Mazighi Mikael, Serfaty Jean-Michel, Labreuche Julien, Laissy Jean-Pierre, Meseguer Elena, Lavallée Philippa C, Cabrejo Lucie, Slaoui Tarik, Guidoux Céline, Lapergue Bertrand, Klein Isabelle F, Olivot Jean-Marc, Abboud Halim, Simon Olivier, Niclot Philippe, Nifle Chantal, Touboul Pierre-Jean, Raphaeli Gai, Gohin Christiane, Claeys Elisabeth Schouman, Amarenco Pierre
Department of Neurology and Stroke Centre, Bichat University Hospital, Paris, France; Diderot University, Paris, France.
Lancet Neurol. 2009 Sep;8(9):802-9. doi: 10.1016/S1474-4422(09)70182-6. Epub 2009 Jul 31.
The efficacy of intravenous (IV) alteplase is restricted by the speed of recanalisation and the site of the occlusion. The aim of this study was to ascertain the effect of a combined IV-endovascular approach (intra-arterial alteplase and, if required, additional thrombectomy) in patients with stroke due to arterial occlusion.
We compared recanalisation rates, neurological improvement at 24 h, and functional outcome at 3 months between two periods (February, 2002, to March, 2007, vs April, 2007, to October, 2008) in patients in a prospective registry who were treated with different regimens of alteplase within 3 h of symptom onset. Patients with confirmed occlusion who were treated before April, 2007, were treated with IV alteplase; after April, 2007, patients were treated with a systematic IV-endovascular approach. Analysis was by intention to treat.
46 (87%) of 53 patients treated with the IV-endovascular approach achieved recanalisation versus 56 (52%) of 107 patients in the IV group (adjusted relative risk [RR] 1.49, 95% CI 1.21-1.84; p=0.0002). Early neurological improvement (NIHSS score of 0 or 1 or an improvement of 4 points or more at 24 h) occurred in 32 (60%) patients in the IV-endovascular group and 42 (39%) patients in the IV group (adjusted RR 1.36, 0.97-1.91; p=0.07). Favourable outcome (mRS of 0-2 at 90 days) occurred in 30 (57%) patients in the IV-endovascular group and 47 (44%) patients in the IV group (adjusted RR 1.16, 0.85-1.58; p=0.35). The mortality rate at 90 days was 17% in both groups, and symptomatic intracranial haemorrhage was reported in five (9%) patients in the IV-endovascular group and in 12 (11%) patients in the IV group. Better clinical outcome was associated with recanalisation in both groups and with time to recanalisation in the IV-endovascular group.
An IV-endovascular approach is associated with higher recanalisation rates than is IV alteplase in patients with stroke and confirmed arterial occlusion. In patients treated with an IV-endovascular approach, a shorter time from symptom onset to recanalisation is associated with better clinical outcomes.
静脉注射阿替普酶的疗效受再通速度和闭塞部位的限制。本研究的目的是确定静脉-血管内联合治疗方法（动脉内注射阿替普酶，必要时进行额外的血栓切除术）对动脉闭塞性卒中患者的影响。
我们比较了前瞻性登记研究中两个时间段（2002年2月至2007年3月与2007年4月至2008年10月）内症状发作3小时内接受不同阿替普酶治疗方案的患者的再通率、24小时时的神经功能改善情况以及3个月时的功能结局。2007年4月之前确诊为闭塞的患者接受静脉注射阿替普酶治疗；2007年4月之后，患者接受系统性静脉-血管内联合治疗方法。分析采用意向性治疗。
接受静脉-血管内联合治疗方法的53例患者中有46例（87%）实现再通，而静脉注射组的107例患者中有56例（52%）实现再通（调整后的相对风险[RR]为1.49，95%置信区间为1.21-1.84；p=0.0002）。静脉-血管内联合治疗组32例（60%）患者出现早期神经功能改善（24小时时美国国立卫生研究院卒中量表[NIHSS]评分为0或1或改善4分及以上），静脉注射组42例（39%）患者出现早期神经功能改善（调整后的RR为1.36，0.97-1.91；p=0.07）。静脉-血管内联合治疗组30例（57%）患者获得良好结局（90天时改良Rankin量表[mRS]评分为0-2），静脉注射组47例（44%）患者获得良好结局（调整后的RR为1.16，0.85-1.58；p=0.35）。两组90天时死亡率均为17%，静脉-血管内联合治疗组5例（9%）患者和静脉注射组12例（11%）患者报告有症状性颅内出血。两组中更好的临床结局均与再通相关，静脉-血管内联合治疗组中还与再通时间相关。
对于确诊为动脉闭塞的卒中患者，静脉-血管内联合治疗方法比静脉注射阿替普酶具有更高的再通率。在接受静脉-血管内联合治疗方法的患者中，从症状发作到再通的时间越短，临床结局越好。
