Dargazanli Cyril, Consoli Arturo, Gory Benjamin, Blanc Raphaël, Labreuche Julien, Preda Cristian, Bourdain Frédéric, Decroix Jean-Pierre, Redjem Hocine, Ciccio Gabriele, Mazighi Mikael, Smajda Stanislas, Desilles Jean-Philippe, Riva Roberto, Labeyrie Paul-Emile, Coskun Oguzhan, Rodesch Georges, Turjman Francis, Piotin Michel, Lapergue Bertrand
Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France.
Cerebrovasc Dis. 2017;43(5-6):305-312. doi: 10.1159/000468995. Epub 2017 Apr 7.
In population-based studies, patients presenting with minor or mild stroke symptoms represent about two-thirds of stroke patients, and almost one-third of these patients are unable to ambulate independently at the time of discharge. Although mechanical thrombectomy (MT) has become the standard of care for acute ischaemic stroke with proximal large vessel occlusion (LVO) in the anterior circulation, the management of patients harbouring proximal occlusion and minor-to-mild stroke symptoms has not yet been determined by recent trials. The purpose of this study was to evaluate the impact of reperfusion on clinical outcome in low National Institutes of Health Stroke Scale (NIHSS) patients treated with MT.
We analysed 138 consecutive patients with acute LVO of the anterior circulation (middle cerebral artery M1 or M2 segment, internal carotid artery or tandem occlusion) with NIHSS <8, having undergone MT in 3 different centres. Reperfusion was graded using the modified thrombolysis in cerebral infarction (TICI) score and 3 grades were defined, ranging from failed or poor reperfusion (TICI 0, 1, 2A) to complete reperfusion (TICI 3). The primary clinical endpoint was an excellent outcome defined as a modified Rankin score (mRs) 0-1 at 3-months. The impact of reperfusion grade was assessed in univariate and multivariate analyses. The secondary endpoints included favourable functional outcome (90-day mRS 0-2), death and safety concerns.
Successful reperfusion was achieved in 81.2% of patients (TICI 2B, n = 47; TICI 3, n = 65). Excellent outcome (mRs 0-1) was achieved in 69 patients (65.0%) and favourable outcome (mRs ≤2) in 108 (78.3%). Death occurred in 7 (5.1%). Excellent outcome increased with reperfusion grades, with a rate of 34.6% in patients with failed/poor reperfusion, 61.7% in patients with TICI 2B reperfusion, and 78.5% in patients with TICI 3 reperfusion (p < 0.001). In multivariate analysis adjusted for patient characteristics associated with excellent outcome, the reperfusion grade remained significantly associated with an increase in excellent outcome; the OR (95% CI) was 3.09 (1.06-9.03) for TICI 2B and 6.66 (2.27-19.48) for TICI 3, using the failed/poor reperfusion grade as reference. Similar results were found regarding favourable outcome (90-day mRs 0-2) or overall mRS distribution (shift analysis).
Successful reperfusion is strongly associated with better functional outcome among patients with proximal LVO in the anterior circulation and minor-to-mild stroke symptoms. Randomized controlled studies are mandatory to assess the benefit of MT compared with optimal medical management in this subset of patients.
在基于人群的研究中，出现轻微或轻度卒中症状的患者约占卒中患者的三分之二，其中近三分之一的患者在出院时无法独立行走。尽管机械取栓术（MT）已成为前循环近端大血管闭塞（LVO）急性缺血性卒中的标准治疗方法，但近期试验尚未确定近端闭塞且有轻微至轻度卒中症状患者的治疗方案。本研究的目的是评估再灌注对接受MT治疗的美国国立卫生研究院卒中量表（NIHSS）评分较低患者临床结局的影响。
我们分析了138例连续的前循环急性LVO（大脑中动脉M1或M2段、颈内动脉或串联闭塞）且NIHSS<8的患者，这些患者在3个不同中心接受了MT治疗。使用改良的脑梗死溶栓（TICI）评分对再灌注进行分级，定义了3个等级，从再灌注失败或不佳（TICI 0、1、2A）到完全再灌注（TICI 3）。主要临床终点是3个月时改良Rankin量表（mRs）评分为0-1的良好结局。在单因素和多因素分析中评估再灌注分级的影响。次要终点包括良好的功能结局（90天mRS 0-2）、死亡和安全性问题。
81.2%的患者实现了成功再灌注（TICI 2B，n=47；TICI 3，n=65）。69例患者（65.0%）获得了良好结局（mRs 0-1），108例患者（78.3%）获得了有利结局（mRs≤2）。7例（5.1%）患者死亡。良好结局随着再灌注分级的提高而增加，再灌注失败/不佳的患者中这一比例为34.6%，TICI 2B再灌注的患者中为61.7%，TICI 3再灌注的患者中为78.5%（p<0.001）。在针对与良好结局相关的患者特征进行调整的多因素分析中，再灌注分级仍然与良好结局的增加显著相关；以再灌注失败/不佳分级为参照，TICI 2B的比值比（95%可信区间）为3.09（1.06-9.03），TICI 3为6.66（2.27-19.48）。在有利结局（90天mRs 0-2）或总体mRS分布（移位分析）方面也发现了类似结果。
在前循环近端LVO且有轻微至轻度卒中症状的患者中，成功再灌注与更好的功能结局密切相关。必须进行随机对照研究，以评估MT与最佳药物治疗相比在这部分患者中的益处。
