Traenka Christopher, Jung Simon, Gralla Jan, Kurmann Rebekka, Stippich Christoph, Simonetti Barbara Goeggel, Gensicke Henrik, Mueller Hubertus, Lovblad Karl, Eskandari Ashraf, Puccinelli Francesco, Vehoff Jochen, Weber Johannes, Wegener Susanne, Steiner Levke, Kägi Georg, Luft Andreas, Sztajzel Roman, Fischer Urs, Bonati Leo H, Peters Nils, Michel Patrik, Lyrer Philippe A, Arnold Marcel, Engelter Stefan T
Department of Neurology and Stroke Center, University Hospital, University of Basel, Basel, Switzerland.
Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland.
Eur Stroke J. 2018 Mar;3(1):47-56. doi: 10.1177/2396987317748545. Epub 2018 Jan 3.
In patients with stroke attributable to cervical artery dissection, we compared endovascular therapy to intravenous thrombolysis regarding three-month outcome, recanalisation and complications.
In a multicentre intravenous thrombolysis/endovascular therapy-register-based cohort study, all consecutive cervical artery dissection patients with intracranial artery occlusion treated within 6 h were eligible for analysis. Endovascular therapy patients (with or without prior intravenous thrombolysis) were compared to intravenous thrombolysis patients regarding (i) excellent three-month outcome (modified Rankin Scale score 0-1), (ii) symptomatic intracranial haemorrhage, (iii) recanalisation of the occluded intracranial artery and (iv) death. Upon a systematic literature review, we performed a meta-analysis comparing endovascular therapy to intravenous thrombolysis in cervical artery dissection patients regarding three-month outcome using a random-effects Mantel-Haenszel model.
Among 62 cervical artery dissection patients (median age 48.8 years), 24 received intravenous thrombolysis and 38 received endovascular therapy. Excellent three-month outcome occurred in 23.7% endovascular therapy and 20.8% with intravenous thrombolysis patients. Symptomatic intracranial haemorrhage occurred solely among endovascular therapy patients (5/38 patients, 13.2%) while four (80%) of these patients had bridging therapy; 6/38 endovascular therapy and 0/24 intravenous thrombolysis patients died. Four of these 6 endovascular therapy patients had bridging therapy. Recanalisation was achieved in 84.2% endovascular therapy patients and 66.7% intravenous thrombolysis patients (odds ratio 3.2, 95% confidence interval [0.9-11.38]). Sensitivity analyses in a subgroup treated within 4.5 h revealed a higher recanalisation rate among endovascular therapy patients (odds ratio 3.87, 95% confidence interval [1.00-14.95]), but no change in the key clinical findings. In a meta-analysis across eight studies (n = 212 patients), cervical artery dissection patients (110 intravenous thrombolysis and 102 endovascular therapy) showed identical odds for favourable outcome (odds ratio 0.97, 95% confidence interval [0.38-2.44]) among endovascular therapy patients and intravenous thrombolysis patients.
In this cohort study, there was no clear signal of superiority of endovascular therapy over intravenous thrombolysis in cervical artery dissection patients, which - given the limitation of our sample size - does not prove that endovascular therapy in these patients cannot be superior in future studies. The observation that symptomatic intracranial haemorrhage and deaths in the endovascular therapy group occurred predominantly in bridging patients requires further investigation.
在因颈动脉夹层导致中风的患者中，我们比较了血管内治疗与静脉溶栓治疗在三个月预后、再通情况及并发症方面的差异。
在一项基于多中心静脉溶栓/血管内治疗登记的队列研究中，所有在6小时内接受治疗的连续颅内动脉闭塞的颈动脉夹层患者均符合分析条件。将接受血管内治疗的患者（无论是否接受过静脉溶栓）与接受静脉溶栓的患者在以下方面进行比较：（i）三个月预后良好（改良Rankin量表评分为0 - 1分）；（ii）有症状性颅内出血；（iii）闭塞颅内动脉的再通情况；（iv）死亡情况。在系统文献综述的基础上，我们使用随机效应Mantel - Haenszel模型进行荟萃分析，比较血管内治疗与静脉溶栓治疗对颈动脉夹层患者三个月预后的影响。
在62例颈动脉夹层患者（中位年龄48.8岁）中，24例接受静脉溶栓治疗，38例接受血管内治疗。接受血管内治疗的患者中有23.7%三个月预后良好，接受静脉溶栓治疗的患者中这一比例为20.8%。有症状性颅内出血仅发生在接受血管内治疗的患者中（38例患者中有5例，占13.2%），其中4例（80%）患者接受了桥接治疗；接受血管内治疗的患者中有6例死亡（38例中的6例），接受静脉溶栓治疗的患者中无死亡病例（24例中的0例）。这6例接受血管内治疗死亡的患者中有4例接受了桥接治疗。接受血管内治疗的患者中有84.2%实现了再通，接受静脉溶栓治疗的患者中这一比例为66.7%（优势比3.2，95%置信区间[0.9 - 11.38]）。在4.5小时内接受治疗的亚组中进行的敏感性分析显示，接受血管内治疗的患者再通率更高（优势比3.87，95%置信区间[1.00 - 14.95]），但关键临床结果无变化。在对八项研究（n = 212例患者）进行的荟萃分析中，颈动脉夹层患者（110例接受静脉溶栓治疗，102例接受血管内治疗）在血管内治疗组和静脉溶栓治疗组中获得良好预后的几率相同（优势比0.97，95%置信区间[0.38 - 2.44]）。
在这项队列研究中，在颈动脉夹层患者中血管内治疗相对于静脉溶栓治疗没有明显的优势信号，鉴于我们样本量的局限性，这并不证明在未来研究中血管内治疗对这些患者不会更具优势。血管内治疗组中有症状性颅内出血和死亡主要发生在接受桥接治疗患者中的这一观察结果需要进一步研究。
