计算机断层扫描或磁共振血管造影显示的动脉阻塞与缺血性卒中对静脉溶栓的反应
Arterial Obstruction on Computed Tomographic or Magnetic Resonance Angiography and Response to Intravenous Thrombolytics in Ischemic Stroke.
作者信息
Mair Grant, von Kummer Rüdiger, Adami Alessandro, White Philip M, Adams Matthew E, Yan Bernard, Demchuk Andrew M, Farrall Andrew J, Sellar Robin J, Sakka Eleni, Palmer Jeb, Perry David, Lindley Richard I, Sandercock Peter A G, Wardlaw Joanna M
机构信息
From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.).
出版信息
Stroke. 2017 Feb;48(2):353-360. doi: 10.1161/STROKEAHA.116.015164. Epub 2016 Dec 22.
BACKGROUND AND PURPOSE
Computed tomographic angiography and magnetic resonance angiography are used increasingly to assess arterial patency in patients with ischemic stroke. We determined which baseline angiography features predict response to intravenous thrombolytics in ischemic stroke using randomized controlled trial data.
METHODS
We analyzed angiograms from the IST-3 (Third International Stroke Trial), an international, multicenter, prospective, randomized controlled trial of intravenous alteplase. Readers, masked to clinical, treatment, and outcome data, assessed prerandomization computed tomographic angiography and magnetic resonance angiography for presence, extent, location, and completeness of obstruction and collaterals. We compared angiography findings to 6-month functional outcome (Oxford Handicap Scale) and tested for interactions with alteplase, using ordinal regression in adjusted analyses. We also meta-analyzed all available angiography data from other randomized controlled trials of intravenous thrombolytics.
RESULTS
In IST-3, 300 patients had prerandomization angiography (computed tomographic angiography=271 and magnetic resonance angiography=29). On multivariable analysis, more extensive angiographic obstruction and poor collaterals independently predicted poor outcome (P<0.01). We identified no significant interaction between angiography findings and alteplase effect on Oxford Handicap Scale (P≥0.075) in IST-3. In meta-analysis (5 trials of alteplase or desmoteplase, including IST-3, n=591), there was a significantly increased benefit of thrombolytics on outcome (odds ratio>1 indicates benefit) in patients with (odds ratio, 2.07; 95% confidence interval, 1.18-3.64; P=0.011) versus without (odds ratio, 0.88; 95% confidence interval, 0.58-1.35; P=0.566) arterial obstruction (P for interaction 0.017).
CONCLUSIONS
Intravenous thrombolytics provide benefit to stroke patients with computed tomographic angiography or magnetic resonance angiography evidence of arterial obstruction, but the sample was underpowered to demonstrate significant treatment benefit or harm among patients with apparently patent arteries.
CLINICAL TRIAL REGISTRATION
URL: http://www.isrctn.com. Unique identifier: ISRCTN25765518.
背景与目的
计算机断层血管造影（CTA）和磁共振血管造影（MRA）越来越多地用于评估缺血性脑卒中患者的动脉通畅情况。我们利用随机对照试验数据确定了哪些基线血管造影特征可预测缺血性脑卒中患者对静脉溶栓治疗的反应。
方法
我们分析了IST-3（第三次国际卒中试验）的血管造影图像，这是一项关于静脉注射阿替普酶的国际、多中心、前瞻性随机对照试验。阅片者在不知道临床、治疗和结局数据的情况下，评估随机分组前的CTA和MRA，以确定阻塞和侧支循环的存在、范围、位置及完整性。我们将血管造影结果与6个月时的功能结局（牛津残疾量表）进行比较，并在调整分析中使用有序回归检验与阿替普酶的相互作用。我们还对其他静脉溶栓随机对照试验的所有可用血管造影数据进行了荟萃分析。
结果
在IST-3中，300例患者进行了随机分组前血管造影（CTA=271例，MRA=29例）。多变量分析显示，血管造影阻塞范围越大和侧支循环不良独立预测结局不良（P<0.01）。在IST-3中，我们未发现血管造影结果与阿替普酶对牛津残疾量表的影响之间存在显著相互作用（P≥0.075）。荟萃分析（5项阿替普酶或去氨普酶试验，包括IST-3，n=591）显示，与无动脉阻塞（比值比，0.88；95%置信区间，0.58-1.35；P=0.566）的患者相比，有动脉阻塞（比值比，2.07；95%置信区间，1.18-3.64；P=0.011）的患者溶栓治疗对结局的获益显著增加（比值比>1表示获益）（相互作用P=0.017）。
结论
静脉溶栓治疗对有CTA或MRA证据显示动脉阻塞的脑卒中患者有益，但样本量不足，无法证明在动脉明显通畅的患者中治疗有显著获益或危害。
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