Liebeskind David S, Jahan Reza, Nogueira Raul G, Jovin Tudor G, Lutsep Helmi L, Saver Jeffrey L
Neurovascular Imaging Research Core and the UCLA Stroke Center, Los Angeles, California, USA.
UCLA Stroke Center, Los Angeles, California, USA.
J Neurointerv Surg. 2016 Jun;8(6):553-8. doi: 10.1136/neurintsurg-2015-011758. Epub 2015 May 11.
Increasing time from symptom onset to emergency department arrival may incur greater ischemic injury and decreased likelihood of good outcomes after acute stroke therapy. The impact of time may be assessed bythe extent of acute CT changes, status of collateral vessels, and clinical outcomes.
The SOLITAIRE FR With the Intention For Thrombectomy (SWIFT) trial comparing two neurothrombectomy treatments was analyzed by time, Alberta Stroke Program Early CT Scores (ASPECTS), angiographic collaterals, and 90-day modified Rankin Scale outcomes. We determined the interaction of time with ASPECTS, collateral grade, reperfusion, and clinical outcomes, with established determinants of angiographic and clinical outcomes as covariates.
137 patients (52% female) of mean age 67±12 years and median pretreatment NIH Stroke Scale score 18 (range 8-28) were enrolled. Median onset to door (OTD) time was 180 min (IQR 95-250). Presentation within 3 h of last known well was associated with absence of any prestroke disability and presence of atrial fibrillation but was unrelated to age, sex, other vascular risk factors, deficit severity, glucose level, or blood pressure. Worse collaterals were noted with longer OTD intervals: collateral grade 0-1 (n=32): mean 232±84 min; grade 2 (n=48): 164±99 min; grade 3 (n=35): 155±104 min; grade 4 (n=4): 54±16 min (p<0.001). Later presentation was associated with more extensive early infarct imaging changes (median ASPECTS 8 (IQR 7-9) >3 h vs 9 (IQR 8-10) <3 h, p=0.015). Multivariable analyses identified time >3 h as the only predictor of extensive infarct on imaging (ASPECTS ≤7), p=0.003. Earlier presentation was strongly associated with better 90-day modified Rankin Scale outcomes (p<0.001).
Time was a critical factor in successful clinical outcomes for neurothrombectomy in the SWIFT trial. Shorter times to presentation were associated with better collaterals, smaller established infarcts, and better clinical outcome after revascularization.
从症状发作到抵达急诊科的时间延长可能会导致急性缺血性卒中治疗后缺血性损伤加重，良好预后的可能性降低。时间的影响可通过急性CT改变的程度、侧支血管状态和临床结局来评估。
对比较两种神经血管内血栓切除术治疗方法的“旨在血栓切除术的Solitaire FR（SWIFT）试验”，按时间、阿尔伯塔卒中项目早期CT评分（ASPECTS）、血管造影侧支循环以及90天改良Rankin量表结局进行分析。我们确定了时间与ASPECTS、侧支循环分级、再灌注及临床结局之间的相互作用，并将血管造影和临床结局的既定决定因素作为协变量。
共纳入137例患者（52%为女性），平均年龄67±12岁，治疗前美国国立卫生研究院卒中量表评分中位数为18（范围8 - 28）。从发病到入院（OTD）的中位时间为180分钟（四分位间距95 - 250）。在最后一次已知健康状态后3小时内就诊与无前驱性残疾及存在心房颤动相关，但与年龄、性别、其他血管危险因素、神经功能缺损严重程度、血糖水平或血压无关。OTD间隔时间越长，侧支循环越差：侧支循环分级0 - 1级（n = 32）：平均232±84分钟；2级（n = 48）：164±99分钟；3级（n = 35）：155±104分钟；4级（n = 4）：54±16分钟（p < 0.001）。就诊时间越晚，早期梗死灶影像学改变越广泛（ASPECTS中位数8（四分位间距7 - 9）>3小时 vs 9（四分位间距8 - 10）<3小时，p = 0.015）。多变量分析确定就诊时间>3小时是影像学上广泛梗死（ASPECTS≤7）的唯一预测因素，p = 0.003。更早就诊与90天改良Rankin量表结局更好密切相关（p < 0.001）。
在SWIFT试验中，时间是神经血管内血栓切除术取得成功临床结局的关键因素。就诊时间越短，侧支循环越好，已形成的梗死灶越小，血管再通后的临床结局越好。
