Interventional Neuroradiology Unit - Monash Imaging, Monash Health, Melbourne, Victoria, Australia; School of Medicine, Faculty of Health, Deakin University, Waurn Ponds, Victoria, Australia.
NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, New South Wales, Australia.
World Neurosurg. 2019 Dec;132:e235-e245. doi: 10.1016/j.wneu.2019.08.192. Epub 2019 Sep 5.
Up to 20% of patients fail to achieve reperfusion with modified Thrombolysis in Cerebral Infarction (mTICI) scores of 0-1 after mechanical thrombectomy (MT). Furthermore, underlying intracranial atherosclerotic disease, particularly when associated with >70% residual or flow limiting stenosis, is associated with higher rates of failed MT and high failure risk MT. The aim of this study was to systematically review the procedural and clinical outcomes in patients with failed MT and high failure risk MT. We also explored differences between patients receiving acute rescue stenting compared with medical management alone.
A systematic literature search was conducted in Ovid MEDLINE, PubMed, Embase, and Cochrane online scientific publication databases for English language publications from their date of inception until October 2018. Studies including adult patients with acute ischemic stroke because of emergent large vessel occlusion with failed (mTICI score 0-1) or high failure risk MT within the anterior circulation who underwent rescue stenting were included. A systematic review and meta-analysis of proportions was performed.
Rescue intracranial stenting after failed MT or high failure risk MT results in improved clinical outcomes compared with patients without stenting (48.5% vs. 19.7%, respectively; P < 0.001), without an increase in the rate of symptomatic intracranial hemorrhage, despite additional use of antiplatelet agents (9.7% vs. 14.1%, respectively; P = 0.04).
In patients who fail initial attempts at MT or are high risk for acute reocclusion, rescue intracranial stenting could be considered with the aim to improve functional outcomes. Antiplatelet agents do not increase the risk of hemorrhage in these patients.
在机械取栓（MT）后，改良脑梗死溶栓（mTICI）评分 0-1 的患者中，多达 20%的患者未能实现再灌注。此外，颅内动脉粥样硬化性疾病（特别是当与 >70%的残余或血流限制狭窄相关时）与 MT 失败率较高和高失败风险 MT 相关。本研究旨在系统地评估 MT 失败和高失败风险 MT 患者的手术和临床结局。我们还探讨了接受急性补救支架置入术与单纯药物治疗的患者之间的差异。
我们在 Ovid MEDLINE、PubMed、Embase 和 Cochrane 在线科学出版物数据库中进行了系统的文献检索，以获取自成立日期至 2018 年 10 月发表的英文文献。纳入研究对象为接受 MT 治疗的急性大动脉闭塞所致急性缺血性脑卒中的成年患者，其中包括 MT 失败（mTICI 评分 0-1）或高失败风险 MT 患者，且接受了补救性支架置入术。我们对比例进行了系统的综述和荟萃分析。
与未接受支架置入术的患者相比，MT 失败或高失败风险 MT 后进行补救性颅内支架置入术可改善临床结局（分别为 48.5%和 19.7%；P < 0.001），且尽管联合应用抗血小板药物，但症状性颅内出血发生率并未增加（分别为 9.7%和 14.1%；P = 0.04）。
对于初始 MT 尝试失败或急性再闭塞风险高的患者，可以考虑进行补救性颅内支架置入术，以改善功能结局。这些患者应用抗血小板药物不会增加出血风险。
