神經(jīng)系統(tǒng)、全身 實驗室檢查：病因、危險因素 治療 術(shù)前評估 影像 腦實質(zhì) 腦灌注 腦血管 治療 腦實質(zhì) 頭顱CT 頭顱MRI 治療 腦灌注 灌注CT 磁共振的PWI 氙CT PET SPECT 治療 腦血管 超聲檢查 CTA CEMRA 腦血管造影腦血管造影 治療 造影分型 Mori分型 A型病變：同心性或適度偏心性狹窄，長度5mm B型病變：偏心性狹窄，長度5-10mm，或閉塞，但時間10mm，血管明顯扭曲，或閉塞時間3 個月 PTA時 A型 B型 C型 卒中率 8% 26% 87% 1年的再狹窄率 0 33% 87%

13、治療 LMA分型 部位（Location）分型 病變的形態(tài)學(xué)（Morphology）分型 徑路（Access）分型 治療 部位（Location）分型 N型：非分叉處病變 A型：分叉前病變 B型：分叉后病變 C型：跨分叉，但邊支無狹窄 D型：跨分叉，但邊支有狹窄 E型：邊支開口狹窄 F型：分叉前狹窄，并邊支狹窄 A E F A B C D 治療 病變的形態(tài)學(xué)（Morphology）分型 A型：長度 45） 或不規(guī)則狹窄，閉塞時間10mm，成角（ 90）狹窄，或 狹窄周圍有許多細小新生血管，閉塞時間3個 月 治療 徑路（Access）分型 型：適度迂曲，管壁光滑 型：較嚴(yán)重的迂曲 型：嚴(yán)重迂曲，

14、管壁不光滑 治療 術(shù)前準(zhǔn)備 術(shù)前7天，口服阿司匹林 300mg，qd 氯吡格雷 75mg，qd 術(shù)前2小時，靜脈泵注尼膜同 對于次全閉塞的病變可給予抗凝治療 心、肺功能的評價（全麻） 治療 手術(shù)過程 全麻或局麻 入路的選擇 上肢 下肢 術(shù)中肝素 治療 手術(shù)過程 導(dǎo)引導(dǎo)管的置入 微導(dǎo)絲的放置 直接放置 交換技術(shù) 支架的置入 常規(guī)置入方法 特殊置入方法 治療 顱內(nèi)專用支架 國際 Wingspan 國內(nèi) Apollo 治療 術(shù)后的治療和監(jiān)護 TCD的監(jiān)測和術(shù)后評價 即刻神經(jīng)功能的評價 即刻頭顱CT 術(shù)后抗凝、抗血小板 血壓的調(diào)控 危險因素的治療 有待探討的問題 PTA與支架的對照研究 藥物與支架的隨機、對照研究 顱內(nèi)血管的定義 顱內(nèi)血管病變性質(zhì)的確定 最佳支架置入時機 藥物洗脫支架的應(yīng)用 謝 謝 顱內(nèi)血管的特點 血管與其相應(yīng)供血區(qū)的關(guān)系 血管壁的結(jié)構(gòu) 穿支的問題 血管走行特點 治療 術(shù)前評估 臨床 病史: 現(xiàn)病史、既往史、過敏史 物理檢查：神經(jīng)系統(tǒng)、全身 實驗