脑卒中康复研究的进展
中国康复研究中心神经康复科 (100077)
在20世纪最后的脑的十年中，国内外康复医学界在脑卒中康复的研究方面取得了不少进展。了解这些情况对我们今后的工作有所帮助
一、脑卒中康复机构网络化及其管理
急性期在综合医院(acute hospital)中的早期康复医疗；亚急性期在专业化康复机构中恢复期早期的综合性康复；恢复中后期在社区和家庭中的社区康复形成了一个完整的网络。
二、高新技术和信息技术在脑卒中康复中的应用
继美国在80年代初建立全国统一的医学康复数据库(uniform data system for medical rehabilitation，UDSMR) 和信息技术网络之后，欧洲联盟各国又建立了统一的欧洲联盟电信技术应用计划(telematics applications programme of the EU，TIDE)。不仅大量的、统一的、系统的数据可以获得共享，而且许多康复训练，如言语和认知功能的康复训练，也可以在网上远距离的进行。
, 百拇医药
三、偏瘫患者的预后预测(outcome prediction)
准确地预测患者的康复后果是选择病例和确定是否需要继续进行康复的前提条件。用一些残损和残疾指标来定量评定预测预后，成为一个热门课题。
四、脑卒中康复的投入—产出效益分析(cost-effective analysis)
以FIM为中心。脑卒中康复的投入—产出效益分析目前仍是一个热门课题。
五、卫生经济学的初步研究
对159例有完整资料的患者进行卫生经济学的初步研究，其中康复组77例，男49例，女28例，平均年龄(62.14±10.59)岁；对照组82例，男51例，女31例，平均年龄(60.57±10.93)岁 。
, 百拇医药 观察指标：
1.康复组与对照组直接费用、间接费用在不同阶段的构成比。
2.康复组与对照组不同时期的BI和SF36的最小成本分析。
结论，康复组与对照组直接费用、间接费用在不同阶段的构成比有显著性差异，不同时期的BI和SF36的最小成本分析康复组强于对照组。
六、基础理论研究方面
脑和脊髓的可塑性及有关痉挛的研究。主要集中在：
突触的可塑性：
轴突的发芽(sprouting)和树突量的增加：集中在神经生长因子的作用研究上。
失神经支配后的超敏感性(denervation supersensitivity)。
, 百拇医药
中枢神经对运动的双侧支配。
学习和记忆。
区域性功能重组(functional reorganization)。
丰富的环境刺激的作用。
其他：神经干细胞及其移植等。
强制性使用运动疗法在脑卒中康复中的应用：选取15例卒中后偏瘫6个月以上运动功能无明显进步的患者，除去睡眠时间和30 min活动时间，要求患者健侧上肢全天穿戴夹板2周。患者的患侧上肢要接受6 h的监督下训练任务，实验后，15名患者上肢功能均有进步。功能性磁共振显示治疗前后脑的功能活动信号有明显的变化。
痉挛(spasticity)的研究，一个重点是痉挛机理的基础性研究，特别是有关脊髓神经元的γ-氨酪酸(GABA-B)受体在痉挛中的作用问题。另一个重点是痉挛处理方法的研究，特别是抗痉挛药物的研究。
, 百拇医药
七、作业治疗
作业治疗(occupational therapy，OT)的作用和规模明显增加，以至在国外一些康复医疗单位中OT的规模甚至超过了PT。
八、有关言语康复问题
言语—语言病理学(speech-language pathology，SLP)和言语治疗学(speech therapy，ST)形成了独立的专业。
失语症的疗效观察
有关神经心理学(neuropsychology)和认知功能的康复神经心理学形成了一个庞大的专业，有关言语、智力、记忆、失用、失认、忽略、体像障碍等成为研究的热点。
The progress of stroke rehabilitation research
, 百拇医药
ZHANG Tong China Rehabilitation Research Center 100077, China
In the last ten years of the 20th century, there are lots of progress in the field of stroke rehabilitation around the world. It is helpful for us to understand this situation.
1. The stroke rehabilitation organizations and management
early rehabilitation therapy in polyclinics during the acute period of stroke;
, 百拇医药
integrated rehabilitation in the professional rehabilitation organizations during the sub- acute period;
persistent rehabilitation in family and community during the resume period.
2. The use of high techniques and information techniques in the stroke rehabilitation
The United States formed uniform data system for medical rehabilitation (UDSMR) and information technique network in 1980’s. Europe Union established telematics applications programme of the EU (TIDE). Uniform and systematic data could be shared and lots of rehabilitation therapy such as speech and recognize rehabilitation could be taken in the network from far distance.
, 百拇医药
3. Outcome prediction of stroke
Outcome prediction of stroke patients is precondition of selecting cases and planning rehabilitation program. To chose some index of disability and disable to predict the outcome is very popular.
4. Cost-effective analysis of stroke rehabilitation
The cost-effective analysis of stroke rehabilitation based on FIM is still a focus of research.
, 百拇医药
5. We took pilot research of health economics in 159 stroke patients including 77 in rehab group (49 male and 28 female, average age 62.14±10.59) and 82 in control group (51 male and 31 female, average age 60.57±10.93).
Observe index:
1) direct and indirect fee and the ratio of different fees in.
2) cost-effect analysis between two groups in different stages and their change.
, 百拇医药
The result is that the therapy group patients spent less money to get better outcome while the control group patients spent more money in drug and caring fee.
6. basic theory research
The research about plasticity of brain and spine and spasticity focused in:
◆plasticity of synapse
◆sprouting of axon and increase of dendrite, focus on the study of NGF.
, 百拇医药
◆denervation supersensitivity
◆bilateral dominating of CNS for movement
◆learning and memory
◆regional functional reorganization
◆stimulating effect of rich environment
◆ others: implant of neuro stem cells
The use of CIM therapy in stroke rehabilitation
, http://www.100md.com Select 15 stroke patients which got no obvious progress in 6 months after stroke. They put up splints during the day time for 2 weeks. The suffer arms took place 6 hours therapy under the supervise. After therapy all the patients improved their arm function. fMRI shows significant changes in the functional signal before and after therapy.
Research of spasticity
One key point is the mechanism research of spasticity, especially the function of GABA-B receptor in spinal neurons;
, http://www.100md.com
Another key point is therapy methods of spasticity, especially the anti spasticity drugs.。
7. Occupational therapy
The effect and scope of occupational therapy (OT) improved sharply. In some institute the size of OT is even bigger than PT.
8. Speech rehabilitation
Speech—language pathology (SLP) and speech therapy (ST) formed new profession.
, 百拇医药
Therapy of aphasia
Neuropsychology and recognition rehabilitation psychology have become a huge profession. The research about speech, intelligence, memory, neglect and aphasia has become the focus of study.
Direct stenting for symptomatic intracranial stenosis:
A report of 155 patients
JIANG Weijian , WANG Yongjun , DU Bin, JIN Min , XU Xiaotong, Wang Qinghe,MA Ning, WANG Longyi, DAI Jianping ,From the Neurovascular Angioplasty Team, Department of Neurology and Neuroradiology, Beijing Tiantan Hospital, Capital University of Medical Sciences, Beijing, China.
, http://www.100md.com
Background and Purpose：
Annual stroke rates might be as high as 10% to 24% in patients with symptomatic intracranial stenosis in spite of best medical therapy. This was a single center, nonrandomized prospective study to evaluate the safety, feasibility and clinical efficacy of stenting for patients with symptomatic intracranial stenosis.
Methods：
One hundred and fifty-five consecutive patients with 170 symptomatic intracranial stenoses of ≥ 50%, resulted in transient ischemic attacks or minor stroke, were enrolled from September 5, 2001 to August 12, 2004. Their age was 50.9 years ± SD of 12.98, 132 patients were male and 150 had ≥ 1 risk factors of atherosclerosis.
, 百拇医药
The “offending” lesions were situated at middle cerebral (n=93), intracranial internal carotid (n=19), basilar (n=29), intracranial vertebral (n=28) and posterior inferior cerebellar (n=1).
Patients received neurological evaluation with National Institutes of Health Stroke Scale (NIHSS) score before and immediately after procedure, and one-, three-, six-, and 12-month after the procedure. Disable stroke was defined as one that led to a modified Rankin scale (mRS) score of ≥2.
, 百拇医药
Results：
1. Results of the Periprocedural Period: Total of 177 balloon-expandable stents was used.
Stent Success, defined as stent-assisted angioplasty successfully, resulting in ≤ 20 % residual stenosis, was obtained in 157 lesions (92.4%, 157/170) and 142 patients (91.2 %, 142/155). The stenosis rate of pre- and post –procedure for all patients was 78.2% ± SD of 13.93 and 10.8 %± SD 20.77, respectively
, http://www.100md.com
The Procedure-related Complications were 11.8 % for lesion (20/170) and 12.9% for patients (20/155), including 6 acute / subacute occlusions and 1 asymptomatic dissection, which all obtained complete patency by means of endovascular therapy at once without sequelae; 6 intracranial hemorrhage, 3 of them recovered (NIHSS at 30-day ≤ pre-procedure’s) and one remained hemiparesis with 2 points on NIHSS score at the discharging time, and two died; 1TIA , disappeared after 3 days; 1 reversible and 4 irreversible ischemic penetrator strokes, and1 irreversible embolic stroke . The rate of complications in stent success group (G1) was 13.4% (19/142) compared with 7.7% (1/13) in stent failure group (G2). The rates of disable stroke (n=5) and death (n=2) within 30 days were 4.5 % (7/155) for total patients, 4.9 % in G1 (7/142), and 0 in G2 (0 /13), respectively.
, 百拇医药
Endovascular Procedure Success was achieved in 144 lesions (84.7 %, 144/170) and in 129 patients (83.2%, 129/155). Procedure success was defined as stent success without disable stroke or death at discharge by means of endovascular therapy, in spite of complications, such as acute / subacute occlusion or dissection.
Treatment Success, defined as stent success without inability stroke and death at the 30th day, by means of endovascular and medical therapy, was obtained in 150 lesions (88.2%, 150/170) and in 135 patients (87.1%, 135/155).
, http://www.100md.com
2. Results of Clinical and Angiographic Follow-up:
Clinical Follow-up, median 344 days (ranged from 30 days to 1057 days, 378 days ± SD of 270.2), was performed in 150 patients (140 in G1 and 10 in G2). Ischemic neurological events in the distribution of the target lesion occurred in 5 patients (3.3%, 5/150), including 2 strokes and 1 death (2.0 %, 3/150), and 2 TIAs (1.3 %, 2/150) during the follow-up. Death and stroke (20.0%, 2/10), and TIAs (10.0%, 1 /10) in G2 were higher than that in G1 (0.7%, 1/140 and 0.7%, 1/140, respectively) after one month.
, 百拇医药
Cumulated neurological events occurred in 15.5% (24 /155) of total patients, included TIAs in 3(1.9 %, 3/155), and symptomatic and asymptomatic stroke in 21(13.5%, 21/155), which resulted in 3 deaths (1.9%, 3/155). Cumulated disable stroke and death occurred in 9 patients (5.8%, 9/155).
Cumulated neurological events, stroke, and disable stroke and death were 14.1% (20/142), 12.7%(18/142) and 4.9%, (7/142), respectively, in G1, compared with 30.8 %( 4/13), 23.1%(3/13) and 15.4%(2/13), respectively in G2.
, http://www.100md.com
NIHSS of pre-procedure (n=155) and last visit (n =149, 3 died and 3 lost) was 1.0±1.88 and 0.5±1.18, respectively.
Angiographic Follow-up, median 6 months (ranging from 3 months to 16 months; 3 at 3 to 5 months, 28 at ≥ 6 months), was performed in 31 patients with 33 stented vessels. Restenosis was found in 6 patients (19.4%, 6 /31)) and 6 stented vessels (18.2%, 6/33), four of them were asymptomatic (66.7%, 4/6).
3. Secondary Endovascular
, 百拇医药
Therapy was performed successfully in 3 patients (2%, 3/155). One patient had acute occlusion of stented basilar artery 3 months later, which obtained complete patency within 3 hours by intrathrombus thrombolysis, without sequelae. Another patient had severe restenosis asymptomatically, which was treated by re-stent therapy successfully. Emergency stenting was performed on a patient with acute stroke, resulted from severe basilar artery stenosis, which failed to the primary basilar stent 4 month ago. The patient survived but remained disable (mRS of 3).
, 百拇医药
Conclusions：
Direct stenting appears to be a feasible and effective therapy for symptomatic intracranial stenosis, but also appears to have higher procedure-related complications, which need strict procedural and periprocedural management to improve procedure success and treatment success, and to reduce the risk of disable stroke and death. Further studies are needed to confirm the benefits of stenting.
Stenting of Intracranial Artery Stenosis：Complications and Management
, 百拇医药
JIANG Weijian, WANG Yongjun, DU Bin , JIN Min , XU Xiaotong , WANG Qinghe , MA Ning ,WANG Longyi , DAI Jianping Dai,From the Neurovascular Angioplasty Team, Department of Neurology and Neuroradiology, Beijing Tiantan Hospital, Capital University of Medical Sciences, Beijing, China.
Background and Purpose：Symptomatic intracranial artery stenosis is a high-risk factor of ipsilateral ischemic stroke. Angioplasty with stent has been introduced to treat patients with transient ischemic attack (TIA) and minor stroke attributed to intracranial stenosis since 1996. However, procedure-related neurological complications, either ischemic or hemorrhagic, could result in stroke and death, and benefits of stenting might be offset by higher disable stroke and death. So, the neurovascular angioplasty team should make great efforts to control procedural complications below an acceptable level, such as 10%, because it is impossible to avoid complication absolutely. The team should also be able to recognize, analyze and manage various procedure-related complications, to reduce the risk of disable stroke and death. The purposes of this article were to report our experiences of 20 complications, which occurred during the period of periprocedure.
, http://www.100md.com
Methods：Between September 5, 2001 and August 12, 2004, a total of 155 patients with 170 symptomatic intracranial stenoses of ≥ 50% received intracranial stenting. The management strategies for complication were as follow: ① intra-thrombus urokinase thrombolysis through micro-catheter for acute or subacute occlusion. ② another stenting for dissection. ③ antiplatelet and anticoagulion therapy for penetrator events. ④ continuing nimodipine intravenously for vasospasm. ⑤ to control blood pressure below 110/70 mm Hg, to neutralize heparin with protamine sulfate and to discontinue antithrombotic agents, etc, for intracranial hemorrhage. Disable stroke was defined as one that led to a modified Rankin scale (mRS) score of ≥2, 30 days after stroke.
, http://www.100md.com
Results：Procedure–related neurological complications occurred in 20 patients (12.9%, 20/ 155) and 20 lesions (11.7%, 20/ 170), including 6 intracranial hemorrhage (symptomatic, n=4; asymptomatic, n=2), 13 ischemic cerebral events (stroke, n=12; transient ischemic attacks, n=1) and 1 asymptomatic dissection. The probable causes, managements and outcomes of 20 complications are shown in table. Finally, by the means of aggressive endovascular and medical therapies, disable stroke and death within 30 days was 3.2% (5/155) and 1.3% (2/155), respectively.
, 百拇医药
Conclusion：Higher risk of procedure-related neurological complications may occur in stenting of intracranial stenosis. To reduce the possibility of disable stroke and death within 30 days, it is mandatory to develop strict procedural and periprocedural management strategies.
Table: Causes, managements and outcomes of 20 complications
Complication (stent site)
No.
, http://www.100md.com
Probable cause
Strategy
Outcome
TIAs (R-MCA)
1
R-MCA spasm related to discontinuing nimodipine 3 hours after stent
Resume nimodipine
TIAs disappeared after 7 days. 9 months FU , no events
Dissection (L-V4)
, 百拇医药
1
Stent oversized
Another stent
Asymtomatic for 6 months
Acute and subacute Thrombosis (BA, n=1; R-V4, n=1; R-C7, n=1; R-MCA, n=1; LMCA, n=2)
6
One due to no pre procedure antiplatelet therapy; one to antiplatelet agents discontinued immediately after stent due to confusion with hemorrhage; 4 probably to intima tear
, http://www.100md.com
Intrathrombus thombolysis
Reversible stroke, n=6. FU of 1, 3, 6, 6, 10 and 20 months, respectively, no TIA and stroke in 6 pats.
Distal embolization (BA)
1
Repeatedly adjusting stent position
Antithombotic therapy
Irreversible stroke. 34-month FU, no TIAs but thalamic pain syndrome to remain
, 百拇医药
Penetrator events (BA, n=3; R-MCA, n=1, L-MCA, n=1)
5
Atheroma was squashed to origin of perforators in 4 patients with complex events of lacuna and low-flow. Low BP (below 70/50 mm Hg) for 10 minutes during procedure under general anesthesia in 1
Antithombotic therapy
Irreversible stroke (n=4); at the 30th days, their NIHSS was 2, 5, 4, 2, and at 23, 14, 5, 2 months, was 1, 2, 3, 2, respectively. Reversible stroke (n=1, FU: 3 months). No new events in 5 pats
, 百拇医药
Symptomatic Intracranial hemorrhage (L-MCA, n=2; R-MCA, n=1; VBJ, n=1)
4
Hyperperfusion syndrome, n=1; Double tandem stents n=3
Control BP, neutralize heparin, etc.
Death, n=2; Irreversible stroke n=1, reversible, n=1. FU of 14 and 23 months, both survivors have no new neurological events, and both NIHSS was 2, respectively
, 百拇医药 Asymptomatic hemorrhage ( RC7, n=1; L-MCA, n=1)
2
Distal vessel perforation, n=1; Uncertain, n=1
Control BP, neutralize heparin, etc.
FU of 20 and 23 months, respectively, both have no new neurological events
Note: R, right; L, left; MCA, middle cerebral artery; C7, communication segment of internal carotid; BA, basilar artery; V4, intracranial vertebral; VBJ, vertebrobasilar junction; BP, blood pressure; FU, follow up, 百拇医药(张通)
在20世纪最后的脑的十年中，国内外康复医学界在脑卒中康复的研究方面取得了不少进展。了解这些情况对我们今后的工作有所帮助
一、脑卒中康复机构网络化及其管理
急性期在综合医院(acute hospital)中的早期康复医疗；亚急性期在专业化康复机构中恢复期早期的综合性康复；恢复中后期在社区和家庭中的社区康复形成了一个完整的网络。
二、高新技术和信息技术在脑卒中康复中的应用
继美国在80年代初建立全国统一的医学康复数据库(uniform data system for medical rehabilitation，UDSMR) 和信息技术网络之后，欧洲联盟各国又建立了统一的欧洲联盟电信技术应用计划(telematics applications programme of the EU，TIDE)。不仅大量的、统一的、系统的数据可以获得共享，而且许多康复训练，如言语和认知功能的康复训练，也可以在网上远距离的进行。
, 百拇医药
三、偏瘫患者的预后预测(outcome prediction)
准确地预测患者的康复后果是选择病例和确定是否需要继续进行康复的前提条件。用一些残损和残疾指标来定量评定预测预后，成为一个热门课题。
四、脑卒中康复的投入—产出效益分析(cost-effective analysis)
以FIM为中心。脑卒中康复的投入—产出效益分析目前仍是一个热门课题。
五、卫生经济学的初步研究
对159例有完整资料的患者进行卫生经济学的初步研究，其中康复组77例，男49例，女28例，平均年龄(62.14±10.59)岁；对照组82例，男51例，女31例，平均年龄(60.57±10.93)岁 。
, 百拇医药 观察指标：
1.康复组与对照组直接费用、间接费用在不同阶段的构成比。
2.康复组与对照组不同时期的BI和SF36的最小成本分析。
结论，康复组与对照组直接费用、间接费用在不同阶段的构成比有显著性差异，不同时期的BI和SF36的最小成本分析康复组强于对照组。
六、基础理论研究方面
脑和脊髓的可塑性及有关痉挛的研究。主要集中在：
突触的可塑性：
轴突的发芽(sprouting)和树突量的增加：集中在神经生长因子的作用研究上。
失神经支配后的超敏感性(denervation supersensitivity)。
, 百拇医药
中枢神经对运动的双侧支配。
学习和记忆。
区域性功能重组(functional reorganization)。
丰富的环境刺激的作用。
其他：神经干细胞及其移植等。
强制性使用运动疗法在脑卒中康复中的应用：选取15例卒中后偏瘫6个月以上运动功能无明显进步的患者，除去睡眠时间和30 min活动时间，要求患者健侧上肢全天穿戴夹板2周。患者的患侧上肢要接受6 h的监督下训练任务，实验后，15名患者上肢功能均有进步。功能性磁共振显示治疗前后脑的功能活动信号有明显的变化。
痉挛(spasticity)的研究，一个重点是痉挛机理的基础性研究，特别是有关脊髓神经元的γ-氨酪酸(GABA-B)受体在痉挛中的作用问题。另一个重点是痉挛处理方法的研究，特别是抗痉挛药物的研究。
, 百拇医药
七、作业治疗
作业治疗(occupational therapy，OT)的作用和规模明显增加，以至在国外一些康复医疗单位中OT的规模甚至超过了PT。
八、有关言语康复问题
言语—语言病理学(speech-language pathology，SLP)和言语治疗学(speech therapy，ST)形成了独立的专业。
失语症的疗效观察
有关神经心理学(neuropsychology)和认知功能的康复神经心理学形成了一个庞大的专业，有关言语、智力、记忆、失用、失认、忽略、体像障碍等成为研究的热点。
The progress of stroke rehabilitation research
, 百拇医药
ZHANG Tong China Rehabilitation Research Center 100077, China
In the last ten years of the 20th century, there are lots of progress in the field of stroke rehabilitation around the world. It is helpful for us to understand this situation.
1. The stroke rehabilitation organizations and management
early rehabilitation therapy in polyclinics during the acute period of stroke;
, 百拇医药
integrated rehabilitation in the professional rehabilitation organizations during the sub- acute period;
persistent rehabilitation in family and community during the resume period.
2. The use of high techniques and information techniques in the stroke rehabilitation
The United States formed uniform data system for medical rehabilitation (UDSMR) and information technique network in 1980’s. Europe Union established telematics applications programme of the EU (TIDE). Uniform and systematic data could be shared and lots of rehabilitation therapy such as speech and recognize rehabilitation could be taken in the network from far distance.
, 百拇医药
3. Outcome prediction of stroke
Outcome prediction of stroke patients is precondition of selecting cases and planning rehabilitation program. To chose some index of disability and disable to predict the outcome is very popular.
4. Cost-effective analysis of stroke rehabilitation
The cost-effective analysis of stroke rehabilitation based on FIM is still a focus of research.
, 百拇医药
5. We took pilot research of health economics in 159 stroke patients including 77 in rehab group (49 male and 28 female, average age 62.14±10.59) and 82 in control group (51 male and 31 female, average age 60.57±10.93).
Observe index:
1) direct and indirect fee and the ratio of different fees in.
2) cost-effect analysis between two groups in different stages and their change.
, 百拇医药
The result is that the therapy group patients spent less money to get better outcome while the control group patients spent more money in drug and caring fee.
6. basic theory research
The research about plasticity of brain and spine and spasticity focused in:
◆plasticity of synapse
◆sprouting of axon and increase of dendrite, focus on the study of NGF.
, 百拇医药
◆denervation supersensitivity
◆bilateral dominating of CNS for movement
◆learning and memory
◆regional functional reorganization
◆stimulating effect of rich environment
◆ others: implant of neuro stem cells
The use of CIM therapy in stroke rehabilitation
, http://www.100md.com Select 15 stroke patients which got no obvious progress in 6 months after stroke. They put up splints during the day time for 2 weeks. The suffer arms took place 6 hours therapy under the supervise. After therapy all the patients improved their arm function. fMRI shows significant changes in the functional signal before and after therapy.
Research of spasticity
One key point is the mechanism research of spasticity, especially the function of GABA-B receptor in spinal neurons;
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Another key point is therapy methods of spasticity, especially the anti spasticity drugs.。
7. Occupational therapy
The effect and scope of occupational therapy (OT) improved sharply. In some institute the size of OT is even bigger than PT.
8. Speech rehabilitation
Speech—language pathology (SLP) and speech therapy (ST) formed new profession.
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Therapy of aphasia
Neuropsychology and recognition rehabilitation psychology have become a huge profession. The research about speech, intelligence, memory, neglect and aphasia has become the focus of study.
Direct stenting for symptomatic intracranial stenosis:
A report of 155 patients
JIANG Weijian , WANG Yongjun , DU Bin, JIN Min , XU Xiaotong, Wang Qinghe,MA Ning, WANG Longyi, DAI Jianping ,From the Neurovascular Angioplasty Team, Department of Neurology and Neuroradiology, Beijing Tiantan Hospital, Capital University of Medical Sciences, Beijing, China.
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Background and Purpose：
Annual stroke rates might be as high as 10% to 24% in patients with symptomatic intracranial stenosis in spite of best medical therapy. This was a single center, nonrandomized prospective study to evaluate the safety, feasibility and clinical efficacy of stenting for patients with symptomatic intracranial stenosis.
Methods：
One hundred and fifty-five consecutive patients with 170 symptomatic intracranial stenoses of ≥ 50%, resulted in transient ischemic attacks or minor stroke, were enrolled from September 5, 2001 to August 12, 2004. Their age was 50.9 years ± SD of 12.98, 132 patients were male and 150 had ≥ 1 risk factors of atherosclerosis.
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The “offending” lesions were situated at middle cerebral (n=93), intracranial internal carotid (n=19), basilar (n=29), intracranial vertebral (n=28) and posterior inferior cerebellar (n=1).
Patients received neurological evaluation with National Institutes of Health Stroke Scale (NIHSS) score before and immediately after procedure, and one-, three-, six-, and 12-month after the procedure. Disable stroke was defined as one that led to a modified Rankin scale (mRS) score of ≥2.
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Results：
1. Results of the Periprocedural Period: Total of 177 balloon-expandable stents was used.
Stent Success, defined as stent-assisted angioplasty successfully, resulting in ≤ 20 % residual stenosis, was obtained in 157 lesions (92.4%, 157/170) and 142 patients (91.2 %, 142/155). The stenosis rate of pre- and post –procedure for all patients was 78.2% ± SD of 13.93 and 10.8 %± SD 20.77, respectively
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The Procedure-related Complications were 11.8 % for lesion (20/170) and 12.9% for patients (20/155), including 6 acute / subacute occlusions and 1 asymptomatic dissection, which all obtained complete patency by means of endovascular therapy at once without sequelae; 6 intracranial hemorrhage, 3 of them recovered (NIHSS at 30-day ≤ pre-procedure’s) and one remained hemiparesis with 2 points on NIHSS score at the discharging time, and two died; 1TIA , disappeared after 3 days; 1 reversible and 4 irreversible ischemic penetrator strokes, and1 irreversible embolic stroke . The rate of complications in stent success group (G1) was 13.4% (19/142) compared with 7.7% (1/13) in stent failure group (G2). The rates of disable stroke (n=5) and death (n=2) within 30 days were 4.5 % (7/155) for total patients, 4.9 % in G1 (7/142), and 0 in G2 (0 /13), respectively.
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Endovascular Procedure Success was achieved in 144 lesions (84.7 %, 144/170) and in 129 patients (83.2%, 129/155). Procedure success was defined as stent success without disable stroke or death at discharge by means of endovascular therapy, in spite of complications, such as acute / subacute occlusion or dissection.
Treatment Success, defined as stent success without inability stroke and death at the 30th day, by means of endovascular and medical therapy, was obtained in 150 lesions (88.2%, 150/170) and in 135 patients (87.1%, 135/155).
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2. Results of Clinical and Angiographic Follow-up:
Clinical Follow-up, median 344 days (ranged from 30 days to 1057 days, 378 days ± SD of 270.2), was performed in 150 patients (140 in G1 and 10 in G2). Ischemic neurological events in the distribution of the target lesion occurred in 5 patients (3.3%, 5/150), including 2 strokes and 1 death (2.0 %, 3/150), and 2 TIAs (1.3 %, 2/150) during the follow-up. Death and stroke (20.0%, 2/10), and TIAs (10.0%, 1 /10) in G2 were higher than that in G1 (0.7%, 1/140 and 0.7%, 1/140, respectively) after one month.
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Cumulated neurological events occurred in 15.5% (24 /155) of total patients, included TIAs in 3(1.9 %, 3/155), and symptomatic and asymptomatic stroke in 21(13.5%, 21/155), which resulted in 3 deaths (1.9%, 3/155). Cumulated disable stroke and death occurred in 9 patients (5.8%, 9/155).
Cumulated neurological events, stroke, and disable stroke and death were 14.1% (20/142), 12.7%(18/142) and 4.9%, (7/142), respectively, in G1, compared with 30.8 %( 4/13), 23.1%(3/13) and 15.4%(2/13), respectively in G2.
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NIHSS of pre-procedure (n=155) and last visit (n =149, 3 died and 3 lost) was 1.0±1.88 and 0.5±1.18, respectively.
Angiographic Follow-up, median 6 months (ranging from 3 months to 16 months; 3 at 3 to 5 months, 28 at ≥ 6 months), was performed in 31 patients with 33 stented vessels. Restenosis was found in 6 patients (19.4%, 6 /31)) and 6 stented vessels (18.2%, 6/33), four of them were asymptomatic (66.7%, 4/6).
3. Secondary Endovascular
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Therapy was performed successfully in 3 patients (2%, 3/155). One patient had acute occlusion of stented basilar artery 3 months later, which obtained complete patency within 3 hours by intrathrombus thrombolysis, without sequelae. Another patient had severe restenosis asymptomatically, which was treated by re-stent therapy successfully. Emergency stenting was performed on a patient with acute stroke, resulted from severe basilar artery stenosis, which failed to the primary basilar stent 4 month ago. The patient survived but remained disable (mRS of 3).
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Conclusions：
Direct stenting appears to be a feasible and effective therapy for symptomatic intracranial stenosis, but also appears to have higher procedure-related complications, which need strict procedural and periprocedural management to improve procedure success and treatment success, and to reduce the risk of disable stroke and death. Further studies are needed to confirm the benefits of stenting.
Stenting of Intracranial Artery Stenosis：Complications and Management
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JIANG Weijian, WANG Yongjun, DU Bin , JIN Min , XU Xiaotong , WANG Qinghe , MA Ning ,WANG Longyi , DAI Jianping Dai,From the Neurovascular Angioplasty Team, Department of Neurology and Neuroradiology, Beijing Tiantan Hospital, Capital University of Medical Sciences, Beijing, China.
Background and Purpose：Symptomatic intracranial artery stenosis is a high-risk factor of ipsilateral ischemic stroke. Angioplasty with stent has been introduced to treat patients with transient ischemic attack (TIA) and minor stroke attributed to intracranial stenosis since 1996. However, procedure-related neurological complications, either ischemic or hemorrhagic, could result in stroke and death, and benefits of stenting might be offset by higher disable stroke and death. So, the neurovascular angioplasty team should make great efforts to control procedural complications below an acceptable level, such as 10%, because it is impossible to avoid complication absolutely. The team should also be able to recognize, analyze and manage various procedure-related complications, to reduce the risk of disable stroke and death. The purposes of this article were to report our experiences of 20 complications, which occurred during the period of periprocedure.
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Methods：Between September 5, 2001 and August 12, 2004, a total of 155 patients with 170 symptomatic intracranial stenoses of ≥ 50% received intracranial stenting. The management strategies for complication were as follow: ① intra-thrombus urokinase thrombolysis through micro-catheter for acute or subacute occlusion. ② another stenting for dissection. ③ antiplatelet and anticoagulion therapy for penetrator events. ④ continuing nimodipine intravenously for vasospasm. ⑤ to control blood pressure below 110/70 mm Hg, to neutralize heparin with protamine sulfate and to discontinue antithrombotic agents, etc, for intracranial hemorrhage. Disable stroke was defined as one that led to a modified Rankin scale (mRS) score of ≥2, 30 days after stroke.
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Results：Procedure–related neurological complications occurred in 20 patients (12.9%, 20/ 155) and 20 lesions (11.7%, 20/ 170), including 6 intracranial hemorrhage (symptomatic, n=4; asymptomatic, n=2), 13 ischemic cerebral events (stroke, n=12; transient ischemic attacks, n=1) and 1 asymptomatic dissection. The probable causes, managements and outcomes of 20 complications are shown in table. Finally, by the means of aggressive endovascular and medical therapies, disable stroke and death within 30 days was 3.2% (5/155) and 1.3% (2/155), respectively.
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Conclusion：Higher risk of procedure-related neurological complications may occur in stenting of intracranial stenosis. To reduce the possibility of disable stroke and death within 30 days, it is mandatory to develop strict procedural and periprocedural management strategies.
Table: Causes, managements and outcomes of 20 complications
Complication (stent site)
No.
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Probable cause
Strategy
Outcome
TIAs (R-MCA)
1
R-MCA spasm related to discontinuing nimodipine 3 hours after stent
Resume nimodipine
TIAs disappeared after 7 days. 9 months FU , no events
Dissection (L-V4)
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1
Stent oversized
Another stent
Asymtomatic for 6 months
Acute and subacute Thrombosis (BA, n=1; R-V4, n=1; R-C7, n=1; R-MCA, n=1; LMCA, n=2)
6
One due to no pre procedure antiplatelet therapy; one to antiplatelet agents discontinued immediately after stent due to confusion with hemorrhage; 4 probably to intima tear
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Intrathrombus thombolysis
Reversible stroke, n=6. FU of 1, 3, 6, 6, 10 and 20 months, respectively, no TIA and stroke in 6 pats.
Distal embolization (BA)
1
Repeatedly adjusting stent position
Antithombotic therapy
Irreversible stroke. 34-month FU, no TIAs but thalamic pain syndrome to remain
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Penetrator events (BA, n=3; R-MCA, n=1, L-MCA, n=1)
5
Atheroma was squashed to origin of perforators in 4 patients with complex events of lacuna and low-flow. Low BP (below 70/50 mm Hg) for 10 minutes during procedure under general anesthesia in 1
Antithombotic therapy
Irreversible stroke (n=4); at the 30th days, their NIHSS was 2, 5, 4, 2, and at 23, 14, 5, 2 months, was 1, 2, 3, 2, respectively. Reversible stroke (n=1, FU: 3 months). No new events in 5 pats
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Symptomatic Intracranial hemorrhage (L-MCA, n=2; R-MCA, n=1; VBJ, n=1)
4
Hyperperfusion syndrome, n=1; Double tandem stents n=3
Control BP, neutralize heparin, etc.
Death, n=2; Irreversible stroke n=1, reversible, n=1. FU of 14 and 23 months, both survivors have no new neurological events, and both NIHSS was 2, respectively
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2
Distal vessel perforation, n=1; Uncertain, n=1
Control BP, neutralize heparin, etc.
FU of 20 and 23 months, respectively, both have no new neurological events
Note: R, right; L, left; MCA, middle cerebral artery; C7, communication segment of internal carotid; BA, basilar artery; V4, intracranial vertebral; VBJ, vertebrobasilar junction; BP, blood pressure; FU, follow up, 百拇医药(张通)