From the Stroke Unit, Department of Neurology (A.G.-T., M. Requena, M. Rubiera, M.M., J.P., D.R.-L., M.D., J.J., N.R.-V., S.B., M.O.-G., C.A.M., M. Ribo), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain.
Department of Neurorradiology (A.T., D.H.), Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Spain.
Stroke. 2019 Jul;50(7):1781-1788. doi: 10.1161/STROKEAHA.119.025088. Epub 2019 Jun 10.
Background and Purpose- Substantial proportion of patients who achieve successful recanalization of acute ischemic stroke due to large vessel occlusion do not achieve good functional outcome. We aim to analyze the effect of number of thrombectomy device passes and degree of the recanalization (by modified Thrombolysis in Cerebral Infarction) on the clinical and functional outcome. Methods- Five hundred forty-two consecutive patients underwent mechanical thrombectomy for large vessel occlusion in the anterior circulation at a single tertiary stroke center. Baseline characteristics, number of passes, recanalization degree, clinical outcome at 24 hours (measured by National Institutes of Health Scale score), and functional outcome (measured by modified Rankin Scale at 90 days) were registered. Multivariate analysis was performed to determine the association of number of passes and degree of recanalization with dramatical clinical recovery (final National Institutes of Health Scale score ≤2 or decrease in 8 or more National Institutes of Health Scale score points in 24 hours) and good functional outcome (modified Rankin Scale score ≤2 at 90 days). Results- Four hundred fifty-nine patients (84%) achieved successful recanalization (modified Thrombolysis in Cerebral Infarction 2B-3), 213 (39%) of them after first device pass. In the multivariate analysis, first-pass recanalization and modified Thrombolysis in Cerebral Infarction 3 were independent predictors of good functional outcome (odds ratio, 2.5; 95% CI, 1.4-4.5; P=0.002 and odds ratio, 2.6 CI; 1.5-4.7; P=0.001, respectively) and dramatical clinical recovery (odds ratio, 1.8; 95% CI, 1.1-3; P=0.032 and odds ratio, 2.9; 95% CI, 1.7-5.1; P<0.001, respectively). Rate of recanalization declined after each pass 39% (213/542), 35% (113/310), 33% (63/190), and 24% (26/154) for passes 1 to 4, respectively and 28% (45/158) for every attempt above 4 passes ( P<0.001). In patients who achieved recanalization, a linear association between number of passes and good functional outcome was observed: 1 pass (58.6%), 2 passes (50.5%), 3 passes (48.4%), 4 passes (38.5%), or 5 or more passes (25.6%; P<0.001) as compared with patients who did not achieve recanalization (16.9%). Conclusions- High number of device passes and less degree of recanalization are associated with worse outcome in patients with acute ischemic stroke secondary to large vessel occlusion. Future studies should investigate the optimal number of passes that should be attempted in patients without substantial recanalization.
背景与目的- 尽管相当一部分大血管闭塞导致的急性缺血性卒中患者成功再通，但他们并未获得良好的功能结局。我们旨在分析取栓装置的使用次数和再通程度（改良脑梗死溶栓分级）对临床和功能结局的影响。方法- 在一家单中心的三级卒中中心，542 例连续接受了机械取栓治疗的大血管闭塞前循环卒中患者。登记了基线特征、使用取栓装置的次数、再通程度、24 小时时的临床结局（以国立卫生研究院卒中量表评分衡量）以及 90 天时的功能结局（以改良 Rankin 量表评分衡量）。采用多变量分析来确定取栓装置使用次数和再通程度与戏剧性临床改善（最终国立卫生研究院卒中量表评分≤2 分或 24 小时内国立卫生研究院卒中量表评分下降 8 分或更多）和良好功能结局（90 天时改良 Rankin 量表评分≤2 分）之间的关联。结果- 459 例（84%）患者实现了成功再通（改良脑梗死溶栓分级 2B-3），其中 213 例（39%）在首次使用取栓装置后实现再通。多变量分析显示，首次再通和改良脑梗死溶栓分级 3 是良好功能结局的独立预测因素（比值比，2.5；95%置信区间，1.4-4.5；P=0.002 和比值比，2.6；95%置信区间，1.5-4.7；P=0.001），也是戏剧性临床改善的独立预测因素（比值比，1.8；95%置信区间，1.1-3；P=0.032 和比值比，2.9；95%置信区间，1.7-5.1；P<0.001）。再通率随取栓装置使用次数的增加而下降，分别为第 1 次至第 4 次为 39%（213/542）、35%（113/310）、33%（63/190）和 24%（26/154），第 4 次以上为 28%（45/158）（P<0.001）。在实现再通的患者中，可观察到使用取栓装置的次数与良好功能结局之间存在线性关联：1 次（58.6%）、2 次（50.5%）、3 次（48.4%）、4 次（38.5%）或 5 次或更多次（25.6%；P<0.001），与未实现再通的患者相比（16.9%）。结论- 在大血管闭塞导致的急性缺血性卒中患者中，取栓装置使用次数多、再通程度低与结局较差相关。未来的研究应探讨在未获得明显再通的患者中应尝试的最佳取栓装置使用次数。
