Mueller L, Pult F, Meisterernst J, Heldner M R, Mono M-L, Kurmann R, Buehlmann M, Fischer U, Mattle H P, Arnold M, Mordasini P, Gralla J, Schroth G, El-Koussy M, Jung S
Department of Neurology, Inselspital, University Hospital Bern, Bern and University of Bern, Bern.
Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland.
Eur J Neurol. 2017 Aug;24(8):1016-1021. doi: 10.1111/ene.13330. Epub 2017 Jun 25.
Randomized controlled trials have shown that bridging endovascular therapy (EVT) after intravenous thrombolysis (IVT) therapy improves outcome in patients with stroke with large-artery anterior circulation stroke compared with IVT alone. It remains unknown whether IVT adds any benefit to EVT in these patients. The aim of this study was to assess recanalization rates and thrombus dislocation before initiation of EVT in patients receiving bridging therapy.
All patients in the Bernese stroke registry (2008-2015) in whom bridging therapy was considered were included in this analysis. Relevant recanalization before EVT, thrombus dislocation and increase in thrombus load between initial and control imaging were assessed retrospectively.
A total of 319 patients were included. Relevant recanalization before EVT occurred in 8.8% and thrombus dislocation in 7.2% of patients before EVT. Recanalization rates were significantly higher in distal compared with large and more proximal vessel occlusions of the anterior circulation (occlusion of internal carotid artery, 5.4%; middle cerebral artery segment M1, 8.1%; middle cerebral artery segment M2, 17.6%) and in drip-and-ship patients compared with mother-ship patients. In multivariable regression analysis the occlusion site was the only independent predictor of relevant recanalization before EVT (P = 0.046).
Relevant recanalization after IVT and prior to EVT in patients receiving bridging therapy was highly dependent on the occlusion site. These findings suggest that future randomized controlled trials should consider occlusion site and treatment paradigm to specify patients who benefit most from bridging therapy in comparison to EVT or IVT alone.
随机对照试验表明，与单纯静脉溶栓（IVT）相比，静脉溶栓后进行桥接血管内治疗（EVT）可改善大动脉前循环卒中患者的预后。在这些患者中，IVT是否能为EVT带来额外益处尚不清楚。本研究的目的是评估接受桥接治疗的患者在开始EVT之前的再通率和血栓移位情况。
纳入伯尔尼卒中登记处（2008 - 2015年）中所有考虑进行桥接治疗的患者。回顾性评估EVT前的相关再通情况、血栓移位以及初始影像与对照影像之间血栓负荷的增加情况。
共纳入319例患者。EVT前出现相关再通的患者占8.8%，血栓移位的患者占7.2%。前循环远端血管闭塞的再通率显著高于大血管及更近端血管闭塞（颈内动脉闭塞，5.4%；大脑中动脉M1段，8.1%；大脑中动脉M2段，17.6%），且与“转运-治疗”模式患者相比，“静脉溶栓-转运-治疗”模式患者的再通率更高。在多变量回归分析中，闭塞部位是EVT前相关再通的唯一独立预测因素（P = 0.046）。
接受桥接治疗的患者在IVT后及EVT前的相关再通高度依赖于闭塞部位。这些发现表明，未来的随机对照试验应考虑闭塞部位和治疗模式，以明确与单独进行EVT或IVT相比，哪些患者从桥接治疗中获益最大。
