Haussen Diogo C, Turjman Francis, Piotin Michel, Labreuche Julien, Steglich-Arnholm Henrik, Holtmannspötter Markus, Taschner Christian, Eiden Sebastian, Nogueira Raul G, Papanagiotou Panagiotis, Boutchakova Maria, Siddiqui Adnan H, Lapergue Bertrand, Dorn Franziska, Cognard Christophe, Killer Monika, Mangiafico Salvatore, Ribo Marc, Psychogios Marios N, Spiotta Alejandro M, Labeyrie Marc-Antoine, Mazighi Mikael, Biondi Alessandra, Richard Sébastien, Grossberg Jonathan A, Anxionnat René, Bracard Serge, Gory Benjamin
Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, Georgia, USA.
Department of Interventional Neuroradiology, Hospices Civils, Lyon, France.
Interv Neurol. 2020 Jan;8(2-6):92-100. doi: 10.1159/000496292. Epub 2019 Feb 15.
We aim to evaluate the speed and rates of reperfusion in tandem large vessel occlusion acute stroke patients undergoing upfront cervical lesion treatment (Neck-First: angioplasty and/or stent before thrombectomy) as compared to direct intracranial occlusion therapy (Head-First) in a large international multicenter cohort.
The Thrombectomy In TANdem Lesions (TITAN) collaboration pooled individual data of prospectively collected thrombectomy international databases for all consecutive anterior circulation tandem patients who underwent emergent thrombectomy. The co-primary outcome measures were rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b/3) and time from groin puncture to successful reperfusion.
In total, 289 patients with tandem atherosclerotic etiology were included in the analysis (182 Neck-First and 107 Head-First patients). Except for differences in the Alberta Stroke Program Early CT Score (ASPECTS; median 8 [range 7-10] Neck-First vs. 7 [range 6-8] Head-First; < 0.001) and cervical internal carotid artery (ICA) lesion severity (complete occlusion in 35% of the Neck-First vs. 57% of the Head-First patients; < 0.001), patient characteristics were well balanced. After adjustments, there was no difference in successful reperfusion rates between the study groups (odds ratio associated with Neck-First: 1.18 [95% confidence interval, 0.60-2.17]). The time to successful reperfusion from groin puncture was significantly shorter in the Head-First group after adjustments (median 56 min [range 39-90] vs. 70 [range 50-102]; = 0.001). No significant differences in the rates of full reperfusion, symptomatic hemorrhage, 90-day independence, or mortality were observed. Sensitivity analysis excluding patients with complete cervical ICA occlusion yielded similar results.
The upfront approach of the intracranial lesion in patients with tandem large vessel occlusion strokes leads to similar reperfusion rates but faster reperfusion as compared to initial cervical revascularization followed by mechanical thrombectomy. Controlled studies are warranted.
我们旨在评估在一个大型国际多中心队列中，与直接颅内闭塞治疗（头优先）相比，接受前期颈部病变治疗（颈优先：血栓切除术前行血管成形术和/或支架置入术）的串联大血管闭塞急性卒中患者的再灌注速度和比率。
串联病变血栓切除术（TITAN）协作组汇总了前瞻性收集的所有连续接受急诊血栓切除术的前循环串联患者的血栓切除术国际数据库的个体数据。共同主要结局指标为成功再灌注率（改良脑梗死溶栓2b/3级）和从股动脉穿刺到成功再灌注的时间。
总共289例病因是串联动脉粥样硬化的患者纳入分析（182例颈优先患者和107例头优先患者）。除阿尔伯塔卒中项目早期CT评分（ASPECTS）存在差异（颈优先组中位数为8[范围7 - 10]，头优先组为7[范围6 - 8]；<0.001）以及颈内动脉（ICA）病变严重程度不同（颈优先组35%为完全闭塞，头优先组为57%；<0.001）外，患者特征均衡。调整后，研究组间成功再灌注率无差异（与颈优先相关的比值比：1.18[95%置信区间，0.60 - 2.17]）。调整后，头优先组从股动脉穿刺到成功再灌注的时间显著更短（中位数56分钟[范围39 - 90]对70[范围50 - 102]； = 0.001）。在完全再灌注率、症状性出血、90天独立生活能力或死亡率方面未观察到显著差异。排除颈内动脉完全闭塞患者的敏感性分析得出了类似结果。
与先进行颈部血管再通然后进行机械血栓切除术相比，串联大血管闭塞性卒中患者先行颅内病变治疗的方法导致相似的再灌注率，但再灌注速度更快。需要进行对照研究。
