经滑车上动脉逆行或颈外动脉顺行介入溶栓治疗视网膜中央动脉阻塞伴同侧颈内动脉闭塞的疗效观察

摘要

目的 观察经滑车上动脉逆行或颈外动脉顺行介入溶栓治疗视网膜中央动脉阻塞(CRAO)伴同侧颈内动脉闭塞的疗效.方法 临床确诊为CRAO伴同侧颈内动脉闭塞的9例患者9只眼纳入研究.其中,男性5例,女性4例.平均年龄(45.2±18.1)岁,平均发病时间24 h.视力无光感4只眼,光感3只眼,手动2只眼.荧光素眼底血管造影(FFA)检查,视网膜动脉荧光充盈延迟,可见动脉荧光充盈前峰,部分患眼可见逆行充盈荧光.臂-视网膜循环时间(A-Rct)≥35s4只眼,≥25 s～＜35 s 5只眼;视网膜动脉主干-分支末梢充盈时间≥15s2只眼,≥12s～＜15s3只眼,≥9s～＜12s4只眼.确诊后参照急性脑梗死溶栓治疗适应证和禁忌症行经滑车上动脉逆行介入溶栓治疗8只眼,颈外动脉顺行介入溶栓治疗1只眼.采用间歇性注药方式注入尿激酶,总用量40万U.尿激酶注射完毕后行数字减影血管造影(DSA)检查,观察眼动脉及其分支有无变化以及循环时间、眼环显影状况.以眼动脉及其分支增粗、循环时间缩短2s以上为治疗有效.介入溶栓治疗后24 h复查视力、眼底及FFA,对比分析治疗前后视力、眼底及视网膜血液循环状况.以A-Rct≤15s和视网膜动脉主干-分支末梢充盈时间在2s内为显效,即恢复正常;A-Rct较治疗前缩短但在16～20 s以内,视网膜动脉主干-分支末梢充盈时间3～8 s为有效;A-Rct虽较治疗前缩短但仍≥21s,视网膜动脉主干-分支末梢充盈时间≥9s为无效.同时观察患者有无眼球活动异常、玻璃体积血以及切口部位血肿、颅内出血、脑栓塞等局部及全身不良反应发生.结果 DSA检查,眼动脉及其分支血管增粗6只眼,占66.7％;眼环显影较前明显6只眼,占66.7％.循环时间缩短2s者3只眼,3s者3只眼,4s者2只眼,无变化1只眼.FFA检查,A-Rct均较治疗前缩短,为16～20 s.视网膜血液循环变化显效4只眼,占44.4％;有效4只眼,占44.4％;无效1只眼,占11.2％.视力提高3行4只眼,占44.4％;提高2行3只眼,占33.3％;变化在1行以内1只眼,占11.2％;无变化1只眼,占11.2％.所有患眼眶部皮肤伤口愈合.治疗及随访过程中均未发生切口部位血肿、颅内出血、脑栓塞等并发症以及眼球活动异常、玻璃体积血等眼部不良反应.结论 经滑车上动脉逆行或颈外动脉顺行介入溶栓治疗CRAO伴同侧颈内动脉闭塞,可改善患眼视网膜血液循环及视力;治疗及随访过程中均未发生全身及眼部并发症.%Objective To observe the effect of interventional thrombolytic therapy for central retinal artery occlusion (CRAO) with ipsilateral internal carotid artery occlusion via supratrochlear artery retrogradely or external carotid artery anterogradely.Methods Nine CRAO patients (9 eyes) were enrolled in this study,including 5 males and 4 females.The mean age was (45.2 ± 18.1) years.The mean onset duration was 24 hours.There were 4 eyes with vision of no light perception,3 eyes with light perception and 2 eyes with hand movement.Fundus fluorescein angiography (FFA) examination showed that the retinal artery was filled with delayed fluorescence.The peak of fluorescence was seen in the anterior part of the artery,and some of the eyes showed retrograde filling.The arm-retinal circulation time (A-Rct) was ≥35 s in 4 eyes,≥35 s-＜25 s in 5 eyes.The filling time of retinal artery and its branches (FT) was ≥ 15 s in 2 eyes,≥ 12 s-＜15 s in 3 eyes,≥9 s-＜ 12 s in 4 eyes.All the patients received the treatment of interventional thrombolytic therapy via supratrochlear artery retrogradely (8 eyes) or external carotid artery anterogradely (1 eye) according to the indications and contraindications of thrombolytic therapy in acute cerebral infraction patients.Urokinase (0.4 million U in total) was intermittently injected into the arteries.After artery thrombolysis,the changes of digital subtraction angiography (DSA),filling time of retinal artery and its branches on FFA within 24 hours and the visual acuity were observed.According to the A-Rct and FT on FFA,the therapeutic effects on retinal circulation were defined as effective markedly (A-Rct≤ 15 s,FT ≤2 s),effective (A-Rct was improved but in the range of 16-20 s,FT was in 3-8 s) and no effect (A-Rct was improved but ≥21 s,FT≥9 s).The related local or systemic complications were recorded.Results After the injection ofurokinase into the catheter,the ophthalmic artery and its branches were increased in 6 eyes (66.7％),and the development of the eye ring was significantly more than that of the eyes before thrombolysis.The circulation time in ophthalmic artery was speeded up for 2 s before thrombolysis in 3 eyes,3 s in 3 eyes,and 4 s in 2 eyes.Within 24 hours after thrombolysis treatment,the A-Rct was significantly decreased than that of before interventional therapy.The retinal circulation was effective markedly in 4 eyes (44.4％),effective in 4 eyes (44.4％) and no effect in 1 eyes (11.2％).The vision was improved 3 lines in 4 eyes (44.4％),2 lines in 3 eyes (33.3％),1 line in 1 eye (11.2％) and no change in 1 eye (11.2％).There were no abnormal eye movements,vitreous hemorrhage and incision hematoma,intracranial hemorrhage,cerebral embolism,and other local and systemic adverse effeetives during the follow-up.Conclusions The interventional thrombolytic therapy via supratrochlear artery retrogradely or external carotid artery anterogradely for CRAO with the ipsilateral internal carotid artery occlusion can improve retinal circulation and vision.There are no related local or systemic complications.