Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.
Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.
J Neurointerv Surg. 2022 Apr;14(4):314-320. doi: 10.1136/neurintsurg-2020-017202. Epub 2021 Apr 28.
Endovascular therapy (EVT) is effective and safe in patients with tandem occlusion. The benefit of intravenous thrombolysis (IVT) prior to EVT in acute tandem occlusion is debatable.
To compare EVT alone with EVT plus IVT in patients with acute ischemic stroke due to anterior circulation tandem occlusions.
This is an individual patient pooled analysis of the Thrombectomy In TANdem lesions (TITAN) and Endovascular Treatment in Ischemic Stroke (ETIS) Registries. Patients were divided into two groups based on prior IVT treatment: (1) IVT+ group, which included patients who received IVT prior to EVT, (2) IVT- group, which included patients who did not receive IVT prior to EVT. Propensity score (inverse probability of treatment weighting (IPTW)) was used to reduce baseline between-group differences. The primary outcome was favorable outcome-that is, modified Rankin Scale (mRS) score 0 to 2 at 90 days.
Overall, 602 consecutive patients with an acute stroke with tandem occlusion were included (380 and 222 in the bridging therapy and EVT alone groups, respectively). Onset to imaging time was shorter in the IVT+ group (median 103 vs 140 min). In contrast, imaging to puncture time was longer in the IVT+ group (median 107 vs 91 min). In IPTW analysis, the IVT+ group had higher odds of favorable outcome, excellent outcome (90-day mRS score 0-1), and successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b/3 at the end of EVT). There was no difference in the risk of significant hemorrhagic complications between groups. In secondary analysis of patients treated with acute cervical internal carotid artery stenting, bridging therapy was associated with higher odds of favorable outcome and lower odds of mortality at 90 days.
Our results suggest that bridging therapy in patients with acute ischemic stroke due to anterior tandem occlusion is safe and may improve functional outcome, even in the setting of acute cervical internal carotid artery stenting during EVT.
血管内治疗（EVT）对串联闭塞患者有效且安全。在急性串联闭塞患者中，血管内溶栓（IVT）是否优于 EVT 仍存在争议。
比较急性前循环串联闭塞患者单独 EVT 与 EVT 联合 IVT 的疗效。
这是一项对 Thrombectomy In TANdem lesions（TITAN）和 Endovascular Treatment in Ischemic Stroke（ETIS）登记研究的个体患者汇总分析。根据是否接受过 IVT 治疗，患者分为两组：（1）IVT+组，包括接受 EVT 前接受 IVT 的患者；（2）IVT-组，包括未接受 EVT 前接受 IVT 的患者。采用倾向评分（逆概率治疗加权（IPTW））来减少基线组间差异。主要结局为 90 天改良 Rankin 量表（mRS）评分 0-2 的良好结局。
共纳入 602 例急性串联闭塞卒中患者（桥接治疗组 380 例，单独 EVT 组 222 例）。IVT+组的发病至影像学时间更短（中位数 103 分钟比 140 分钟）。相反，IVT+组的影像学至穿刺时间更长（中位数 107 分钟比 91 分钟）。在 IPTW 分析中，IVT+组有更高的良好结局、优秀结局（90 天 mRS 评分 0-1）和成功再灌注（结束时改良脑梗死溶栓评分 2b/3）的几率。两组之间严重出血并发症的风险无差异。在接受急性颈内动脉支架置入术治疗的患者的亚组分析中，桥接治疗与更好的结局和更低的 90 天死亡率相关。
我们的研究结果表明，对于急性前循环串联闭塞患者，桥接治疗是安全的，甚至在 EVT 期间进行急性颈内动脉支架置入术时，也可能改善功能结局。
