Mair Grant, von Kummer Rüdiger, Morris Zoe, von Heijne Anders, Bradey Nick, Cala Lesley, Peeters André, Farrall Andrew J, Adami Alessandro, Potter Gillian, Cohen Geoff, Sandercock Peter A G, Lindley Richard I, Wardlaw Joanna M
From the Division of Neuroimaging Sciences (G.M., Z.M., A.J.F., G.C., J.M.W.) and the Division of Clinical Neurosciences (P.A.G.S.), University of Edinburgh, UK; the Department of Neuroradiology (R.v.K.), Dresden University Stroke Centre, Germany; Danderyd Hospital (A.v.H.), Stockholm, Sweden; Neuroradiology (N.B.), James Cook University Hospital, Middlesborough, UK; School of Pathology and Laboratory Medicine (L.C.), University of Western Australia, Perth; Cliniques Universitaires St Luc (A.P.), Neurologie, Belgium; Stroke Center (A.A.), Sacro Cuore-Don Calabria Hospital, Negrar, Italy; the Department of Neuroradiology (G.P.), Salford Royal NHS Foundation Trust, Manchester, UK; and the Westmead Hospital Clinical School and The George Institute for Global Health (R.I.L.), University of Sydney, Australia.
Neurology. 2016 Jan 12;86(2):118-25. doi: 10.1212/WNL.0000000000002236. Epub 2015 Dec 9.
To investigate whether the location and extent of the CT hyperdense artery sign (HAS) at presentation affects response to IV alteplase in the randomized controlled Third International Stroke Trial (IST-3).
All prerandomization and follow-up (24-48 hours) CT brain scans in IST-3 were assessed for HAS presence, location, and extent by masked raters. We assessed whether HAS grew, persisted, shrank, or disappeared at follow-up, the association with 6-month functional outcome, and effect of alteplase. IST-3 is registered (ISRCTN25765518).
HAS presence (vs absence) independently predicted poor 6-month outcome (increased Oxford Handicap Scale [OHS]) on adjusted ordinal regression analysis (odds ratio [OR] 0.66, p < 0.001). Outcome was worse in patients with more (vs less) extensive HAS (OR 0.61, p = 0.027) but not in proximal (vs distal) HAS (p = 0.420). Increasing age was associated with more HAS growth at follow-up (OR 1.01, p = 0.013). Treatment with alteplase increased HAS shrinkage/disappearance at follow-up (OR 0.77, p = 0.006). There was no significant difference in HAS shrinkage with alteplase in proximal (vs distal) or more (vs less) extensive HAS (p = 0.516 and p = 0.580, respectively). There was no interaction between presence vs absence of HAS and benefit of alteplase on 6-month OHS (p = 0.167).
IV alteplase promotes measurable reduction in HAS regardless of HAS location or extent. Alteplase increased independence at 6 months in patients with and without HAS.
This study provides Class I evidence that for patients within 6 hours of ischemic stroke with a CT hyperdense artery sign, IV alteplase reduced intra-arterial hyperdense thrombus.
在随机对照的第三次国际卒中试验（IST-3）中，研究发病时CT高密度动脉征（HAS）的位置和范围是否会影响静脉注射阿替普酶的疗效。
IST-3中所有随机分组前及随访（24 - 48小时）的脑部CT扫描均由经过培训的评估人员评估是否存在HAS、其位置及范围。我们评估了随访时HAS是否增大、持续、缩小或消失，其与6个月功能结局的相关性，以及阿替普酶的作用。IST-3已注册（ISRCTN25765518）。
在调整后的有序回归分析中，HAS的存在（与不存在相比）独立预测6个月结局较差（牛津残疾量表[OHS]增加）（优势比[OR] 0.66，p < 0.001）。HAS范围较大（与较小相比）的患者结局更差（OR 0.61，p = 0.027），但近端（与远端）HAS患者的结局无差异（p = 0.420）。年龄增加与随访时HAS增大更多相关（OR 1.01，p = 0.013）。阿替普酶治疗增加了随访时HAS缩小/消失的比例（OR 0.77，p = 0.006）。近端（与远端）或范围较大（与较小）的HAS患者中，阿替普酶导致HAS缩小的情况无显著差异（分别为p = 0.516和p = 0.580）。HAS的存在与否与阿替普酶对6个月OHS的益处之间无相互作用（p = 0.167）。
无论HAS的位置或范围如何，静脉注射阿替普酶均可促使HAS出现可测量的缩小。阿替普酶增加了有或无HAS患者6个月时的独立能力。
本研究提供了I类证据，即对于缺血性卒中6小时内伴有CT高密度动脉征的患者，静脉注射阿替普酶可减少动脉内高密度血栓形成。
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