Nogueira Raul G, Haussen Diogo C, Liebeskind David, Jovin Tudor G, Gupta Rishi, Jadhav Ashutov, Budzik Ron F, Baxter Blaise, Krajina Antonin, Bonafe Alain, Malek Ali, Narata Ana Paula, Shields Ryan, Zhang Yanchang, Morgan Patricia, Bartolini Bruno, English Joey, Frankel Michael R, Veznedaroglu Erol
Department of Neurology, Emory University School of Medicine, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., M.R.F.).
Department of Neurology, UCLA, Los Angeles, CA (D.L.).
Stroke. 2021 Jan;52(2):491-497. doi: 10.1161/STROKEAHA.120.031685. Epub 2021 Jan 12.
Advanced imaging has been increasingly used for patient selection in endovascular stroke therapy. The impact of imaging selection modality on endovascular stroke therapy clinical outcomes in extended time window remains to be defined. We aimed to study this relationship and compare it to that noted in early-treated patients.
Patients from a prospective multicentric registry (n=2008) with occlusions involving the intracranial internal carotid or the M1- or M2-segments of the middle cerebral arteries, premorbid modified Rankin Scale score 0 to 2 and time to treatment 0 to 24 hours were categorized according to treatment times within the early (0-6 hour) or extended (6-24 hour) window as well as imaging modality with noncontrast computed tomography (NCCT)±CT angiography (CTA) or NCCT±CTA and CT perfusion (CTP). The association between imaging modality and 90-day modified Rankin Scale, analyzed in ordinal (modified Rankin Scale shift) and dichotomized (functional independence, modified Rankin Scale score 0-2) manner, was evaluated and compared within and across the extended and early windows.
In the early window, 332 patients were selected with NCCT±CTA alone while 373 also underwent CTP. After adjusting for identifiable confounders, there were no significant differences in terms of 90-day functional disability (ordinal shift: adjusted odd ratio [aOR], 0.936 [95% CI, 0.709-1.238], =0.644) or independence (aOR, 1.178 [95% CI, 0.833-1.666], =0.355) across the CTP and NCCT±CTA groups. In the extended window, 67 patients were selected with NCCT±CTA alone while 180 also underwent CTP. No significant differences in 90-day functional disability (aOR, 0.983 [95% CI, 0.81-1.662], =0.949) or independence (aOR, 0.640 [95% CI, 0.318-1.289], =0.212) were seen across the CTP and NCCT±CTA groups. There was no interaction between the treatment time window (0-6 versus 6-24 hours) and CT selection modality (CTP versus NCCT±CTA) in terms of functional disability at 90 days (=0.45).
CTP acquisition was not associated with better outcomes in patients treated in the early or extended time windows. While confirmatory data is needed, our data suggests that extended window endovascular stroke therapy may remain beneficial even in the absence of advanced imaging.
先进成像技术在血管内治疗急性缺血性卒中患者选择中应用日益广泛。成像选择方式对血管内治疗急性缺血性卒中临床结局在延长时间窗内的影响仍有待明确。我们旨在研究这种关系，并将其与早期治疗患者的情况进行比较。
前瞻性多中心登记研究中的患者（n = 2008），其颅内颈内动脉或大脑中动脉M1或M2段闭塞，病前改良Rankin量表评分0至2分，治疗时间0至24小时，根据治疗时间分为早期（0 - 6小时）或延长（6 - 24小时）时间窗，成像方式分为非增强计算机断层扫描（NCCT）±CT血管造影（CTA）或NCCT±CTA及CT灌注（CTP）。以有序（改良Rankin量表变化）和二分法（功能独立，改良Rankin量表评分0 - 2）分析成像方式与90天改良Rankin量表之间的关联，并在延长和早期时间窗内及不同时间窗之间进行比较。
在早期时间窗，仅通过NCCT±CTA选择了332例患者，另有373例还接受了CTP检查。在调整可识别的混杂因素后，CTP组和NCCT±CTA组在90天功能残疾（有序变化：调整后的优势比[aOR]，0.936 [95% CI，0.709 - 1.238]，P = 0.644）或功能独立（aOR，1.178 [95% CI，0.833 - 1.666]，P = 0.355）方面无显著差异。在延长时间窗，仅通过NCCT±CTA选择了67例患者，另有180例还接受了CTP检查。CTP组和NCCT±CTA组在90天功能残疾（aOR，0.983 [95% CI，0.81 - 1.662]，P = 0.949）或功能独立（aOR，0.640 [95% CI，0.318 - 1.289]，P = 0.212）方面无显著差异。在90天功能残疾方面，治疗时间窗（0 - 6小时与6 - 24小时）与CT选择方式（CTP与NCCT±CTA）之间无交互作用（P = 0.45）。
在早期或延长时间窗治疗的患者中，CTP检查与更好的结局无关。虽然需要进一步证实性数据，但我们的数据表明，即使没有先进成像技术，延长时间窗内的血管内治疗急性缺血性卒中可能仍然有益。
