Wee Chee-Keong, McAuliffe William, Phatouros Constantine C, Phillips Timothy J, Blacker David, Singh Tejinder P, Baker Ellen, Hankey Graeme J
Department of Neurology, Sir Charles Gairdner Hospital, Perth, Washington, Australia.
Neurological Intervention and Imaging Service of Western Australia (NIISWA), Perth, Washington, Australia.
Cerebrovasc Dis Extra. 2017;7(2):95-102. doi: 10.1159/000470855. Epub 2017 May 2.
Endovascular thrombectomy (EVT) improves the functional outcome when added to best medical therapy, including alteplase, in patients with acute ischaemic stroke secondary to large vessel occlusion (LVO) in the anterior circulation. However, the evidence for EVT in alteplase-ineligible patients is less compelling. It is also uncertain whether alteplase is necessary in patients with successful recanalization by EVT, as the treatment effect of EVT may be so powerful that bridging alteplase may not add to efficacy and may compromise safety by increasing bleeding risks. We aimed to survey the proportion of patients suitable for EVT who are alteplase-ineligible and to compare the safety and effectiveness of standard care of acute large artery ischaemic stroke by EVT plus thrombolysis with that of EVT alone in a tertiary hospital clinical stroke service.
We performed a retrospective analysis of acute ischaemic stroke patients treated with EVT at our centre between October 2013 and April 2016, based on a registry with prospective and consecutive patient collection. Individual patient records were retrieved for review. Significant early neurological improvement was defined as a NIHSS score of 0-1, or a decrease from baseline of ≤8, at 24 h after stroke onset.
Fifty patients with acute ischaemic stroke secondary to LVO in the anterior circulation received EVT in this period, of whom 21 (42%) received concurrent alteplase and 29 (58%) EVT alone. The 2 groups had similar baseline characteristics and similar outcomes. Significant neurological improvement at 24 h occurred in 47.6% of the patients with EVT and bridging alteplase and in 51.7% of the patients with EVT alone (p = 0.774). Mortality during acute hospitalization was 20% for the bridging alteplase group versus 7.1% for EVT alone (p = 0.184). Intracranial haemorrhage rates were 14.3% for bridging alteplase versus 20.7% for EVT alone (p = 0.716). Local complications, groin haematoma (23.8 vs. 10.3%) and groin pseudoaneurysms (4.8 vs. 0%) (p = 0.170), were not significantly different.
Our study highlights the relatively large proportion of patients suitable for EVT who have a contraindication to alteplase and raises the hypothesis that adding alteplase to successful EVT may not be necessary to optimize functional outcome. The results are consistent with observational data from other endovascular centres and support a randomised controlled trial of EVT versus EVT with bridging alteplase.
对于前循环大血管闭塞（LVO）所致急性缺血性卒中患者，血管内血栓切除术（EVT）联合包括阿替普酶在内的最佳药物治疗可改善功能预后。然而，在不符合阿替普酶治疗条件的患者中，EVT的证据尚不充分。对于通过EVT成功再通的患者，阿替普酶是否必要也不确定，因为EVT的治疗效果可能非常强大，桥接使用阿替普酶可能不会增加疗效，反而可能因增加出血风险而影响安全性。我们旨在调查不符合阿替普酶治疗条件但适合EVT的患者比例，并比较在三级医院临床卒中服务中，EVT联合溶栓与单纯EVT治疗急性大动脉缺血性卒中的安全性和有效性。
我们对2013年10月至2016年4月在本中心接受EVT治疗的急性缺血性卒中患者进行了回顾性分析，该登记系统对患者进行前瞻性连续收集。检索个体患者记录进行审查。显著早期神经功能改善定义为卒中发作后24小时美国国立卫生研究院卒中量表（NIHSS）评分为0 - 1分，或较基线下降≤8分。
在此期间，50例前循环LVO所致急性缺血性卒中患者接受了EVT，其中21例（42%）同时接受了阿替普酶治疗，29例（58%）仅接受了EVT治疗。两组患者的基线特征和结局相似。接受EVT联合桥接阿替普酶治疗的患者中，47.6%在24小时出现显著神经功能改善；仅接受EVT治疗的患者中，这一比例为51.7%（p = 0.774）。桥接阿替普酶组急性住院期间死亡率为20%，单纯EVT组为7.1%（p = 0.184）。颅内出血率在桥接阿替普酶组为14.3%，单纯EVT组为20.7%（p = 0.716）。局部并发症，腹股沟血肿（23.8%对10.3%）和腹股沟假性动脉瘤（4.8%对0%）（p = 0.170），差异无统计学意义。
我们的研究突出了适合EVT但有阿替普酶禁忌证的患者比例相对较大，并提出了一个假设，即在成功的EVT基础上加用阿替普酶可能并非优化功能预后所必需。这些结果与其他血管内治疗中心的观察数据一致，并支持进行EVT与EVT联合桥接阿替普酶的随机对照试验。
