From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands.
Biomedical Engineering and Physics (H.C.A., B.G.D., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands.
Stroke. 2019 Nov;50(11):3156-3163. doi: 10.1161/STROKEAHA.119.026107. Epub 2019 Oct 10.
Background and Purpose- The location of the thrombus as observed on first digital subtraction angiography during endovascular treatment may differ from the initial observation on initial noninvasive imaging. We studied the incidence of thrombus dynamics, its impact on patient outcomes, and its association with intravenous thrombolytics. Methods- We included patients from the MR CLEAN registry (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke) with an initial target occlusion on computed tomography angiography located in the intracranial internal carotid artery, M1, or M2. The conventional angiography target occlusion was defined during endovascular treatment. Thrombus dynamics were classified as growth, stability, migration, and resolution. The primary outcome was functional outcome at 90 days (modified Rankin Scale). The secondary outcomes were successful and complete reperfusion (extended treatment in cerebral infarction scores of 2b-3 and 3, respectively). Results- The analysis included 1349 patients. Thrombus migration occurred in 302 (22%) patients, thrombus growth in 87 (6%), and thrombus resolution in 39 (3%). Intravenous treatment with alteplase was associated with more thrombus migration (adjusted odds ratio, 2.01; CI, 1.29-3.11) and thrombus resolution (adjusted odds ratio, 1.85; CI, 1.22-2.80). Thrombus migration was associated with a lower chance of complete reperfusion (adjusted odds ratio, 0.57; CI, 0.42-0.78) and successful reperfusion (adjusted odds ratio, 0.74; CI, 0.55-0.99). In the subgroup of patients with M1 initial target occlusion, thrombus migration was associated with better functional outcome (adjusted common odds ratio, 1.49; CI, 1.02-2.17), and there was a trend towards better functional outcome in patients with thrombus resolution (adjusted common odds ratio, 2.23; CI, 0.93-5.37). Conclusions- In patients with acute ischemic stroke, thrombus location regularly changes between computed tomography angiography and digital subtraction angiography. Administration of intravenous alteplase increases the chance of thrombus migration and resolution. Thrombus migration is associated with better functional outcome but reduces the rate of complete reperfusion.
背景与目的-血管内治疗期间首次数字减影血管造影观察到的血栓位置可能与初始无创影像学观察到的初始位置不同。我们研究了血栓动力学的发生率、对患者结局的影响及其与静脉溶栓治疗的关系。方法-我们纳入了 MR CLEAN 登记研究（急性缺血性脑卒中血管内治疗多中心随机临床试验）中初始 CT 血管造影显示颅内颈内动脉、M1 或 M2 段存在靶血管闭塞的患者。血管内治疗期间定义了常规血管造影的靶血管闭塞。血栓动力学分为生长、稳定、迁移和溶解。主要结局为 90 天的功能结局（改良 Rankin 量表）。次要结局为成功和完全再灌注（分别为扩展治疗脑梗死评分 2b-3 和 3）。结果-分析纳入了 1349 例患者。302 例（22%）患者发生血栓迁移，87 例（6%）发生血栓生长，39 例（3%）发生血栓溶解。阿替普酶静脉治疗与更多的血栓迁移（调整后的优势比，2.01；95%置信区间，1.29-3.11）和血栓溶解（调整后的优势比，1.85；95%置信区间，1.22-2.80）相关。血栓迁移与完全再灌注的可能性降低相关（调整后的优势比，0.57；95%置信区间，0.42-0.78）和成功再灌注（调整后的优势比，0.74；95%置信区间，0.55-0.99）。在 M1 初始靶血管闭塞的患者亚组中，血栓迁移与更好的功能结局相关（调整后的共同优势比，1.49；95%置信区间，1.02-2.17），血栓溶解患者的功能结局有改善趋势（调整后的共同优势比，2.23；95%置信区间，0.93-5.37）。结论-在急性缺血性脑卒中患者中，CT 血管造影和数字减影血管造影之间血栓位置经常发生变化。静脉注射阿替普酶增加了血栓迁移和溶解的可能性。血栓迁移与更好的功能结局相关，但降低了完全再灌注的比率。
