Major Damar Oklüzyonu Olan Akut Diseksiyon Hastalarinda Endovasküler Tedavi Deneyimimiz

Öz

Amaç Diseksiyona bağlı akut iskemik inmenin tedavisinde intravenöz trombolitik tedavi etkin ve güvenilir bir yöntemdir. İntrakranial damar oklüzyonu ile birlikte görülen diseksiyonunun endovasküler tedavisinin klinik sonuçları ve reperfüzyon oranlarıyla ilgili bilgilerimiz ise kısıtlıdır. Çalışmamızda endovasküler tedavi uyguladığımız etyolojisinde akut diseksiyon olan hastalarımızı sunmayı amaçladık. Yöntem Ocak 2015- Ağustos 2020 tarihleri arasında Eskişehir Osmangazi Üniversitesi Tıp Fakültesi İnme Ünitesinde majör damar okluzyonuna bağlı iskemik inme nedeniyle endovasküler tedavi yapılan ve etyolojide diseksiyon saptanan hastaların prospektif girilen verileri retrospektif olarak değerlendirildi. Hastaların yaşı, cinsiyeti, semptom zamanı, acile geliş zamanı, trombolitik tedavi uygulanması, başvuru National Institute of Health Stroke Skalası (NIHSS) skoru, Alberta Stroke Program Early CT Score (ASPECT), etyolojik tanıları, trombektomi yöntemi, rekanalizasyon oranı, işlem sonrası intraserebral kanama, taburculuktaki ve 3 ay sonraki modifiye Rankin skoru kaydedildi. Bulgular Yaş ortalaması 43 ± 9.84 olan toplam 13 hasta çalışmaya dahil edildi. Hastalarımızın % 46.1’i erkek (n=6), % 53.8’i kadındı (n=7). İki hastanın son bir hafta içinde künt travma öyküsü mevcuttu. Anjiyografi görüntülemesinde 12 hastamızda internal karotis arter diseksiyonu mevcuttu. Bir hastamızda ise vertebral arter V4 segment diseksiyonuna bağlı baziller arter oklüzyonu mevcuttu. Hastalarımızın %15’ine (n=2) trombolitik tedavi uygulandı, %30’unun ise (n=4) trombolitik tedavi için kontrendikasyonu mevcuttu. Hastalarımızın %46.1’ine (n=6) tromboaspirasyon, %23’üne (n=3) izole stent, %30’una (n=4) kombine teknik uygulandı. İlk işlemde başarılı rekanalizasyon %38.4’ünde (n=5) elde edildi. Hastaların %58.3’ünde (n=7) iki veya daha fazla intrakranial işlem uygulandı. Olguların %92.3’ünde (n=12) başarılı rekanalizasyon (TICI 2b-3) sağlandı. Bir olguda başarılı rekanalizasyon sağlanamadı. Hiçbir hastada işlem sonrası semptomatik kanama izlenmedi. Hastaların %76.9’unun (n=10) üç ay sonraki modified Rankin Scale (mRS) değeri 0-2 idi. Sonuç Diseksiyona bağlı akut iskemik inmenin endovasküler tedavisi etkin ve güvenilirdir Endovasküler tedavinin etkinliğinin değerlendirilmesi ve daha iyi klinik sonlanım sağlayan tekniklerin belirlenmesi için daha fazla çalışma gereklidir.

Anahtar Kelimeler

• Akut İnme
• Mekanik Trombektomi
• Diseksiyon
• Girişimsel Nöroloji

Our Experience of Endovascular Treatment in Patients with Acute Dissection and Major Vessel Occlusion

Öz

Intravenous thrombolytic therapy is an effective and safe method in the treatment of acute ischemic stroke due to dissection. Our knowledge about the clinical results and reperfusion rates of the endovascular treatment of dissection associated with intracranial vessel occlusion is limited. In our study, we aimed to present our patients with acute dissection in the etiology for which we applied endovascular treatment. Patients who underwent endovascular treatment of acute ischemic stroke due to a major vessel occlusion secondary to extracranial or intracranial vessel dissection were extrapolated from Eskisehir Osmangazi Stroke Center Database between January 2015 and May 2020. Patients' age, gender, symptom time, time of arrival to the emergency room, administration of thrombolytic therapy, admission NIHSS score, ASPECT, etiological diagnoses, thrombectomy method, recanalization rate, post-procedure intracerebral bleeding (SITS-MOST), modified Rankin score at discharge and 3 months later were recorded. A total of 13 patients with a mean age of 43 ± 9.84 years were included in the study. Of the patients, 46.1% were male (n=6) and 53.8% were female (n=7). Two patients had a history of blunt trauma within the last week. In diagnostic digital subtraction angiography (DSA), it was observed that 12 patients had internal carotid artery dissection. One patient had vertebrobasilar occlusion due to dissection of V4 segment of vertebral artery. TPA was applied to 15% (n=2) of the patients. There were contraindications for tPA in 30% of the patients (n=4). Thromboaspiration method was applied in 46.1% of the patients (n=6) as the first technique in the procedure (Figure 4). Isolated stent was applied in 23% of the patients (n=3) as the first technique. Combined technique was applied in 30% (n=4) of the patients. First pass recanalization rate was found to be 38.4% (n=5). Two or more intracranial procedures had to be performed in 58.3% of the patients (n=7). The rate of complete recanalization (TICI 2b-3) was 92.3% (n=12). Recanalization could not be achieved in one patient. First pass recanalization rate was 38.4% (n=5). Clinical progression and worsening of symptoms due to bleeding (NIHSS> 4) were not observed. The rate of patients who were living independently (mRS ≤2) was 76.9% (n=10). Endovascular treatment of acute ischemic stroke due to dissection is effective and safe. More studies are needed to evaluate the effectiveness of endovascular therapy and to identify techniques that provide better clinical outcomes.

Anahtar Kelimeler

• Interventional Neurology
• Acute stroke
• Dissection
• Mechanical Thrombectomy

Kaynakça

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