From the Departments of Neurology (S.N., M.M., P.A.R.), Heidelberg University Hospital, Germany.
Department of Neurology, Emory University, Atlanta, GA (M.B., D.C.H., R.G.N.).
Stroke. 2018 Oct;49(10):2391-2397. doi: 10.1161/STROKEAHA.118.021106.
Background and Purpose- We aimed to describe the safety and efficacy of immediate mechanical thrombectomy (MT) in patients with large vessel occlusions and low National Institutes of Health Stroke Scale (NIHSS) versus best medical management. Methods- Patients from prospectively collected databases of 6 international comprehensive stroke centers with large vessel occlusions (distal intracranial internal carotid, middle cerebral artery-M1 and M2 segments, or basilar artery with or without tandem occlusions) and NIHSS 0 to 5 were identified and divided into 2 groups for analysis: immediate MT or initial best medical management which included rescue MT after neurological deterioration (best medical management-MT). Uni- and multivariate analyses and patient-level matching for age, baseline NIHSS, and occlusion site were performed to compare baseline and outcome variables across the 2 groups. The primary outcome was defined as good outcome (modified Rankin Scale score, 0-2) at day 90. Safety outcome was symptomatic intracranial hemorrhage as defined by the ECASS (European Cooperative Acute Stroke Study) II and mortality at day 90. Results- Compared with best medical management-MT (n=220), patients with immediate MT (n=80) were younger (65.3±13.5 versus 69.5±14.1; P=0.021), had more often atrial fibrillation (44.8% versus 28.2%; P=0.012), higher baseline NIHSS (4, 0-5 versus 3, 0-5; P=0.005), higher Alberta Stroke Program Early CT Score (10, 7-10 versus 10, 5-10; P=0.023), more middle cerebral artery-M1, and less middle cerebral artery-M2 (41.3% versus 21.9% and 28.8% versus 49.3%; P=0.016) occlusions. The adjusted odds ratio for good outcome was 3.1 (95% CI, 1.4-6.9) favoring immediate MT. In the matched analysis, there was a 14.4% absolute difference in good outcome (84.4% versus 70.1%; P=0.03) at day 90 favoring immediate MT. There were no safety concerns. Conclusions- Our retrospective, pilot analysis suggests that immediate thrombectomy in large vessel occlusions patients with low NIHSS on presentation may be safe and has the potential to result in improved outcomes. Randomized clinical trials are warranted to establish the optimal management for this patient population.
背景与目的- 我们旨在描述即刻机械取栓（MT）治疗大血管闭塞且 NIHSS 评分较低的患者的安全性和有效性，与最佳药物治疗相比。方法- 我们从 6 个国际综合卒中中心前瞻性收集的数据库中确定了患有大血管闭塞（远端颅内颈内动脉、大脑中动脉 M1 和 M2 段或基底动脉伴或不伴串联闭塞）和 NIHSS 评分为 0 至 5 的患者，并将其分为 2 组进行分析：即刻 MT 或初始最佳药物治疗，包括神经功能恶化后的补救性 MT（最佳药物治疗-MT）。对两组的基线和结局变量进行单变量和多变量分析以及基于年龄、基线 NIHSS 和闭塞部位的患者水平匹配分析。主要结局定义为第 90 天改良 Rankin 量表评分（mRS）0-2 的良好结局。安全性结局为 ECASS II（欧洲急性卒中合作研究）定义的症状性颅内出血和第 90 天的死亡率。结果- 与最佳药物治疗-MT（n=220）相比，即刻 MT 组（n=80）的患者更年轻（65.3±13.5 岁 vs. 69.5±14.1 岁；P=0.021），心房颤动的发生率更高（44.8% vs. 28.2%；P=0.012），基线 NIHSS 评分更高（4 分，0-5 分 vs. 3 分，0-5 分；P=0.005），Alberta 卒中项目早期 CT 评分更高（10 分，7-10 分 vs. 10 分，5-10 分；P=0.023），大脑中动脉 M1 段闭塞更多，大脑中动脉 M2 段闭塞更少（41.3% vs. 21.9% 和 28.8% vs. 49.3%；P=0.016）。即刻 MT 组良好结局的调整优势比为 3.1（95%CI，1.4-6.9）。在匹配分析中，即刻 MT 组第 90 天的良好结局（84.4% vs. 70.1%）有 14.4%的绝对差异（P=0.03）。没有安全性问题。结论- 我们的回顾性、初步分析表明，对于 NIHSS 评分较低的大血管闭塞患者，即刻 MT 治疗可能是安全的，并有可能改善结局。需要进行随机临床试验以确定该患者人群的最佳治疗方法。
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