Bruggeman Agnetha A E, Kappelhof Manon, Arrarte Terreros Nerea, Tolhuisen Manon L, Konduri Praneeta R, Boodt Nikki, van Beusekom Heleen M M, Hund Hajo M, Taha Aladdin, van der Lugt Aad, Roos Yvo B W E M, van Es Adriaan C G M, van Zwam Wim H, Postma Alida A, Dippel Diederik W J, Lingsma Hester F, Marquering Henk A, Emmer Bart J, Majoie Charles B L M
Departments of1Radiology and Nuclear Medicine.
2Biomedical Engineering and Physics, and.
J Neurosurg. 2021 Apr 2;135(5):1402-1412. doi: 10.3171/2020.9.JNS201798. Print 2021 Nov 1.
Calcified cerebral emboli (CCE) are a rare cause of acute ischemic stroke. The authors aimed to assess the association of CCE with functional outcome, successful reperfusion, and mortality. Furthermore, they aimed to assess the effectiveness of intravenous alteplase treatment and endovascular treatment (EVT), as well as the best first-line EVT approach in patients with CCE.
The Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) Registry is a prospective, observational multicenter registry of patients treated with EVT for acute ischemic stroke in 16 intervention hospitals in the Netherlands. The association of CCE with functional outcome, reperfusion, and mortality was evaluated using logistic regression models. Univariable comparisons were made to determine the effectiveness of intravenous alteplase treatment and the best first-line EVT approach in CCE patients.
The study included 3077 patients from the MR CLEAN Registry. Fifty-five patients (1.8%) had CCE. CCE were not significantly associated with worse functional outcome (adjusted common OR 0.71, 95% CI 0.44-1.15), and 29% of CCE patients achieved functional independence. An extended Thrombolysis in Cerebral Infarction score ≥ 2B was significantly less often achieved in CCE patients compared to non-CCE patients (adjusted OR [aOR] 0.52, 95% CI 0.28-0.97). Symptomatic intracranial hemorrhage occurred in 8 CCE patients (15%) vs 171 of 3022 non-CCE patients (6%; p = 0.01). The median improvement on the National Institutes of Health Stroke Scale (NIHSS) was 2 in CCE patients versus 4 in non-CCE patients (p = 0.008). CCE were not significantly associated with mortality (aOR 1.16, 95% CI 0.64-2.12). Intravenous alteplase use in CCE patients was not associated with functional outcome or reperfusion. In CCE patients with successful reperfusion, stent retrievers were more often used as the primary treatment device (p = 0.04).
While patients with CCE had significantly lower reperfusion rates and less improvement on the NIHSS after EVT, CCE were not significantly associated with worse functional outcome or higher mortality rates. Therefore, EVT should still be considered in this specific group of patients.
钙化性脑栓塞（CCE）是急性缺血性卒中的一种罕见病因。作者旨在评估CCE与功能结局、成功再灌注及死亡率之间的关联。此外，他们还旨在评估静脉注射阿替普酶治疗和血管内治疗（EVT）的有效性，以及CCE患者最佳的一线EVT方法。
荷兰急性缺血性卒中血管内治疗多中心随机对照试验（MR CLEAN）登记处是荷兰16家干预医院对急性缺血性卒中患者进行EVT治疗的前瞻性观察性多中心登记处。使用逻辑回归模型评估CCE与功能结局、再灌注及死亡率之间的关联。进行单变量比较以确定静脉注射阿替普酶治疗的有效性以及CCE患者最佳的一线EVT方法。
该研究纳入了MR CLEAN登记处的3077例患者。55例患者（1.8%）患有CCE。CCE与较差的功能结局无显著关联（校正后的共同比值比为0.71，95%可信区间为0.44 - 1.15），29%的CCE患者实现了功能独立。与非CCE患者相比，CCE患者达到扩展脑梗死溶栓评分≥2B的情况明显更少（校正比值比[aOR]为0.52，95%可信区间为0.28 - 0.97）。8例CCE患者（15%）发生了症状性颅内出血，而3022例非CCE患者中有171例（6%；p = 0.01）。国立卫生研究院卒中量表（NIHSS）的中位改善值在CCE患者中为2，而在非CCE患者中为4（p = 0.008）。CCE与死亡率无显著关联（aOR为1.16，95%可信区间为0.64 - 2.12）。CCE患者使用静脉注射阿替普酶与功能结局或再灌注无关。在成功再灌注的CCE患者中，支架取栓器更常被用作主要治疗器械（p = 0.04）。
虽然CCE患者在EVT后再灌注率显著较低且NIHSS改善较少，但CCE与较差的功能结局或较高的死亡率无显著关联。因此，对于这一特定患者群体仍应考虑进行EVT。
