From the Neurology Department (P.S., G.T., J.-L.M., J.-C.B.), INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, Paris, France.
Radiology Department (O.N., L.L., C.O.), INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, Paris, France.
Stroke. 2018 Dec;49(12):2975–2982. doi: 10.1161/STROKEAHA.118.022335.
Background and Purpose—Whether all acute stroke patients with large vessel occlusion need to undergo intravenous thrombolysis before mechanical thrombectomy (MT) is debated as (1) the incidence of post-thrombolysis early recanalization (ER) is still unclear; (2) thrombolysis may be harmful in patients unlikely to recanalize; and, conversely, (3) transfer for MT may be unnecessary in patients highly likely to recanalize. Here, we determined the incidence and predictors of post-thrombolysis ER in patients referred for MT and derive ER prediction scores for trial design. Methods—Registries from 4 MT-capable centers gathering patients referred for MT and thrombolyzed either on site (mothership) or in a non MT-capable center (drip-and-ship) after magnetic resonance– or computed tomography–based imaging between 2015 and 2017. ER was identified on either first angiographic run or noninvasive imaging. In the magnetic resonance imaging subsample, thrombus length was determined on T2*-based susceptibility vessel sign. Independent predictors of no- ER were identified using multivariable logistic regression models, and scores were developed according to the magnitude of regression coefficients. Similar registries from 4 additional MT-capable centers were used as validation cohort. Results—In the derivation cohort (N=633), ER incidence was ≈20%. In patients with susceptibility vessel sign (n=498), no-ER was independently predicted by long thrombus, proximal occlusion, and mothership paradigm. A 6-point score derived from these variables showed strong discriminative power for no-ER (C statistic, 0.854) and was replicated in the validation cohort (n=353; C statistic, 0.888). A second score derived from the whole sample (including negative T2* or computed tomography–based imaging) also showed good discriminative power and was similarly validated. Highest grades on both scores predicted no-ER with >90% specificity, whereas low grades did not reliably predict ER. Conclusions—The substantial ER rate underlines the benefits derived from thrombolysis in bridging populations. Both prediction scores afforded high specificity for no-ER, but not for ER, which has implications for trial design.
背景与目的——对于是否所有大血管闭塞的急性卒中患者都需要在机械取栓（MT）之前进行静脉溶栓，目前仍存在争议，原因如下：（1）溶栓后早期再通（ER）的发生率尚不清楚；（2）在不太可能再通的患者中，溶栓可能有害；相反，（3）在极有可能再通的患者中，可能不需要转院进行 MT。在这里，我们确定了在转诊进行 MT 的患者中溶栓后 ER 的发生率和预测因素，并为临床试验设计制定了 ER 预测评分。方法——在 2015 年至 2017 年期间，4 个具有 MT 能力的中心的注册中心收集了基于磁共振或计算机断层扫描成像后，在现场（母船）或在不具备 MT 能力的中心（滴注和转运）进行溶栓并转诊进行 MT 的患者。在首次血管造影或无创成像中识别 ER。在磁共振成像亚样本中，基于 T2*-加权的血栓长度确定血栓长度基于血栓长度。使用多变量逻辑回归模型确定无 ER 的独立预测因素，并根据回归系数的大小制定评分。另外 4 个具有 MT 能力的中心的类似注册中心被用作验证队列。结果——在推导队列（n=633）中，ER 的发生率约为 20%。在具有血栓长度信号的患者中（n=498），长血栓、近端闭塞和母船范式独立预测了无 ER。从这些变量中得出的 6 分评分对无 ER 具有很强的区分能力（C 统计量，0.854），并在验证队列（n=353；C 统计量，0.888）中得到验证。从整个样本（包括阴性 T2*或基于计算机断层扫描的成像）中得出的第二个评分也具有良好的区分能力，并且得到了类似的验证。两个评分中得分最高的均提示无 ER 的特异性>90%，而得分最低的并不能可靠地预测 ER。结论——在桥接人群中，溶栓后 ER 发生率较高，因此溶栓获益较大。两个预测评分对无 ER 均具有高特异性，但对 ER 无特异性，这对临床试验设计有影响。
