1 Department of Neurology, Mayo Clinic, Rochester, MN, USA.
2 Department of Neurology, Stanford University, Stanford, CA, USA.
Int J Stroke. 2019 Jan;14(1):23-31. doi: 10.1177/1747493018799979. Epub 2018 Sep 6.
Endovascular therapy with mechanical thrombectomy is a formidable treatment for severe acute ischemic stroke caused by occlusion of a proximal intracranial artery. Its strong beneficial effect is explained by the high rates of very good and excellent reperfusion achieved with current endovascular techniques. However, there is a sizable proportion of patients who do not experience clinical improvement despite successful recanalization of the occluded artery and reperfusion of the ischemic territory. Factors such as baseline reserve, collateral flow, anesthesia and systemic factors have been identified as potential culprits for lack of improvement in the setting of timely and successful revascularization. Older age, baseline disability and perhaps radiological markers of chronic brain injury can affect the prognosis of patients treated with endovascular therapy. Collateral flow is a major determinant of outcome after endovascular therapy and it is manifested by the size of the core in relation to the volume of the salvageable tissue. Parenchymal and vascular imaging can help assess the quality of collateral flow, but the optimal radiological strategy for daily practice (i.e. the optimal combination of rapid availability and diagnostic precision) has not been established. A sizable body of observational evidence indicates that acute hypertension, hyperglycemia and fever are associated with worse outcomes after a stroke even after optimal reperfusion with endovascular therapy. Lastly, current randomized controlled trials in anesthesia for stroke demonstrate similar rates of good functional outcome between general anesthesia and conscious sedation suggesting equipoise exists.
血管内治疗伴机械取栓是治疗因近端颅内动脉闭塞引起的严重急性缺血性脑卒中的有效方法。目前的血管内技术可实现非常好和极好的再灌注率，这解释了其强大的有益效果。然而，尽管闭塞动脉再通和缺血区域再灌注成功，仍有相当一部分患者没有出现临床改善。基线储备、侧支循环、麻醉和全身因素等因素已被确定为及时成功血管再通后缺乏改善的潜在原因。年龄较大、基线残疾以及可能的慢性脑损伤的影像学标志物可能会影响血管内治疗患者的预后。侧支循环是血管内治疗后结局的主要决定因素，它表现为核心与可挽救组织体积的大小关系。实质和血管成像可以帮助评估侧支循环的质量，但对于日常实践的最佳影像学策略（即快速可用性和诊断精度的最佳组合）尚未确定。大量观察性证据表明，即使在血管内治疗实现最佳再灌注后，急性高血压、高血糖和发热与卒中后更差的结局相关。最后，目前关于卒中麻醉的随机对照试验表明，全身麻醉和清醒镇静之间的良好功能结局发生率相似，这表明两者之间存在平衡。
