Erasmus MC, University Medical Center, Rotterdam, The Netherlands (M.J.H.L.M., E.V., V.C., K.C.J.C., B.R., H.F.L., A.v.d.L., D.W.J.D.).
Academic Medical Center, Amsterdam, The Netherlands (I.G.H.J., Y.B.W.E.M.R., C.B.L.M.M.).
Circulation. 2018 Jul 17;138(3):232-240. doi: 10.1161/CIRCULATIONAHA.117.032600. Epub 2018 Mar 26.
Randomized, clinical trials in selected acute ischemic stroke patients reported that for every hour delay of endovascular treatment (EVT), chances of functional independence diminish by up to 3.4%. These findings may not be fully generalizable to clinical practice because of strict in- and exclusion criteria in these trials. Therefore, we aim to assess the association of time to EVT with functional outcome in current, everyday clinical practice.
The MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands) is an ongoing, prospective, observational study in all centers that perform EVT in The Netherlands. Data were analyzed from patients treated between March 2014 and June 2016. In the primary analysis we assessed the association of time from stroke onset to start of EVT and time from stroke onset to successful reperfusion with functional outcome (measured with the modified Rankin Scale), by means of ordinal logistic regression.
We analyzed 1488 patients with acute ischemic stroke who underwent EVT. An increased time to start of EVT was associated with worse functional outcome (adjusted common odds ratio, 0.83 per hour; 95% confidence interval, 0.77-0.89) and a 2.2% increase in mortality. Every hour increase from stroke onset to EVT start resulted in a 5.3% decreased probability of functional independence (modified Rankin Scale, 0-2). In the 742 patients with successful reperfusion, every hour increase from stroke onset to reperfusion was associated with a 7.7% decreased probability of functional independence.
Time to EVT for acute ischemic stroke in current clinical practice is strongly associated with functional outcome. Our data suggest that this association might be even stronger than previously suggested in reports on more selected patient populations from randomized, controlled trials. These findings emphasize that functional outcome of EVT patients can be greatly improved by shortening onset to treatment times.
在一些急性缺血性脑卒中患者的随机临床试验中报告，血管内治疗（EVT）每延迟 1 小时，功能独立性的机会就会减少多达 3.4%。这些发现可能不完全适用于临床实践，因为这些试验中的入组和排除标准非常严格。因此，我们旨在评估 EVT 时间与当前日常临床实践中功能结局的相关性。
MR CLEAN 登记研究（荷兰多中心急性缺血性脑卒中血管内治疗随机临床试验）是一项正在进行的、前瞻性、观察性研究，纳入了荷兰所有进行 EVT 的中心。数据来自于 2014 年 3 月至 2016 年 6 月期间接受治疗的患者。在主要分析中，我们通过有序逻辑回归评估了从卒中发病到 EVT 开始的时间和从卒中发病到成功再灌注的时间与功能结局（采用改良 Rankin 量表测量）的相关性。
我们分析了 1488 例接受 EVT 的急性缺血性脑卒中患者。EVT 开始时间的延长与较差的功能结局相关（调整后的常见比值比，每小时 0.83；95%置信区间，0.77-0.89），死亡率增加 2.2%。从卒中发病到 EVT 开始每增加 1 小时，功能独立的概率就会降低 5.3%（改良 Rankin 量表，0-2 分）。在 742 例成功再灌注的患者中，从卒中发病到再灌注的每小时增加与功能独立的概率降低 7.7%相关。
当前临床实践中急性缺血性脑卒中 EVT 的时间与功能结局密切相关。我们的数据表明，这种关联可能比以前在更具选择性的随机对照试验报告中对更具选择性的患者群体的报告中所表明的更为强烈。这些发现强调，通过缩短发病到治疗的时间，可以大大改善 EVT 患者的功能结局。
