Department of Cerebrovascular Medicine (K.F., K. Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan.
Division of Stroke Care Unit (K. Tanaka, H.Y.), National Cerebral and Cardiovascular Center, Suita, Japan.
Stroke. 2021 May;52(5):1561-1569. doi: 10.1161/STROKEAHA.120.031386. Epub 2021 Mar 1.
Outcomes in patients ≥90 years of age with stroke due to large vessel occlusion were compared between endovascular therapy (EVT) and medical management.
Of 2420 acute ischemic stroke patients with large vessel occlusion in a prospective, multicenter, nationwide registry in Japan, patients aged ≥90 years with occlusion of the internal carotid artery or M1 segment of the middle cerebral artery were included. The primary effectiveness outcome was a favorable outcome at 3 months, defined as achieving a modified Rankin Scale score of 0 to 2 or return to at least the prestroke modified Rankin Scale score at 3 months. Safety outcomes included symptomatic intracranial hemorrhage within 72 hours after onset. Intergroup biases were adjusted by multivariable adjustment with inverse probability of treatment weighting.
A total of 150 patients (median age, 92 [interquartile range, 90-94] years; median prestroke modified Rankin Scale score, 2 [interquartile range, 0-4]) were analyzed. EVT was performed in 49 patients (32.7%; mechanical thrombectomy, n=43). The EVT group showed shorter time from onset to hospital arrival (=0.03), higher Alberta Stroke Program Early CT Score (<0.01), and a higher rate of treatment with intravenous thrombolysis (<0.01) than the medical management group. The favorable outcome was seen in 28.6% of the EVT group and 6.9% of the medical management group (<0.01). EVT was associated with the favorable outcome (adjusted odds ratio, 8.44 [95% CI, 1.88-37.97]). Rates of symptomatic intracranial hemorrhage were similar between the EVT group (0.0%) and the medical management group (3.9%; =0.30).
Patients who underwent EVT showed better functional outcomes than those with medical management without increased symptomatic intracranial hemorrhages. Given proper patient selection, withholding EVT solely on the basis of the age of patients may not offer the best chance of good outcome. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02419794.
对比血管内治疗（EVT）与药物治疗在 90 岁以上伴有大血管闭塞的卒中患者中的疗效。
在日本一项前瞻性、多中心、全国性注册登记研究中，共纳入 2420 例急性大动脉闭塞性卒中患者，入选年龄≥90 岁、颈内动脉或大脑中动脉 M1 段闭塞的患者。主要有效性结局为 3 个月时的良好预后，定义为改良 Rankin 量表（mRS）评分 0~2 分或 3 个月时恢复至卒中前 mRS 评分至少 1 分。安全性结局包括发病后 72 小时内症状性颅内出血。通过逆概率治疗加权法进行多变量调整，调整组间偏倚。
共分析 150 例患者（中位年龄 92 岁[四分位距 9094 岁]；中位卒中前 mRS 评分 2 分[四分位距 04 分]）。49 例行 EVT（32.7%；机械血栓切除术 n=43）。EVT 组从发病到入院的时间更短（P=0.03）， Alberta 卒中项目早期 CT 评分更高（P<0.01），静脉溶栓治疗率更高（P<0.01）。EVT 组良好预后率为 28.6%，药物治疗组为 6.9%（P<0.01）。EVT 与良好预后相关（校正优势比 8.44[95%可信区间 1.88~37.97]）。EVT 组症状性颅内出血发生率为 0.0%，药物治疗组为 3.9%（P=0.30）。
与药物治疗相比，EVT 治疗能改善功能结局，且不增加症状性颅内出血。如果进行适当的患者选择，单纯基于年龄而不进行 EVT 治疗可能无法获得最佳预后机会。注册信息：网址：https://www.clinicaltrials.gov；注册号：NCT02419794。
