Department of Neurology, University of Louisville School of Medicine, Louisville, Ky 40202, USA.
Stroke. 2010 Sep;41(9):1996-2000. doi: 10.1161/STROKEAHA.110.578997. Epub 2010 Jul 22.
The traditional time window for acute ischemic stroke intra-arterial therapy (IAT) is <6 hours, which is based on pharmacological thrombolysis without penumbral imaging. This study was conducted to determine the safety of patient selection for IAT based on perfusion mismatch rather than time.
A cohort of consecutive patients treated with IAT was identified by database review. Patients were selected for IAT based on the presence of perfusion mismatch using CT perfusion or MRI regardless of stroke duration. Thrombolytics were minimized after 6 hours in favor of mechanical embolectomy or angioplasty+/-stenting. Outcomes (National Institutes of Health Stroke Scale, modified Rankin Scale) were assessed by independent examiners. A multivariate analysis was performed to compare those treated <6 hours (early) with those treated >6 hours (late).
Fifty-five patients (mean National Institutes of Health Stroke Scale=19.7+/-5.7) were treated, 34 early and 21 late, with mean time-to-intervention of 3.4+/-1.6 hours and 18.6+/-16.0 hours, respectively. Thrombolysis In Myocardial Ischemia 2 or 3 recanalization was achieved in 82.8% early and 85.7% late patients (P=1.0). Intracerebral hemorrhage occurred in 25.5% overall, but symptomatic intracerebral hemorrhage occurred in 8.8% of the early and 9.5% of the late patients (P=1.0). Thirty-day mortality was similar (29.4% versus 23.8%, P=0.650). At 3 months, 41.2% and 42.9%, respectively, achieved a modified Rankin Scale <or=2 (P=0.902). Only presenting National Institutes of Health Stroke Scale was a predictor of modified Rankin Scale <or=2 (OR 0.794[95% CI 0.68 to 0.92], P=0.009) and death (adjusted OR 1.29[95% CI 1.04 to 1.59], P=0.019).
In appropriately selected patients, IAT for acute ischemic stroke can be performed safely regardless of stroke duration. The concept of an acute ischemic stroke treatment window for IAT should be re-evaluated with a clinical trial selecting patients with perfusion mismatch.
急性缺血性脑卒中血管内治疗（IAT）的传统时间窗为＜6 小时，该时间窗基于无缺血半暗带成像的药物溶栓。本研究旨在确定基于灌注不匹配而非时间选择 IAT 患者的安全性。
通过数据库回顾确定接受 IAT 治疗的连续患者队列。使用 CT 灌注或 MRI 选择接受 IAT 的患者，无论卒中持续时间如何，均基于灌注不匹配情况。在 6 小时后，减少溶栓药物治疗，以机械取栓或血管成形术+/-支架置入为主。通过独立检查者评估结局（国立卫生研究院卒中量表，改良 Rankin 量表）。进行多变量分析，比较治疗＜6 小时（早期）和＞6 小时（晚期）的患者。
共治疗了 55 例患者（平均国立卫生研究院卒中量表=19.7+/-5.7），34 例为早期，21 例为晚期，中位治疗时间分别为 3.4+/-1.6 小时和 18.6+/-16.0 小时。早期和晚期患者的血栓再通率分别为 82.8%和 85.7%（P=1.0）。总体颅内出血发生率为 25.5%，但早期和晚期患者的症状性颅内出血发生率分别为 8.8%和 9.5%（P=1.0）。30 天死亡率相似（29.4%与 23.8%，P=0.650）。3 个月时，分别有 41.2%和 42.9%的患者改良 Rankin 量表评分＜或=2（P=0.902）。仅发病时的国立卫生研究院卒中量表是改良 Rankin 量表评分＜或=2（优势比 0.794[95%置信区间 0.68 至 0.92]，P=0.009）和死亡（校正优势比 1.29[95%置信区间 1.04 至 1.59]，P=0.019）的预测因素。
在适当选择的患者中，无论卒中持续时间如何，急性缺血性脑卒中的 IAT 均可安全进行。对于 IAT，急性缺血性脑卒中治疗时间窗的概念应重新评估，通过临床试验选择存在灌注不匹配的患者。
