Tomsick T A, Carrozzella J, Foster L, Hill M D, von Kummer R, Goyal M, Demchuk A M, Khatri P, Palesch Y, Broderick J P, Yeatts S D, Liebeskind D S
From the Department of Radiology (T.A.T., J.C.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio
From the Department of Radiology (T.A.T., J.C.), University of Cincinnati Academic Health Center, University Hospital, Cincinnati, Ohio.
AJNR Am J Neuroradiol. 2017 Jan;38(1):84-89. doi: 10.3174/ajnr.A4979. Epub 2016 Oct 20.
Uncertainty persists regarding the safety and efficacy of endovascular therapy of M2 occlusions following IV tPA. We reviewed the impact of revascularization on clinical outcomes in 83 patients with M2 occlusions in the Interventional Management of Stroke III trial according to specific M1-M2 segment anatomic features.
Perfusion of any M2 branch distinguished M2-versus-M1 occlusion. Prespecified modified TICI and arterial occlusive lesion revascularization and clinical mRS 0-2 end points at 90 days for endovascular therapy-treated M2 occlusions were analyzed. Post hoc analyses of the relationship of outcomes to multiple baseline angiographic M2 and M1 subgroup characteristics were performed.
Of 83 participants with M2 occlusion who underwent endovascular therapy, 41.0% achieved mRS 0-2 at 90 days, including 46.6% with modified TICI 2-3 reperfusion compared with 26.1% with modified TICI 0-1 reperfusion (risk difference, 20.6%; 95% CI, -1.4%-42.5%). mRS 0-2 outcome was associated with reperfusion for M2 trunk (n = 9) or M2 division (n = 42) occlusions, but not for M2 branch occlusions (n = 28). Of participants with trunk and division occlusions, 63.2% with modified TICI 2a and 42.9% with modified TICI 2b reperfusion achieved mRS 0-2 outcomes; mRS 0-2 outcomes for M2 trunk occlusions (33%) did not differ from distal (38.2%) and proximal (26.9%) M1 occlusions.
mRS 0-2 at 90 days was dependent on reperfusion for M2 trunk but not for M2 branch occlusions. For M2 division occlusions, good outcome with modified TICI 2b reperfusion did not differ from that in modified TICI 2a. M2 segment definition and occlusion location may contribute to differences in revascularization and good outcome between Interventional Management of Stroke III and other endovascular therapy studies.
静脉注射组织型纤溶酶原激活剂（IV tPA）后，M2段闭塞的血管内治疗的安全性和有效性仍存在不确定性。我们在卒中介入管理III试验中，根据特定的M1 - M2段解剖特征，回顾了83例M2段闭塞患者血管再通对临床结局的影响。
任何M2分支的灌注情况区分M2段与M1段闭塞。分析了预先设定的改良脑梗死溶栓分级（modified TICI）和动脉闭塞病变再通情况，以及血管内治疗的M2段闭塞患者在90天时的临床改良Rankin量表（mRS）评分为0 - 2的终点指标。对结局与多个基线血管造影M2和M1亚组特征之间的关系进行了事后分析。
在接受血管内治疗的83例M2段闭塞患者中，41.0%在90天时mRS评分为0 - 2，其中改良TICI 2 - 3级再通的患者占46.6%，而改良TICI 0 - 1级再通的患者占26.1%（风险差异为20.6%；95%置信区间为 - 1.4% - 42.5%）。mRS评分为0 - 2的结局与M2主干（n = 9）或M2分支（n = 42）闭塞的再通相关，但与M2分支闭塞（n = 28）无关。在主干和分支闭塞的患者中，改良TICI 2a级再通的患者中有63.2%、改良TICI 2b级再通的患者中有42.9%达到了mRS评分为0 - 2的结局；M2主干闭塞患者的mRS评分为0 - 2的结局（33%）与M1段远端（38.2%）和近端（26.9%）闭塞患者的结局无差异。
90天时mRS评分为0 - 2取决于M2主干的再通，而非M2分支闭塞的再通。对于M2分支闭塞，改良TICI 2b级再通的良好结局与改良TICI 2a级再通的结局无差异。M2段定义和闭塞位置可能导致卒中介入管理III试验与其他血管内治疗研究在血管再通和良好结局方面存在差异。
