直接接受血管内治疗的患者术前再灌注的比例和质量。
Rates and Quality of Preinterventional Reperfusion in Patients With Direct Access to Endovascular Treatment.
机构信息
From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., F.Z., P.J.M., T.D., E.P., M.E.-K., P.M., J.G.).
Department of Neurology (J.K., M.G., S.B., M.A., S.J., U.F.), University Hospital Bern, University of Bern, Inselspital, Switzerland.
出版信息
Stroke. 2018 Aug;49(8):1924-1932. doi: 10.1161/STROKEAHA.118.021579.
Background and Purpose- Preinterventional reperfusion before endovascular treatment (ET) is a benefit of bridging with intravenous tPA (tissue-type plasminogen activator). However, detailed data on reperfusion quality and rates of obviating ET in a cohort of patients with immediate access to ET is lacking. Purpose of this analysis was to evaluate prevalence and quality of preinterventional reperfusion in mothership patients. Methods- All mothership patients (n=627) from a prospective registry subjected to angiography with an intention to perform ET were reviewed. Preinterventional change of occlusion site (COS) was categorized into COS with Thrombolysis in Cerebral Infarction (TICI) 0/1, COS with TICI ≥2a, COS with TICI ≥2b, and COS with perfusion worsening. Predictors and clinical relevance were evaluated using multivariable logistic regression and results are displayed as adjusted odds ratios (aOR) and corresponding 95% confidence intervals (95% CI). Results- Prevalence of COS in all patients was 10.7% (95% CI, 8.3%-13.1%), subdividing into 2.7% COS with TICI 0/1, 6.2% COS with ≥TICI 2a (including 2.9% with TICI ≥2b), and 1.8% COS with perfusion worsening. Factors related to COS with ≥TICI 2a were intravenous tPA (aOR, 11.98; 95% CI, 4.5-31.6), cardiogenic thrombus origin (aOR, 2.3; 95% CI, 1.1-4.6), and thrombus length (aOR per 1 mm increase 0.926; 95% CI, 0.87-0.99). Additional ET was performed despite COS with ≥TICI 2a in 51.3%. COS with ≥TICI 2a showed a tendency for favorable outcomes (modified Rankin Scale, ≤2; aOR, 2.65; 95% CI, 0.98-7.17). Rates of COS with ≥TICI 2a were particularly low in internal carotid artery and proximal M1 occlusions (2.2%; 95% CI, 0.9%-5%), where intravenous tPA was associated with perfusion worsening (aOR, 4.33; 95% CI, 1.12-16.80). Conclusions- Prevalence of preinterventional reperfusion is non-negligible in patients with direct access to ET and is clearly favored by intravenous tPA treatment. However, it is often incomplete and often requires additional ET. Preinterventional reperfusion of internal carotid artery and proximal M1 occlusions is rare and usually of low quality, where intravenous tPA may also promote perfusion worsening.
背景与目的——血管内治疗（ET）前的预介入再灌注是静脉注射组织型纤溶酶原激活剂（tPA）桥接的益处。然而，在能够立即接受 ET 的患者队列中，关于再灌注质量和避免 ET 的详细数据尚缺乏。本分析的目的是评估母舰患者中预介入再灌注的发生率和质量。方法——回顾了前瞻性登记的所有拟行血管造影并意图行 ET 的母舰患者（n=627）。将预介入闭塞部位（COS）的变化分为血栓溶解治疗脑梗死（TICI）0/1 的 COS、TICI≥2a 的 COS、TICI≥2b 的 COS 和灌注恶化的 COS。使用多变量逻辑回归评估预测因素和临床相关性，并以调整后的优势比（aOR）和相应的 95%置信区间（95%CI）表示结果。结果——所有患者的 COS 发生率为 10.7%（95%CI，8.3%-13.1%），细分为 2.7%的 TICI 0/1 的 COS、6.2%的 TICI≥2a 的 COS（包括 2.9%的 TICI≥2b 的 COS）和 1.8%的灌注恶化的 COS。与 TICI≥2a 的 COS 相关的因素是静脉注射 tPA（aOR，11.98；95%CI，4.5-31.6）、心源性血栓形成起源（aOR，2.3；95%CI，1.1-4.6）和血栓长度（每增加 1mm，aOR 增加 0.926；95%CI，0.87-0.99）。尽管存在 TICI≥2a 的 COS，但仍有 51.3%的患者行额外的 ET。TICI≥2a 的 COS 有良好结局（改良 Rankin 量表，≤2；aOR，2.65；95%CI，0.98-7.17）的趋势。颈内动脉和近端 M1 闭塞患者中 TICI≥2a 的 COS 发生率特别低（2.2%；95%CI，0.9%-5%），其中静脉注射 tPA 与灌注恶化相关（aOR，4.33；95%CI，1.12-16.80）。结论——直接接受 ET 的患者中预介入再灌注的发生率不容忽视，静脉注射 tPA 治疗明显有利于再灌注。然而，再灌注往往不完整，通常需要额外的 ET。颈内动脉和近端 M1 闭塞的预介入再灌注很少见，且通常质量较差，在此情况下，静脉注射 tPA 也可能导致灌注恶化。
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