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1、动脉粥样硬化性颅内动脉狭窄的支架成形,大纲,颅内血管的特点TIA的病理生理进展治疗有待探讨的问题,颅内血管的特点,血管与其相应供血区的关系血管壁的结构穿支的问题血管走行特点,TIA的病理生理,大动脉狭窄型栓塞型腔隙型混合型,进展,自然病程药物治疗WASID支架治疗首例目前报道的小结,进展,第一例颅内动脉支架（1996年7月）,Cathet Cardiovasc Diagn.1996 Jul;38(3):316-9,Use of coronary Palmaz-Schatz stent in the percutaneous treatment of an intracranial caroti
2、d artery stenosisFeldman 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 su
3、ccessful with 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.,进展,进展,SSYLVIA TrialWINGSPAN Trial（prospective,multicenter study）selfexpanding microstent 45 patie
4、nts with stenoses 50%ipsilateral stroke or death rate of 30-d 4.4%6-m 7.1%,进展,多中心、随机对照研究,进展,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.,Hartman
5、n M,et al.Curr Op Neurol.2005;18:3945.,AJNR Am J Neuroradiol.2005;26:23232327.,进展,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.,进展,This procedure,however,remains hazardous with up to 50%of patients showing new
6、,ipsilateral ischemic lesions on diffusion-weighted MR images.,AJNR Am J Neuroradiol.2005;26:385389.,进展,Intracranial angioplasty with or without stenting should be offered to symptomatic patients with intracranial stenoses who have failed medical therapy Similar to revascularization for extracranial
7、 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,进展,Drug-eluting
8、 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;37:309-311.),治疗,手术适应症
9、TIAs or stroke attributed to intracranial stenoses of 50%diameter reductionEvidences of atherosclerotic risk factors or dissection Evidences of decreased perfusion distal to the stenosis,治疗,狭窄率的测量,AJNR Am J Neuroradiol 21:643646,April 2000,治疗,Determined by the following criteriaFirst choice：The diam
10、eter of the proximal part of the artery at its widest,nontortuous,normal segment was chosen,治疗,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-tortuous normal segment was substitu
11、ted,治疗,Third choice：If the entire intracranial artery was diseased,the most distal,parallel,non-tortuous normal segment of the feeding artery was measured,治疗,技术成功标准Residual stenosis 30%,治疗,术前评估临床影像脑实质脑血管脑灌注术前准备标准的颅内支架置入技术Reduce related procedural complications,治疗,术前评估临床病史:现病史、既往史、过敏史 物理检查：神经系统、全身实验室
12、检查：病因、危险因素,治疗,术前评估影像脑实质脑灌注脑血管,治疗,脑实质头颅CT头颅MRI,治疗,脑灌注灌注CT磁共振的PWI氙CTPETSPECT,治疗,脑血管超声检查CTACEMRA脑血管造影,治疗,造影分型Mori分型A型病变：同心性或适度偏心性狭窄，长度10mm，血管明显扭曲，或闭塞时间3个月,PTA时 A型 B型 C型 卒中率 8%26%87%1年的再狭窄率 0 33%87%,治疗,LMA分型部位（Location）分型病变的形态学（Morphology）分型径路（Access）分型,治疗,部位（Location）分型N型：非分叉处病变A型：分叉前病变B型：分叉后病变C型：跨分叉，但
13、边支无狭窄D型：跨分叉，但边支有狭窄E型：边支开口狭窄F型：分叉前狭窄，并边支狭窄,A,E,F,治疗,病变的形态学（Morphology）分型A型：长度 45）或不规则狭窄，闭塞时间10mm，成角（90）狭窄，或狭窄周围有许多细小新生血管，闭塞时间3个月,治疗,径路（Access）分型型：适度迂曲，管壁光滑型：较严重的迂曲型：严重迂曲，管壁不光滑,治疗,术前准备术前7天，口服阿司匹林 300mg，qd 氯吡格雷 75mg，qd术前2小时，静脉泵注尼膜同对于次全闭塞的病变可给予抗凝治疗心、肺功能的评价（全麻）,治疗,手术过程全麻或局麻入路的选择上肢下肢术中肝素,治疗,手术过程导引导管的置入微导丝的放置直接放置交换技术支架的置入常规置入方法特殊置入方法,治疗,颅内专用支架国际Wingspan 国内Apollo,治疗,术后的治疗和监护TCD的监测和术后评价即刻神经功能的评价即刻头颅CT术后抗凝、抗血小板血压的调控危险因素的治疗,有待探讨的问题,PTA与支架的对照研究药物与支架的随机、对照研究颅内血管的定义颅内血管病变性质的确定最佳支架置入时机药物洗脱支架的应用,谢 谢,
