侧支循环对非急性前循环大动脉闭塞药物治疗患者长期预后的影响

doi:10.3969/j.issn.1673-5765.2021.06.006

摘要/Abstract

摘要： 目的分析侧支循环对非急性期前循环大动脉闭塞患者长期预后的影响，为此类患者临床治疗决策提供依据。方法回顾性收集2009年7月-2015年12月入住西安交通大学第二附属医院接受积极药物治疗的非急性单侧症状性颈内动脉/大脑中动脉闭塞患者。根据美国介入治疗神经放射学会（American Society of Interventional and Therapeutic Neuroradiology，ASITN）/介入放射学会（Society of Interventional Radiology，SIR）侧支血流分级系统标准评估每位患者的侧支循环情况，分为侧支良好组（ASITN/SIR 分级0～2级）及侧支不良组（ASITN/SIR分级3～4级）。应用Kaplan-Meier生存曲线分析两组患者责任血管相关缺血性血管事件复发及相关血管性死亡情况；采用Cox回归法分析缺血性血管事件复发的危险因素。结果共纳入302例患者，其中222例为侧支良好组，80例为侧支不良组，随访2～8年，中位随访时间为4.0（3.0～5.0）年。随访期间，共45例（14.9%）发生了责任血管相关缺血性血管事件复发。侧支良好组缺血性血管事件2年累积复发率及死亡率均低于侧支不良组（血管事件复发率：14.3% vs 23.8%，P =0.008；死亡率：4.4% vs 10%，P =0.006）。Cox回归分析显示年龄≥60岁、冠心病史、侧支循环差（RR 1.86，95%CI 1.03～4.53，P =0.041）和出院时mRS>2分（RR 3.43，95%CI 1.69～6.96， P =0.001）是影响责任血管相关缺血性血管事件复发的独立危险因素。结论对于非急性症状性单侧颈内/大脑中动脉闭塞患者，尤其侧支循环不良者，即使经过严格的药物治疗，2年内仍存在较高的缺血性血管事件复发和血管性死亡风险。高龄、冠心病史、侧支循环差和出院时mRS>2分是其缺血性血管事件复发的独立危险因素。

文章导读： 非急性期症状性颈内动脉/大脑中动脉闭塞患者即使经过积极药物治疗后仍有较高的缺血性血管事件复发和血管性死亡风险，尤其侧支循环不良者，对于此类患者，可尝试常规药物治疗以外的方法以减少血管事件复发风险。

关键词: 脑大动脉闭塞; 侧支循环; 最佳药物治疗; 预后

Abstract: Objective To analyze the effect of collateral circulation on long-term prognosis in patients with anterior circulation large vessel occlusion. Methods Patients with non-acute unilateral internal carotid artery (ICA) / middle cerebral artery (MCA) occlusion and receiving aggressive medicine treatment who were admitted in the Second Affiliated Hospital of Xi'an Jiaotong University were enrolled in this retrospective study. The collateral circulation of all the patients were evaluated using American Society of Interventional Neuroradiology (ASITN) / Society of Interventional Radiology (SIR) collateral flow grading system. All the patients were divided into good collateral circulation group (Grade 0-2) and poor collateral circulation group (Grade 3-4). Kaplan-Meier survival curve analysis were used to compare cumulative incidence of recurrent ischemic vascular events and relevant vascular death between

the two groups. Cox regression analysis was used to determine the risk factors for recurrence of

ischemic vascular events. Results Of 302 patients, 222 were in good collateral group and 80 were in poor collateral group. The follow-up time ranged from 2 to 8 years, and the medium follow-up time was 4.0 (3.0-5.0) years. During follow-up, 45 patients (14.9%) had recurrent ischemic vascular events. The 2-year cumulative incidence of ischemic vascular events and mortality in good collateral circulation group were lower than that in poor collateral circulation group (vascular events: 14.3% vs 23.8%, P =0.046; mortality: 4.4% vs 10%, P =0.006, respectively). Cox regression analysis showed that age ≥60 years, history of coronary heart disease, poor collateral circulation (RR 1.86, 95%CI 1.03-4.53, P =0.041), and mRS score >2 points at discharge (RR 3.43, 95%CI 1.69-6.96, P =0.001) were independent risk factors for recurrent ischemic vascular events. Conclusions Patients with non-acute symptomatic ICA/MCA occlusion, especially those with poor collateral circulation, had a high risk of ischemic vascular events recurrence and vascular death within 2 years, even after aggressive medicine treatment. Age ≥60 years, history of coronary heart disease, poor collateral circulation and mRS score >2 points at discharge were independent risk factors for recurrence of ischemic vascular events.

Key words: Cerebral large artery occlusion; Collateral circulation; Aggressive medicine treatment; Prognosis

李涛, 赵莉莉, 吴宇伦, 王小雅, 王何莹, 坚雅婷, 江毓, 党美娟, 李也, 张益恒, 张磊, 王虎清, 张茹, 张桂莲. 侧支循环对非急性前循环大动脉闭塞药物治疗患者长期预后的影响[J]. 中国卒中杂志, 2021, 16(06): 561-566.

LI Tao, ZHAO Li-Li, WU Yu-Lun, WANG Xiao-Ya, WANG He-Ying, JIAN Ya-Ting, JIANG Yu, DANG Mei-Juan, LI Ye, ZHANG Yi-Heng, ZHANG Lei, WANG Hu-Qing, ZHANG Ru, ZHANG Gui-Lian. Effect of Collateral Circulation on Long-term Prognosis in Non-acute Intracranial Anterior Circulation Large Artery Occlusion Patients Treated with Conventional Medicine#br#[J]. Chinese Journal of Stroke, 2021, 16(06): 561-566.

参考文献

[1] WANG Y J，ZHAO X Q，LIU L P，et al. Prevalence
and outcomes of symptomatic intracranial large
artery stenoses and occlusions in China：the Chinese
Intracranial Atherosclerosis（CICAS）Study[J].
Stroke，2014，45（3）：663-669.
[2] FLAHERTY M L，FLEMMING KD，
MCCLELLAND R，et al. Population-based study
of symptomatic internal carotid artery occlusion：
incidence and long-term follow-up[J/OL]. Stroke，
2004，35（8）：e349-352[2021-02-08]. http：//dx.doi.
org/10.1161/01.STR.0000135024.54608.3f.
[3] PIEDADE G S，SCHIRMER C M，GOREN O，et
al. Cerebral collateral circulation：a review in
the context of ischemic stroke and mechanical
thrombectomy[J/OL]. World Neurosurg，2019，
122：33-42[2021-02-08]. http：//dx.doi.org/10.1016/
j.wneu.2018.10.066.
[4] KIM K M，KANG H S，LEE W J. Clinical
significance of the circle of Willis in intracranial
atherosclerotic stenosis[J]. J Neurointerv Surg，2016，
8（3）：251-255.
[5] LAU A Y，WONG E H，WONG A，et al. Significance
of good collateral compensation in symptomatic
intracranial atherosclerosis[J]. Cerebrovasc Dis，
2012，33（6）：517-524.
[6] YAMAUCHI H，FUKUYAMA H，NAGAHAMA
Y，et al. Significance of increased oxygen extraction
fraction in five-year prognosis of major cerebral
arterial occlusive diseases[J]. J Nucl Med，99，40
（12）：1992-1998.
[7] MOLINARI F，RAGHAVENDRA U，GUDIGAR
A，et al. An efficient data mining framework for the
characterization of symptomatic and asymptomatic
carotid plaque using bidimensional empirical mode
decomposition technique[J]. Med Biol Eng Comput，
2018，56（9）：1579-1593.
[8] KOLODGIE F D，YAHAGI K，MORI H，et al.
High-risk carotid plaque：lessons learned from
histopathology[J]. Semin Vasc Surg，2017，30（1）：
31-43.
[9] PARK M S，KWON S，LEE M J，et al. Identification
of high risk carotid artery stenosis：a multimodal
vascular and perfusion imaging study[J/OL]. Front
Neurol，2019，10：765[2021-02-08]. http：//dx.doi.
org/10.3389/fneur.2019.00765.
[10] MARUSHIMA A，NIEMINEN M，
KREMENETSKAIA I，et al. Balanced single-vector
co-delivery of VEGF/PDGF-BB improves functional
collateralization in chronic cerebral ischemia[J]. J
Cereb Blood Flow Metab，2019，40（2）：404-419.
[11] MURY P，CHIRICO E N，MURA M，et al.
Oxidative stress and inflammation，key targets of
atherosclerotic plaque progression and vulnerability：
potential impact of physical activity[J]. Sports
Medicine，2018，48（12）：2725-2741.
[12] XIANG J，ANDJELKOVIC A V，ZHOU N，et al. Is
there a central role for the cerebral endothelium and
the vasculature in the brain response to conditioning
stimuli?[J] Cond Med，2018，1（5）：220-232.
[13] CHANG K C，CHUANG I C，HUANG Y C，et al.
Risk factors outperform intracranial large artery
stenosis predicting unfavorable outcomes in patients
with stroke[J]. BMC Neurol，2019，19（1）：180.
[14] O'DONNELL M J，CHIN S L，RANGARAJAN
S，et al. Global and regional effects of potentially
modifiable risk factors associated with acute stroke
in 32 countries（INTERSTROKE）：a case-control
study[J]. Lancet，2016，388（10046）：761-775.
[15] WEI L，ERINJERI J P，ROVAINEN C M，et al.
Collateral growth and angiogenesis around cortical
stroke[J]. Stroke，2001，32（9）：2179-2184.