Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
Centre for the Developing Brain & Biomedical Engineering Department, School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK.
Eur Radiol. 2021 Nov;31(11):8228-8235. doi: 10.1007/s00330-021-07980-0. Epub 2021 May 8.
Thrombus microfragmentation causing peripheral emboli (PE) during mechanical thrombectomy (MT) may modulate treatment effects, even in cases with successful reperfusion. This study aims to investigate whether intravenous alteplase is of potential benefit in reducing PE after successful MT.
Patients from a prospective study treated at a tertiary care stroke center between 08/2017 and 12/2019 were analyzed. The main inclusion criterion was successful reperfusion after MT (defined as expanded thrombolysis in cerebral infarction (eTICI) scale ≥ 2b50) of large vessel occlusion anterior circulation stroke. All patients received a high-resolution diffusion-weighted imaging (DWI) follow-up 24 h after MT for PE detection. Patients were grouped as "direct MT" (no alteplase) or as MT plus additional intravenous alteplase. The number and volume of ischemic core lesions and PE were then quantified and analyzed.
Fifty-six patients were prospectively enrolled. Additional intravenous alteplase was administered in 46.3% (26/56). There were no statistically significant differences of PE compared by groups of direct MT and additional intravenous alteplase administration regarding mean numbers (12.1, 95% CI 8.6-15.5 vs. 11.1, 95% CI 7.0-15.1; p = 0.701), and median volume (0.70 mL, IQR 0.21-1.55 vs. 0.39 mL, IQR 0.10-1.62; p = 0.554). In uni- and multivariable linear regression analysis, higher eTICI scores were significantly associated with reduced PE, while the administration of alteplase was neither associated with numbers nor volume of peripheral emboli. Additional alteplase did not alter reperfusion success.
Intravenous alteplase neither affects the number nor volume of sub-angiographic DWI-PE after successful endovascular reperfusion. In the light of currently running randomized trials, further studies are warranted to validate these findings.
• Thrombus microfragmentation during endovascular stroke treatment may cause peripheral emboli that are only detectable on diffusion-weighted imaging and may directly compromise treatment effects. • In this prospective study, the application of intravenous alteplase did not influence the occurrence of peripheral emboli detected on high-resolution diffusion-weighted imaging. • A higher degree of recanalization was associated with a reduced number and volume of peripheral emboli and better functional outcome, while contrariwise, peripheral emboli did not modify the effect of recanalization on modified Rankin Scale scores at day 90.
机械血栓切除术中血栓微碎裂导致外周栓塞（PE）可能会改变治疗效果，即使在再通成功的情况下也是如此。本研究旨在探讨静脉内使用阿替普酶是否有助于减少成功机械取栓后 PE 的发生。
对 2017 年 8 月至 2019 年 12 月在一家三级卒中中心接受治疗的前瞻性研究患者进行分析。主要纳入标准为大血管闭塞性前循环卒中机械取栓后再通成功（定义为扩展血栓溶解程度（eTICI）评分≥2b50）。所有患者在机械取栓后 24 小时均接受高分辨率弥散加权成像（DWI）随访以检测 PE。将患者分为“直接机械取栓”（无阿替普酶）或机械取栓加静脉内阿替普酶。然后定量和分析缺血核心病变和 PE 的数量和体积。
前瞻性纳入 56 例患者。46.3%（26/56）的患者接受了额外的静脉内阿替普酶治疗。直接机械取栓组和额外静脉内阿替普酶治疗组之间的 PE 平均数量（12.1，95%CI 8.6-15.5 比 11.1，95%CI 7.0-15.1；p=0.701）和中位数体积（0.70mL，IQR 0.21-1.55 比 0.39mL，IQR 0.10-1.62；p=0.554）均无统计学差异。单变量和多变量线性回归分析显示，较高的 eTICI 评分与 PE 减少显著相关，而阿替普酶的使用与外周栓塞的数量或体积均无关。额外使用阿替普酶并未改变再通成功率。
静脉内阿替普酶既不影响血管内再通后亚影像学 DWI-PE 的数量，也不影响其体积。鉴于目前正在进行的随机试验，有必要进一步研究以验证这些发现。
血管内卒中治疗过程中的血栓微碎裂可能导致仅在弥散加权成像上检测到的外周栓塞，并且可能直接影响治疗效果。
在这项前瞻性研究中，静脉内使用阿替普酶并未影响高分辨率弥散加权成像上检测到的外周栓塞的发生。
再通程度越高，外周栓塞的数量和体积越小，功能结局越好，而相反，外周栓塞并不能改变再通对 90 天时改良 Rankin 量表评分的影响。
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