Skagen Karolina, Skjelland Mona, Russell David, Jacobsen Eva A
Department of Neurology, Oslo University Hospital, Oslo, Norway.
Department of Neurology, Oslo University Hospital, Oslo, Norway.
J Stroke Cerebrovasc Dis. 2015 Jul;24(7):1532-9. doi: 10.1016/j.jstrokecerebrovasdis.2015.03.020. Epub 2015 Apr 23.
Arterial recanalization is currently considered the main standard of successful early management of acute ischemic stroke. Intravenous (IV) thrombolysis with tissue plasminogen activator (tPa) is the only Food and Drug Administration-approved medical treatment. Large-vessel occlusion, estimated to account for up to 40% of all acute ischemic strokes, is often refractory to IV thrombolysis and is associated with a poor patient outcome. Mechanical recanalization procedures are therefore increasingly used in the treatment of large-vessel occlusion refractory to, or presenting outside the accepted time window for, IV thrombolysis. The aim of this study was to investigate the effect of early vessel recanalization on clinical outcome in patients with large-vessel occlusion stroke.
This is a single-center cohort study, analyzing prospectively collected data on 152 patients with large-vessel occlusion and acute ischemic stroke. Seventy-one patients received endovascular treatment (of whom 57.7% also received IV tPA), and 81 (55.6% of whom also received IV tPa) were not treated with endovascular therapy. Clinical outcome was compared for 2 cohorts: patients who recanalized (n = 46) and patients with persisting large-vessel occlusion (n = 106).
Early recanalization was an independent predictor of a good clinical outcome in only those patients who presented with a severe ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score >15; P = .017). This was not the case for less severe strokes (NIHSS score ≤ 15) where recanalization did not lead to more patients with functional independence at 90-day follow-up (P = .21).
In this study of acute large-vessel occlusion stroke, we found that clinical outcome following early recanalization was dependent on the patient's pretreatment NIHSS score. A non-negligible proportion of patients with milder strokes did well despite persistent large-vessel occlusion. These results may suggest that in patients who are able to maintain adequate collateral flow despite proximal arterial occlusion, effective adaptive mechanisms are present, which for some patients are long-lasting. This may influence the process of appropriate patient selection for endovascular therapy.
动脉再通目前被认为是急性缺血性卒中早期成功治疗的主要标准。静脉注射组织型纤溶酶原激活剂（tPa）溶栓是美国食品药品监督管理局批准的唯一药物治疗方法。据估计，高达40%的急性缺血性卒中由大血管闭塞引起，这类卒中通常对静脉溶栓治疗效果不佳，且患者预后较差。因此，机械再通手术越来越多地用于治疗对静脉溶栓治疗无效或超出静脉溶栓治疗可接受时间窗的大血管闭塞性卒中。本研究旨在探讨早期血管再通对大血管闭塞性卒中患者临床结局的影响。
这是一项单中心队列研究，前瞻性分析了152例大血管闭塞性急性缺血性卒中患者的数据。71例患者接受了血管内治疗（其中57.7%的患者还接受了静脉注射tPa），81例（其中55.6%的患者也接受了静脉注射tPa）未接受血管内治疗。比较了两个队列的临床结局：血管再通的患者（n = 46）和大血管闭塞持续存在的患者（n = 106）。
仅在那些表现为严重缺血性卒中（美国国立卫生研究院卒中量表[NIHSS]评分>15；P = 0.017）的患者中，早期再通是良好临床结局的独立预测因素。对于症状较轻的卒中（NIHSS评分≤15），情况并非如此，在90天随访时，再通并未使更多患者实现功能独立（P = 0.21）。
在这项急性大血管闭塞性卒中研究中，我们发现早期再通后的临床结局取决于患者治疗前的NIHSS评分。尽管大血管闭塞持续存在，但仍有相当比例的轻度卒中患者预后良好。这些结果可能表明，对于尽管近端动脉闭塞但仍能维持足够侧支血流的患者，存在有效的适应性机制，对一些患者来说，这种机制是持久的。这可能会影响血管内治疗合适患者的选择过程。
