1、Basilar Artery Occlusion 08級腦外科研究生 李亞雄Introduction 約20%的缺血性卒中是椎基底動脈閉塞所致。基底動脈閉塞(basilar artery occlusionBAO)有臨床表現復雜、發病兇險、病情重、預后差(90%)等特點，即使采用抗凝和降纖等治療，患者死亡率仍然接近50%。Anatomy Etiopathogenisis動脈粥樣硬化合并狹窄血栓栓塞其它：頸部外傷 動脈炎 基底動脈瘤 高凝狀態 藥物濫用等 Clinical manifestation 臨床表現取決于動脈閉塞的部位、支配的范圍和側支循環狀況。動脈粥樣硬化椎基底動脈 基底動脈近端和中

2、段顱外血栓栓子基底動脈遠端BAO主干閉塞：反復眩暈、惡心、復視、構音障礙等，病情發展快而出現四肢癱、昏迷、并導致死亡分支閉塞： 腦橋腹外側綜合癥 閉鎖綜合癥 基底動脈尖綜合癥 等 (構音障礙、瞳孔改變、球部癥狀和意識障礙）Examination 實驗室檢查：凝血酶原時間、部分凝血活酶時間、膽固醇水平、血脂、心肌同工酶、肌鈣蛋白水平影像學檢查：頭顱CT（24h） MRI和MRA CTA DSA Diagnosis 危險因素 （高血壓、糖尿病） 局灶性神經功能缺損 可有反復TIA影像學資料Therapy急性期治療： 時間再通預后 一般治療 溶栓治療 靜脈溶栓(IVT) 動脈溶栓(IAT) 在BAO

3、急性期，靜脈溶栓聯合機械性血栓取出術(EMT)可以明顯提高閉塞血管的再通率，改善預后。 Inclusion criteria 有明確的BAO的癥狀CT除外腦出血CTA證據6h無IVT禁忌癥Methods Clinical signs (all three required) suggesting acute basilar artery occlusion (BAO): reduced consciousness (GCS 14) oculomotor dysfunction and/or bulbar signs hemi- or tetraparesis and/or ataxia Exc

4、lusion of cerebral hemorrhage on CT Evidence of BAO on CTA Treatment within six hours after symptom onset IVT (0,9 mg/kg rt-PA) Transfer to our Stroke Center(24h) (if patient was initially admitted to Community Hospital) CT and CTA Persisting BAO EMT Intensive Care Unit 或者 CT and CTAPatent Basilar A

5、rteryIntensive Care Unit A total of 106 patients with the clinical syndrome of BAO (symptoms_24 hours) and subsequent confirmation by CT or MRA presented to our institution. Department of Neurology,University of Heidelbergcriteria of the Trial in Myocardial Infarction (TIMI) : TIMI 0, complete occlu

6、sion of the BA; TIMI 1, partial recanalization but remnant occlusion; TIMI 2, incomplete recanalization with continuous BA patency but remnant thrombus; TIMI 3, complete recanalization.個體化原則預防再閉塞： 阿司匹林所有患者在治療后1-7天內都復查CT或MRI出院后隨訪3個月Intravenous abciximab and intraarterial rt-PA (bridging therapy) Resu

7、ltsIVT治療時間窗延長到6hBridging Therapy時間窗延長到24h 缺點：人數少，缺少大規模隨機對照試驗。 聯合治療前景廣闊 (血管成形術/支架置入術)2009 AHA Scientific Statement Mechanical Clot Extraction, Angioplasty and StentingESO-Guidelines for Management of Ischaemic Stroke 2008 ESO-Guidelines for Management of Ischaemic Stroke 2008 (BAO)References Staged E

8、scalation Therapy in Acute Basilar Artery Occlusion: Intravenous Thrombolysis and On-Demand Consecutive Endovascular Mechanical Thrombectomy: Preliminary Experience in 16 Patients stroke. 2008;39:1496-1500References Therapy of Acute Basilar Artery Occlusion Intraarterial Thrombolysis Alone vs Bridging Therapy stroke. 2009;40:140-146ReferencesIn