intra-arterial thrombolysis for cerebral thrombosis

Cerebral thrombosis is a common type of acute ischemic cerebrovascular disease and an important cause of cerebral infarction. Due to cerebral atherosclerosis, the arterial lumen is narrowed or occluded, resulting in focal ischemia, hypoxia, and infarction in the blood supply area, causing focal neurological dysfunction. The most common causes of cerebral thrombosis are arteriosclerosis and hypertension. The predilection site is in the middle part of the middle cerebral artery, the internal carotid artery, and the vertebral artery and the basilar artery. 20% to 30% of thrombosis occurs in the larger arteries of the neck. Brain tissue is very sensitive to ischemia and hypoxia. When a certain artery is completely occluded, the ischemic necrosis, ie cerebral infarction, occurs rapidly in the brain tissue of the blood supply area. Within 6 hours after arterial occlusion, no obvious lesions were often seen and changed to be reversible. 8~48h showed obvious brain swelling and cerebral edema. After 4 to 14 days, brain softening and necrosis gradually reached a peak and began to liquefy. If the lesion range is large, the brain tissue is highly swollen, the midline shifts, and even the cerebral palsy is formed. After 3 to 4 weeks, the necrotic brain tissue is liquefied, phagocytized and removed, and glial fibrosis occurs at the same time. Its clinical manifestations vary with the location, extent and extent of the lesion, but have different neurological dysfunction. Diagnosis based on medical history, combined with CT, MRI and other tests generally no difficulty, need to be identified with other acute cerebrovascular diseases such as cerebral hemorrhage, subarachnoid hemorrhage, cerebral embolism. Comprehensive measures should be taken for treatment. Intra-arterial thrombolysis can be used for acute cerebral thrombosis. Fibrinolytic enzyme (plasmin) is a proteolytic enzyme formed by plasminogen under the action of plasminogen activin, which can cleave non-soluble fibrin into soluble fibrin fragments. Urokinase is A proteolytic enzyme consisting of a polypeptide chain having a molecular weight of 54,000, which activates the lysogen of fibrin to make it a plasmin. Treatment of diseases: cerebral thrombosis cerebral thrombosis Indication 1. Acute cerebral thrombosis, the lesion is located in the main artery of the brain, clinically significant neurological dysfunction, should strive for intra-arterial thrombolysis within 6 hours of the onset, no later than 48h. 2. Acute cerebral thrombosis and cerebral embolism complicated by catheter diagnosis and treatment, clinically significant neurological dysfunction. Contraindications 1. Acute cerebral thrombosis, clinically no obvious neurological dysfunction, or clinical manifestations of significant neurological dysfunction, but the onset time is more than 48h, the patient has obvious cerebral edema, brain swelling, increased intracranial pressure caused by cerebral palsy or sudden death patient. 2. The sequelae of cerebral thrombosis, the brain tissue supplied by the embolized blood vessel has produced irreversible pathological changes. Preoperative preparation Patient preparation 1 Learn more about the medical history, conduct a comprehensive physical examination and systematic neurological examination. 2 Those with a history of epilepsy were treated with antiepileptic drugs before surgery. 3 preoperatively according to the condition of the CT scan plus enhanced scan, MRI, MRA examination. 4 blood, urine routine, bleeding, clotting time, liver and kidney function, chest fluoroscopy, heart, EEG, etc. before surgery. 5 fasting before surgery, iodine allergy test, puncture site (such as the perineum) preparation skin, indwelling catheter. 6 Use a cloth strap to restrain the limbs. 2. Special equipment, drug preparation 1 116G or 18G puncture needle; 2 diameter 0.89mm, length 40cm guide wire; 36F catheter sheath 1; 46F guide tube 1; 5 Magic-3F/1.8F1 root; 6 with three-way soft connection tube 1 718cm long connecting tube; 1Magic-3F/2F microcatheter; 1 9Y with valve connector, 1 two-way switch; 10 pressurized infusion bag 1 set; 1ml syringe 3; urokinase 50,000 U / support × 10. Surgical procedure 1. Transfemoral approach for thrombolysis (1) The perineum and bilateral groin are routinely disinfected and sterile towels are placed. With 1% or 2% lidocaine in the right (or left) side of the inguinal ligament 2 ~ 3cm, the femoral artery pulsation is clearly layer by layer infiltration anesthesia, and the patient is neurologically anesthetized. The right femoral artery was inserted into a 6F catheter sheath. (2) Insert the 6F guiding tube through the 6F catheter sheath, and select the left cerebral artery or the vertebral artery to perform selective cerebral angiography under the supervision of TV to understand the location of thrombosis and the degree of embolism. After the diagnosis is made, the guiding tube is inserted into the internal carotid artery or vertebral artery of the lesion side. (3) The tail end of the 6F guide tube is connected with the Y-shaped valve joint, and the side arm is connected with the infusion tube of the pressurized infusion bag. After the air bubble in the pipeline is drained, the speed of the pressurized infusion is adjusted, and the physiological saline is slowly dropped. Give the patient systemic heparinization. (4) The Y-shaped valve has a valve arm inserted into Magic-3F/1.8F or Magic-3F/3F, and is sent to the vicinity of the thrombus formation under television monitoring. (5) Dissolve urokinase 50,000 U in 250 ml of normal saline, inject it by hand or automatically pressurize the infusion pump, and finish it in 60 minutes. If a dose is not enough, it can be added. Labange reports that it can use 75,000 to 225,000 U continuously for 3 to 6 hours. (6) During the thrombolysis process, the thrombolysis was continuously observed by 6F guiding tube angiography. After thrombolysis, the thrombolytic effect and recanalization were observed by 6F guiding tube angiography. (7) End of thrombolysis, neutralize heparin with protamine as appropriate, pull out the catheter and catheter sheath, and puncture the site for 15-20 min. When there is no bleeding, cover the sterile gauze and partially compress the dressing. 2. Transcatheter approach for thrombolytic therapy Only suitable for internal carotid artery thrombosis. (1) The patient lies on the angiography bed, the back cushion is high, the neck is routinely disinfected, the towel is placed and the local infiltration anesthesia is performed. (2) puncture the common carotid artery with 16G cerebral angiography needle, fix the puncture needle, connect the 18cm long connecting tube to the tail of the needle, connect the Y-shaped valve connector at the end of the connecting tube, and inject the side arm and the pressurized infusion bag. After the tubes are connected, the air in the pipeline is drained, the speed of the pressurized infusion is adjusted, the physiological saline is slowly dropped, and the patient is heparinized. (3) The valve arm is inserted into the Magic-3F/1.8F or Magic-3F/2F microcatheter through the Y-shaped valve connector, and is sent to the internal carotid artery under TV surveillance, close to the thrombus formation. (4) The thrombolysis method and its operation are shown in steps 5, 6, and 7 of the transfemoral thrombolysis procedure described above. complication Secondary intracranial hemorrhage after intracerebral thrombolysis is the most dangerous complication. In addition to clinically closely observed, biochemical monitoring should be strengthened, and plasma fibrinogen, thrombin time, activity, and clotting time should be checked regularly. Once bleeding occurs, thrombolytic therapy should be stopped and 4 to 5 g of 6-aminocaproic acid administered intravenously to neutralize urokinase. Anaphylactic shock can sometimes occur, and adrenaline and hormonal anti-shock treatment should be used quickly.