多支大血管闭塞与单支大血管闭塞急性缺血性脑卒中管理和预后的差异：RESCUE-Japan 注册研究 2 的亚组分析。

Differences in Acute Ischemic Stroke Management and Prognosis between Multiple Large-Vessel Occlusion and Single Large-Vessel Occlusion: Subanalysis of the RESCUE-Japan Registry 2.

机构信息

Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Japan.

Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan.

出版信息

Cerebrovasc Dis. 2021;50(4):397-404. doi: 10.1159/000514369. Epub 2021 Mar 23.

DOI:10.1159/000514369

PMID:33756461

Abstract

INTRODUCTION

The management and prognosis of acute ischemic stroke due to multiple large-vessel occlusion (LVO) (MLVO) are not well scrutinized. We therefore aimed to elucidate the differences in patient characteristics and prognosis of MLVO and single LVO (SLVO).

METHODS

The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) enrolled 2,420 consecutive patients with acute LVO who were admitted within 24 h of onset. We compared patient prognosis between MLVO and SLVO in the favorable outcome, defined as a modified Rankin Scale (mRS) score ≤2, and in mortality at 90 days by adjusting for confounders. Additionally, we stratified MLVO patients into tandem occlusion and different territories, according to the occlusion site information and also examined their characteristics.

RESULTS

Among the 2,399 patients registered, 124 (5.2%) had MLVO. Although there was no difference between the 2 groups in terms of hypertension as a risk factor, the mean arterial pressure on admission was significantly higher in MLVO (115 vs. 107 mm Hg, p = 0.004). MLVO in different territories was more likely to be cardioembolic (42.1 vs. 10.4%, p = 0.0002), while MLVO in tandem occlusion was more likely to be atherothrombotic (39.5 vs. 81.3%, p < 0.0001). Among MLVO, tandem occlusion had a significantly longer onset-to-door time than different territories (200 vs. 95 min, p = 0.02); accordingly, the tissue plasminogen activator administration was significantly less in tandem occlusion (22.4 vs. 47.9%, p = 0.003). However, interestingly, the endovascular thrombectomy (EVT) was performed significantly more in tandem occlusion (63.2 vs. 41.7%; adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1-5.0). The type of MLVO was the only and significant factor associated with EVT performance in multivariate analysis. The favorable outcomes were obtained less in MLVO than in SLVO (28.2 vs. 37.1%; aOR, 0.48; 95% CI, 0.30-0.76). The mortality rate was not significantly different between MLVO and SLVO (8.9 vs. 11.1%, p = 0.42).

DISCUSSION/CONCLUSION: The prognosis of MLVO was significantly worse than that of SLVO. In different territories, we might be able to consider more aggressive EVT interventions.

摘要

简介

多发性大血管闭塞（MLVO）所致急性缺血性脑卒中的治疗和预后尚不清楚。因此，我们旨在阐明 MLVO 和单一大血管闭塞（SLVO）患者特征和预后的差异。

方法

血管内拯救治疗大脑超急性栓塞日本登记研究 2 期（RESCUE-Japan Registry 2）纳入了 2420 例发病 24 小时内就诊的急性 LVO 患者。我们通过调整混杂因素比较了 MLVO 和 SLVO 患者的预后（定义为改良 Rankin 量表（mRS）评分≤2）和 90 天死亡率。此外，我们根据闭塞部位信息将 MLVO 患者分为串联闭塞和不同部位，并检查了他们的特征。

结果

在登记的 2399 例患者中，124 例（5.2%）为 MLVO。尽管两组在高血压作为危险因素方面没有差异，但 MLVO 组入院时平均动脉压明显更高（115 对 107mmHg，p=0.004）。不同部位的 MLVO 更可能是心源性栓塞（42.1%对 10.4%，p=0.0002），而串联闭塞的 MLVO 更可能是动脉粥样硬化血栓形成（39.5%对 81.3%，p<0.0001）。在 MLVO 中，串联闭塞的发病至入院时间明显长于不同部位（200 对 95 分钟，p=0.02）；因此，串联闭塞的组织型纤溶酶原激活剂治疗明显较少（22.4%对 47.9%，p=0.003）。然而，有趣的是，串联闭塞的血管内血栓切除术（EVT）明显更多（63.2%对 41.7%；调整后的优势比[aOR]，2.3；95%置信区间[CI]，1.1-5.0）。多因素分析显示，MLVO 的类型是唯一且与 EVT 表现相关的显著因素。MLVO 的预后明显差于 SLVO（28.2%对 37.1%；aOR，0.48；95%CI，0.30-0.76）。MLVO 和 SLVO 的死亡率无显著差异（8.9%对 11.1%，p=0.42）。

讨论/结论：MLVO 的预后明显差于 SLVO。在不同部位，我们可能能够考虑更积极的 EVT 干预。