Second Department of Neurology, Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
Department of Neurology, St Josef Hospital, Ruhr University Bochum, Bochum, Germany.
Ann Neurol. 2019 Sep;86(3):395-406. doi: 10.1002/ana.25544. Epub 2019 Jul 22.
The substantial clinical improvement in acute ischemic stroke (AIS) patients treated with mechanical thrombectomy (MT), combined with the poor response of proximal intracranial occlusions to intravenous thrombolysis (IVT), led to questions regarding the utility of bridging therapy (BT; IVT followed by MT) compared to direct mechanical thrombectomy (dMT) for AIS patients with large vessel occlusion (LVO).
We aimed to investigate the comparative safety and efficacy of BT and dMT in AIS patients. We included all observational studies and post hoc analyses from randomized controlled clinical trials that provided data on the outcomes of AIS patients with LVO stratified by IVT treatment status prior to MT.
We identified 38 eligible observational studies (11,798 LVO patients, mean age = 68 years, 56% treated with BT). In unadjusted analyses, BT was associated with a higher likelihood of 3-month functional independence (odds ratio [OR] = 1.52, 95% confidence interval [CI] = 1.32-1.76), 3-month functional improvement (common OR [cOR] for 1-point decrease in modified Rankin Scale score = 1.52, 95% CI = 1.18-1.97), early neurological improvement (OR = 1.21, 95% CI = 1.83-1.76), successful recanalization (OR = 1.22, 95% CI = 1.02-1.46), and successful recanalization with ≤2 device passes (OR = 2.28, 95% CI = 1.43-3.64) compared to dMT. BT was also related to a lower likelihood of 3-month mortality (OR = 0.64, 95% CI = 0.57-0.73). In the adjusted analyses, BT was independently associated with a higher likelihood of 3-month functional independence (adjusted OR = 1.55, 95% CI = 1.26-1.91) and lower odds of 3-month mortality (adjusted OR = 0.80, 95% CI = 0.66-0.97) compared to dMT. The two groups did not differ in functional improvement (adjusted cOR = 1.24, 95% CI = 0.89-1.74) or symptomatic intracranial hemorrhage (adjusted OR = 0.87, 95% CI = 0.61-1.25).
BT appears to be associated with improved functional independence without evidence for safety concerns, compared to dMT, for AIS patients with LVO. ANN NEUROL 2019;86:395-406.
急性缺血性脑卒中（AIS）患者接受机械取栓（MT）后可获得显著的临床改善，而对于近端颅内闭塞患者，静脉溶栓（IVT）反应不佳，这引发了对桥接治疗（BT；IVT 后行 MT）与直接机械取栓（dMT）治疗大血管闭塞（LVO）AIS 患者的疗效优劣的疑问。
我们旨在探讨 BT 和 dMT 治疗 AIS 患者的安全性和疗效。我们纳入了所有观察性研究和随机对照临床试验的事后分析，这些研究提供了根据 MT 前 IVT 治疗状态对 LVO AIS 患者结局进行分层的数据。
我们共纳入 38 项符合条件的观察性研究（11798 例 LVO 患者，平均年龄 68 岁，56%接受 BT 治疗）。在未校正分析中，BT 与 3 个月时功能独立性（优势比 [OR] = 1.52，95%置信区间 [CI] = 1.32-1.76）、3 个月时功能改善（改良 Rankin 量表评分每降低 1 分的常见 OR [cOR] = 1.52，95%CI = 1.18-1.97）、早期神经改善（OR = 1.21，95%CI = 1.83-1.76）、成功再通（OR = 1.22，95%CI = 1.02-1.46）、2 次以内器械通过成功再通（OR = 2.28，95%CI = 1.43-3.64）的可能性更高，而与 dMT 相比，3 个月时死亡率（OR = 0.64，95%CI = 0.57-0.73）更低。在调整分析中，BT 与 3 个月时功能独立性（调整 OR = 1.55，95%CI = 1.26-1.91）的可能性更高和 3 个月时死亡率（调整 OR = 0.80，95%CI = 0.66-0.97）的降低相关，而与 dMT 相比，3 个月时功能改善（调整 cOR = 1.24，95%CI = 0.89-1.74）和症状性颅内出血（调整 OR = 0.87，95%CI = 0.61-1.25）无差异。
与 dMT 相比，BT 似乎与 LVO AIS 患者的功能独立性改善相关，而不增加安全性问题的风险。
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