Schonewille Wouter J, Wijman Christine A C, Michel Patrik, Rueckert Christina M, Weimar Christian, Mattle Heinrich P, Engelter Stefan T, Tanne David, Muir Keith W, Molina Carlos A, Thijs Vincent, Audebert Heinrich, Pfefferkorn Thomas, Szabo Kristina, Lindsberg Perttu J, de Freitas Gabriel, Kappelle L Jaap, Algra Ale
Department of Neurology, University Medical Center Utrecht and Rudolf Magnus Institute of Neurosciences, Netherlands.
Lancet Neurol. 2009 Aug;8(8):724-30. doi: 10.1016/S1474-4422(09)70173-5. Epub 2009 Jul 3.
Treatment strategies for acute basilar artery occlusion (BAO) are based on case series and data that have been extrapolated from stroke intervention trials in other cerebrovascular territories, and information on the efficacy of different treatments in unselected patients with BAO is scarce. We therefore assessed outcomes and differences in treatment response after BAO.
The Basilar Artery International Cooperation Study (BASICS) is a prospective, observational registry of consecutive patients who presented with an acute symptomatic and radiologically confirmed BAO between November 1, 2002, and October 1, 2007. Stroke severity at time of treatment was dichotomised as severe (coma, locked-in state, or tetraplegia) or mild to moderate (any deficit that was less than severe). Outcome was assessed at 1 month. Poor outcome was defined as a modified Rankin scale score of 4 or 5, or death. Patients were divided into three groups according to the treatment they received: antithrombotic treatment only (AT), which comprised antiplatelet drugs or systemic anticoagulation; primary intravenous thrombolysis (IVT), including subsequent intra-arterial thrombolysis; or intra-arterial therapy (IAT), which comprised thrombolysis, mechanical thrombectomy, stenting, or a combination of these approaches. Risk ratios (RR) for treatment effects were adjusted for age, the severity of neurological deficits at the time of treatment, time to treatment, prodromal minor stroke, location of the occlusion, and diabetes.
619 patients were entered in the registry. 27 patients were excluded from the analyses because they did not receive AT, IVT, or IAT, and all had a poor outcome. Of the 592 patients who were analysed, 183 were treated with only AT, 121 with IVT, and 288 with IAT. Overall, 402 (68%) of the analysed patients had a poor outcome. No statistically significant superiority was found for any treatment strategy. Compared with outcome after AT, patients with a mild-to-moderate deficit (n=245) had about the same risk of poor outcome after IVT (adjusted RR 0.94, 95% CI 0.60-1.45) or after IAT (adjusted RR 1.29, 0.97-1.72) but had a worse outcome after IAT compared with IVT (adjusted RR 1.49, 1.00-2.23). Compared with AT, patients with a severe deficit (n=347) had a lower risk of poor outcome after IVT (adjusted RR 0.88, 0.76-1.01) or IAT (adjusted RR 0.94, 0.86-1.02), whereas outcomes were similar after treatment with IAT or IVT (adjusted RR 1.06, 0.91-1.22).
Most patients in the BASICS registry received IAT. Our results do not support unequivocal superiority of IAT over IVT, and the efficacy of IAT versus IVT in patients with an acute BAO needs to be assessed in a randomised controlled trial.
Department of Neurology, University Medical Center Utrecht.
急性基底动脉闭塞（BAO）的治疗策略是基于病例系列研究以及从其他脑血管区域的卒中干预试验中推断出的数据，而关于不同治疗方法对未选择的BAO患者疗效的信息较少。因此，我们评估了BAO后的治疗效果及治疗反应差异。
基底动脉国际合作研究（BASICS）是一项前瞻性观察性登记研究，纳入了2002年11月1日至2007年10月1日期间出现急性症状且经影像学证实为BAO的连续患者。治疗时的卒中严重程度分为重度（昏迷、闭锁综合征或四肢瘫）或轻度至中度（任何程度低于重度的缺损）。在1个月时评估结局。不良结局定义为改良Rankin量表评分为4或5分，或死亡。根据患者接受的治疗将其分为三组：仅抗栓治疗（AT），包括抗血小板药物或全身抗凝；静脉溶栓（IVT），包括后续动脉内溶栓；或动脉内治疗（IAT），包括溶栓、机械取栓、支架置入或这些方法的联合应用。治疗效果的风险比（RR）针对年龄、治疗时神经功能缺损的严重程度、治疗时间、前驱小卒中、闭塞部位和糖尿病进行了调整。
619例患者被纳入登记研究。27例患者因未接受AT、IVT或IAT而被排除在分析之外，且均预后不良。在592例接受分析的患者中，183例仅接受AT治疗，121例接受IVT治疗，288例接受IAT治疗。总体而言，接受分析的患者中有402例（68%）预后不良。未发现任何治疗策略具有统计学上的显著优势。与AT治疗后的结局相比，轻度至中度缺损患者（n = 245）接受IVT（校正RR 0.94，95% CI 0.60 - 1.45）或IAT（校正RR 1.29，0.97 - 1.72）后预后不良的风险大致相同，但与IVT相比，IAT后的结局更差（校正RR 1.49，1.00 - 2.23）。与AT相比，重度缺损患者（n = 347）接受IVT（校正RR 0.88，0.76 - 1.01）或IAT（校正RR 0.94，0.86 - 1.02）后预后不良的风险较低，而IAT或IVT治疗后的结局相似（校正RR 1.06，0.91 - 1.22）。
BASICS登记研究中的大多数患者接受了IAT。我们的结果不支持IAT相对于IVT具有明确的优势，急性BAO患者中IAT与IVT疗效的比较需要在随机对照试验中进行评估。
乌得勒支大学医学中心神经内科。
