| Cerebral infarction in the world is still one of the main diseases of death and disability,instantly restore blood flow to save ischemic brain tissue is an important target in super early treatment of acute cerebral infarction.Many large-scale,randomized,double-blind clinical trial confirmed,for within 3 hours of the onset of acute cerebral infarction patients with venous use original activator recombinant tissue fibrinolytic enzyme(rt-PA)can significantly improve clinical outcomes.Despite the latest research results show that the selected cycle before endovascular treatment for patients with cerebral infarction have Ⅰrecommended,but whether it is before the loop cycle after cerebral infarction or cerebral infarction,rt-PA intravenous thrombolysis therapy are various types in super early line treatment of acute cerebral infarction.In the past 20 years,a lot of randomized controlled trials and registration results confirmed that the efficacy and safety of acute cerebral infarction within 4.5 hours of the rt-PA intravenous thrombolysis.However,the posterior circulation cerebral infarction researched rarely about intravenous thrombolysis therapy.Posterior circulation cerebral infarction is often overlooked in previous clinical studies,partly because of its incidence is low,in addition,the posterior circulation cerebral infarction patients compared with the former circulation cerebral infarction have some of the more difficult to identify symptoms,so as to delay in diagnosis and treatment.Few randomized controlled trial of the posterior circulation cerebral infarction as the research object,or a separate discussion of posterior circulation cerebral infarction the safety and efficacy of intravenous thrombolysis treatment.Before the cycle and the clinical features and pathogenesis of posterior circulation cerebral infarction is not the same,at present research results based on the former circulation cerebral infarction is not necessarily applicable to the posterior circulation cerebral infarction.The clinical characteristics,etiology and pathogenesis,and the prognosis of early intravenous thrombolytic therapy in patients with cerebral infarction were different.In order to explore this difference,this study is described from the following three aspects:Part One:Comparison of efficacy and safety of intravenous thrombolysis in patients with posterior circulation infarction and anterior circulation infarctionObjective To compare the efficacy and safety of intravenous thrombolysis with rt-PAin patients with posterior circulation cerebral infarction and anterior circulation cerebral infarction.Methods A retrospective analysis was made on the patients with intravenous thrombolytic therapy in our hospital from September 2013 to December 2016.All patients were treated with intravenous thrombolytic therapy with standard dose of 0.9mg/Kg within4.5 hours of onset.According to results of imaging and signs,the location of infarction was divided into anterior circulation infarction and posterior circulation infarction.The demographic characteristics,baseline NIHSS score,in-hospital mortality,and incidence of intracranial hemorrhage were compared between the two groups,as well as the mRS score of the 90 day.Results From September 2013 to December 2016,393 patients were treated with intravenous thrombolysis in the center of this hospital,excluding stroke mimics in 6 cases,and at the same time before and after the involvement of the circulation in 3 cases.With a total of 384 patients,including 60 cases after cerebral infarction,324 cases of anterior circulation infarction.Patients with posterior circulation cerebral infarction compare with anterior circulation cerebral infarction in younger patients(64.6Vs70.3y),a larger male proportion(63.3%Vs53.5%),the lower proportion of previous history of coronary heart disease(6.7%Vs16%),higher NIHSS(8.4Vs6.2).The OTT was longer(179Vs150.5min,P<0.001)than anterior circulation cerebral infarction,but there was no significant difference between the two groups in DNT.There was no significant difference between the two groups in the mortality rate of the patients(5%Vs10%,P=0.003).The early neurologic deterioration after intravenous thrombolysis were 18.3% and 14.5% respectively,mainly with early unexplained deterioration(72.7%Vs55.3%),the most common TOAST type of early deterioration is the large artery atherosclerosis(45.5%Vs40.5%),followed by cardiogenic embolism(27.2%Vs25.5%).The prognosis of 90 days was higher than that of anterior circulation cerebral infarction(78.3%Vs58%),and the difference was statistically significant(P =0.02)..Conclusion The risk of intracranial hemorrhage in the posterior circulation is lower than that in the anterior circulation.The risk of hemorrhagic transformation after intravenous thrombolytic therapy was significantly lower than that of patients with anterior circulation infarction.90 day prognosis and recovery of neurological function was significantly better than that of anterior circulation infarction.The treatment of posterior circulation cerebral infarction is more safe and effective than that of the anterior circulation.Therefore,the time window of intravenous thrombolysis in patients with posterior circulation infarction may be prolonged.Part Two: Effect of intravenous thrombolytic therapy in patients with acute posterior circulation cerebral infarctionObjective To analyze the clinical characteristics,therapeutic effect and prognosis of intravenous thrombolytic therapy in patients with acute posterior circulation cerebral infarction.Methods A retrospective analysis of cerebrovascular disease center from September2013 to December 2016 during acute intravenous thrombolytic therapy in patients with posterior circulation infarction.To analyze the clinical symptoms,vascular risk factors,the distribution of cerebral infarction and the classification of cerebral infarction.According to the 90 day mRS divided into good prognosis group(0-2 points)and poor prognosis group(3-6 points),analysis of the impact of the treatment efficacy of the relevant factors of the two groups.Results 60 cases of patients with acute posterior circulation infarction received intravenous thrombolytic therapy,including male 38 cases,female 22 cases,aged 35 to 86 years old,average 64.6± 10.7 years.The most common clinical symptoms were limb weakness(70.0%)and vertigo(56.7%).The most common risk factors were hypertension(63.5%),diabetes mellitus(26.7%)and smoking(36.7%).85% patients had a single lesion and distal lesions were the most common.Large artery atherosclerosis(LAA)was the most common subtype(38.3%),followed by cardioembolism(CE)and small artery occlusion(SAO)according to TOAST classification.Single factor analysis showed that age(P=0.004),without hypertension history(P=0.001),lower NIHSS score before thrombolysis(P=0.019)and shorter onset to start of treatment(OTT)(P=0.045)were associated with the good prognosis.Multivariate logistic regression analysis showed that old age,hypertension,and transient ischemic attack or stroke history and higher NIHSS scores in patients with posterior circulation infarction were independently associated with poor functional outcome.Conclusion Intravenous thrombolytic therapy in patients with posterior circulation cerebral infarction was safe and effective.Old age,hypertension,TIA or stroke history and higher NIHSS scores are independent predictors of prognosis.Part Three:High resolution magnetic resonance imaging of the basilar artery wallObjective To study the high resolution magnetic resonance imaging of basilar artery wall in posterior circulation infarction type in the meaning of comparison of basilar artery perforator occlusion infarction and non infarction perforator occlusion type vascular remodeling and plaque characteristics.Methods Atherosclerotic occlusion according to different pathogenesis divided into branch occlusive disease(BOD)lesions and non branch occlusive disease(non-BOD).A total of 32 patients with symptomatic basilar artery stenosis admitted to our hospital were divided into BOD group(n =18)and non-BOD group(n = 14).Application of 3.0T high resolution magnetic resonance blood sequence of basilar artery wall enhancement,then,the CMRtools software was used to measure the plaque load and vascular remodeling index,and to study the characteristics of vascular remodeling and plaque in the two groups.Results High resolution MRI imaging results showed that the degree of vascular stenosis in non-BOD group was significantly higher than that in group BOD(68.9%±19.1%Vs.43.8%±18.8%,P=0.017).Positive remodeling was more common in the non-BOD group(57.2%Vs.16.7%,P=0.036).The wall area index of BOD group was less than that of group non-BOD(2.5Vs4.1,P < 0.001).Two types of vessels with eccentric enhancement,the degree of plaque enhancement had no difference between the two groups(p=0.196),but the degree of enhancement in group BOD than that in group non-BOD,the enhancement degree of the medians were 39.9% and 65.3%(p=0.004).Conclusion Basilar artery perforator artery occlusion infarction and non perforating artery occlusion type infarction both in vascular remodeling or plaque burden were different. |
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