Urra Xabier, San Román Luis, Gil Francisco, Millán Mónica, Cánovas David, Roquer Jaume, Cardona Pere, Ribó Marc, Martí-Fàbregas Joan, Abilleira Sònia, Chamorro Ángel
Functional Unit of Cerebrovascular Diseases, Hospital Clínic, Barcelona, Spain.
Cerebrovasc Dis. 2014;38(6):418-24. doi: 10.1159/000369121. Epub 2014 Dec 3.
A significant proportion of stroke patients presenting with mild symptoms does not have a successful recovery, especially when a large vessel is occluded. IV thrombolysis is safe and may benefit patients presenting with mild symptoms. In this study, we tested whether endovascular therapy (ET) is superior to medical therapy in these patients.
Observational, prospectively collected, multicenter study of 78 consecutive patients admitted from 2009 to 2012 within 6 h of stroke, with NIHSS≤5 at presentation or during initial diagnostic work-up and large vessel occlusion. Data for patients undergoing ET and/or IV thrombolysis were taken from the SONIIA registry of reperfusion therapies in Catalonia, or from our local stroke registry if no reperfusion therapy was delivered. We compared risk factors, clinical course, collateral circulation, revascularization rates, hemorrhagic complications, infarct volume, and the functional outcome at 3 months of patients treated with ET and those not receiving ET. Ordinal regression was used to assess the independent effect of ET on functional outcome.
Baseline characteristics were similar for ET (n=34) and medically (n=44) treated patients, except for older age in the latter. The occlusions were located in the terminal internal carotid artery (1%), M1 segment of the middle cerebral artery (33%), M2 segment (30%), posterior circulation (31%), and 5% of the patients had tandem lesions, with no significant differences between groups. Most patients in both treatment groups had good collateral flow. The rate of successful revascularization (91.2 vs. 63.4%; p=0.006) and the risk of symptomatic intracranial hemorrhage (11.8 vs. 0%; p=0.033) were higher in the ET group. The NIHSS scores were similar at hospital arrival, after initial neuroimaging, and at 24 h in both treatment groups and there were no significant differences in the infarct volume in a follow-up MRI. At 3 months, 35.9% of the patients had some disability. The functional outcome was similar in both treatment groups in univariate analysis and also in models adjusted for age and initial NIHSS or for variables associated to functional outcome on univariate comparison. Conversely, IV thrombolysis was associated with significantly greater chances of full recovery after adjusting for baseline differences (OR 3.70, p=0.015).
One third of stroke patients with mild symptoms and large vessel occlusions do not have a successful recovery. ET is effective to recanalize the occluded vessel but increases the risk of serious bleeding significantly without improving the functional outcome, and is therefore not justified routinely in these patients.
相当一部分症状轻微的中风患者未能成功康复，尤其是在大血管闭塞的情况下。静脉溶栓治疗是安全的，可能对症状轻微的患者有益。在本研究中，我们测试了血管内治疗（ET）在这些患者中是否优于药物治疗。
这是一项观察性、前瞻性收集的多中心研究，研究对象为2009年至2012年中风6小时内入院的78例连续患者，入院时或初始诊断检查时美国国立卫生研究院卒中量表（NIHSS）评分≤5且存在大血管闭塞。接受ET和/或静脉溶栓治疗的患者数据来自加泰罗尼亚的SONIIA再灌注治疗登记处，若未进行再灌注治疗，则来自我们当地的中风登记处。我们比较了接受ET治疗和未接受ET治疗患者的危险因素、临床病程、侧支循环、血管再通率、出血并发症、梗死体积以及3个月时的功能结局。采用有序回归分析评估ET对功能结局的独立影响。
ET治疗组（n = 34）和药物治疗组（n = 44）的基线特征相似，只是后者年龄较大。闭塞部位位于颈内动脉末端（1%）、大脑中动脉M1段（33%）、M2段（30%）、后循环（31%），5%的患者有串联病变，两组之间无显著差异。两个治疗组的大多数患者侧支血流良好。ET组的成功血管再通率（91.2%对63.4%；p = 0.006）和有症状颅内出血风险（11.8%对0%；p = 0.033）更高。两组患者入院时、初始神经影像学检查后及24小时时的NIHSS评分相似，随访MRI中的梗死体积也无显著差异。3个月时，35.9%的患者有一定残疾。在单变量分析以及调整年龄和初始NIHSS或单变量比较中与功能结局相关变量的模型中，两个治疗组的功能结局相似。相反，在调整基线差异后，静脉溶栓与完全恢复的机会显著增加相关（比值比3.70，p = 0.015）。
三分之一症状轻微且存在大血管闭塞的中风患者未能成功康复。ET可有效使闭塞血管再通，但显著增加严重出血风险且未改善功能结局，因此在这些患者中常规应用不合理。
