Chang Adam, Beheshtian Elham, Llinas Edward J, Idowu Oluwatoyin R, Marsh Elisabeth B
Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States.
Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD, United States.
Front Neurol. 2020 Dec 9;11:585929. doi: 10.3389/fneur.2020.585929. eCollection 2020.
Intravenous tissue plasminogen activator (tPA) is indicated prior to mechanical thrombectomy (MT) to treat large vessel occlusion (LVO). However, administration takes time, and rates of clot migration complicating successful retrieval and hemorrhagic transformation may be higher. Given time-to-effectiveness, the benefit of tPA may vary significantly based on whether administration occurs at a thrombectomy-capable center or transferring hospital. We prospectively evaluated 170 individuals with LVO involving the anterior circulation who underwent MT at our Comprehensive Stroke Center over a 3.5 year period. Two thirds ( = 114) of patients were admitted through our Emergency Department (ED). The other 33% were transferred from outside hospitals (OSH). Patients meeting criteria were bridged with IV tPA; the others were treated with MT alone. Clot migration, recanalization times, TICI scores, and hemorrhage rates were compared for those bridged vs. treated with MT alone, along with modified Rankin scores (mRS) at discharge and 90-day follow-up. Multivariable regression was used to determine the relationship between site of presentation and effect of tPA on outcomes. Patients presenting to an OSH had longer mean discovery to puncture/recanalization times, but were actually more likely to receive IV tPA prior to MT (70 vs. 42%). The rate of clot migration was low (11%) and similar between groups, though slightly higher for those receiving IV tPA. There was no difference in symptomatic ICH rate after tPA. TICI scores were also not significantly different; however, more patients achieved TICI 2b or higher reperfusion (83 vs. 67%, = 0.027) after tPA, and TICI 0 reperfusion was seen almost exclusively in patients who were not treated with tPA. Those bridged at an OSH required fewer passes before successful recanalization (2.4 vs. 1.6, = 0.037). Overall, mean mRS scores on discharge and at 90 days were significantly better for those receiving IV tPA (3.9 vs. 4.6, 3.4 vs. 4.4 respectively, ~ 0.01) and differences persisted when comparing only patients recanalized in under 6 h. Independent of site of presentation, IV tPA before MT appears to lead to better radiographic outcomes, without increased rates of clot migration or higher intracranial hemorrhage risk, and overall better functional outcomes.
在进行机械取栓（MT）之前，静脉注射组织型纤溶酶原激活剂（tPA）可用于治疗大血管闭塞（LVO）。然而，给药需要时间，并且血栓迁移导致成功取栓复杂化以及出血转化的发生率可能更高。考虑到起效时间，tPA的益处可能会因给药是在具备取栓能力的中心还是转诊医院而有显著差异。我们前瞻性评估了170例前循环大血管闭塞患者，这些患者在3.5年期间于我们的综合卒中中心接受了MT治疗。三分之二（n = 114）的患者通过我们的急诊科（ED）入院。另外33%是从外部医院（OSH）转诊而来。符合标准的患者采用静脉tPA桥接治疗；其他患者仅接受MT治疗。比较了采用桥接治疗与仅接受MT治疗的患者的血栓迁移、再通时间、脑梗死溶栓分级（TICI）评分和出血率，以及出院时和90天随访时的改良Rankin评分（mRS）。采用多变量回归分析来确定就诊地点与tPA对预后的影响之间的关系。在OSH就诊的患者从发现到穿刺/再通的平均时间更长，但实际上在MT之前接受静脉tPA治疗的可能性更高（70%对42%）。血栓迁移率较低（11%），两组之间相似，尽管接受静脉tPA治疗的患者略高。tPA治疗后有症状性颅内出血的发生率没有差异。TICI评分也没有显著差异；然而，tPA治疗后更多患者实现了TICI 2b或更高的再灌注（83%对67%，P = 0.027），并且几乎仅在未接受tPA治疗的患者中出现TICI 0级再灌注。在OSH进行桥接治疗的患者在成功再通之前所需的操作次数更少（2.4次对1.6次，P = 0.037）。总体而言，接受静脉tPA治疗的患者出院时和90天时的平均mRS评分明显更好（分别为3.9对4.6，3.4对4.4，P约为0.01），并且在仅比较6小时内实现再通的患者时差异仍然存在。无论就诊地点如何，MT前静脉注射tPA似乎能带来更好的影像学结果，不会增加血栓迁移率或颅内出血风险，并且总体功能预后更好。
