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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）CathetCardiovascDiagn.1996Jul;38(3):316-9UseofcoronaryPalmaz-Schatzstentinthepercu

taneoustreatmentofanintracranialcarotidarterystenosisFeldmanRL,TriggL,GaudierJ,GalatJ.OcalaHeartInstit

ute,Florida,USA.A69-yr-oldmanhadchronictransientischemiaattacksduetoseverestenosisoftheintracranialportionoftherightcarotidar

tery.Afterfailureofbothantiplateletandanticoagulanttherapy,treatmentwassuccessfulwithpercutaneoustransluminalangioplastyandacoronary

Palmaz-Schatzstent.Useofthestentledtoabetterangiographicresultthanangioplastyalone.Thepatientisasymptomatic4molater.进展进展•SSYLVIATrial•WING

SPANTrial（prospective,multicenterstudy）–selfexpandingmicrostent–45patientswithstenoses>50%–ipsilateralstrokeordeathrateo

f30-d4.4%6-m7.1%进展•多中心、随机对照研究进展•Astechnologyandexperienceevolve,thisprocedureisbecomingincreasinglyeffectiveandsaf

eforthetreatmentofintracranialatheroscleroticdisease,andguidelinesarebeingdevelopedforitsuse.HartmannM,etal.CurrOpNeurol.2005;18:39–45.AJNR

AmJNeuroradiol.2005;26:2323–2327.进展•Withinperi-procedureStrokeanddeath8.3%•Annualstroke3%-5%NeurosurgClinN

Am.2005;16:297–308.AJNRAmJNeuroradiol.2005;26:525–530.进展•Thisprocedure,however,remainshazardouswithupto

50%ofpatientsshowingnew,ipsilateralischemiclesionsondiffusion-weightedMRimages.AJNRAmJNeuroradiol.2005;26:385–389.进展•Intracrania

langioplastywithorwithoutstentingshouldbeofferedtosymptomaticpatientswithintracranialstenoseswhohavefailedmedicaltherap

y•Similartorevascularizationforextracranialcarotidarterystenosis,patientbenefitfromrevascularizationforsympt

omaticintracranialarterialstenosisiscriticallydependentonalowperiproceduralstrokeanddeathrateandshouldthusbeperformedbyexperiencedne

urointerventionistsJVascIntervRadiol2005;16:1281–1285进展•Drug-elutingstents,althoughshowingpromiseincoronaryand

caninevesselsforthepreventionofrestenosis,arestillnotreadyforhumancerebralarteriesbecauseofdifferinghistologya

ndquestionsofdrugneurotoxicity.PelzD,AdvancesinInterventionalNeuroradiology2005.Stroke.2006;37:309-311.)治疗•手术适应症–TIAsorstrokeattributedtointracrani

alstenosesof≥50%diameterreduction–Evidencesofatheroscleroticriskfactorsordissection–Evidencesofdecreasedperfusion

distaltothestenosis治疗•狭窄率的测量AJNRAmJNeuroradiol21:643–646,April2000治疗•Determinedbythefollowingcriteria–Firstchoice：Thediameteroftheproximalpartofthear

teryatitswidest,nontortuous,normalsegmentwaschosen治疗•Secondchoice：Iftheproximalarterywasdiseased(eg,middlecerebralarteryoriginstenosis),thediame

terofthedistalportionofthearteryatitswidest,parallel,non-tortuousnormalsegmentwassubstituted治疗•Thirdchoice：Iftheentir

eintracranialarterywasdiseased,themostdistal,parallel,non-tortuousnormalsegmentofthefeedingarterywasmeasured治疗•技术成功标准–Residualstenosis≤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–Reducerelatedproceduralcomplications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CT–PET–SPECT治疗•脑血管–超声检查–CTA–CEMRA–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<5mm•B型病变：偏心性狭窄，长度5-10mm，或闭塞，但时间<3个月•C型病变：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033%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AEFABCD治疗

•病变的形态学（Morphology）分型–A型：长度<5mm，同心或适度偏心性狭窄–B型：长度5-10mm，偏心性、成角（>45°）或不规则狭窄，闭塞时间<3个月–C型：长度>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–Ⅰ型：适度迂曲，管壁光滑–Ⅱ型：较严重的迂曲–Ⅲ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