Department of Neurology, Washington University School of Medicine, St. Louis (M.A., A.d.H.).
Department of Neurosurgery, Medical University of South Carolina, Charleston (A.M.S., M.A.).
Stroke. 2021 Oct;52(10):3097-3105. doi: 10.1161/STROKEAHA.120.033032. Epub 2021 Aug 10.
Endovascular therapy for tandem occlusion strokes of the anterior circulation is an effective and safe treatment. The best treatment approach for the cervical internal carotid artery (ICA) lesion is still unknown. In this study, we aimed to compare the functional and safety outcomes between different treatment approaches for the cervical ICA lesion during endovascular therapy for acute ischemic strokes due to tandem occlusion in current clinical practice.
Individual patients’ data were pooled from the French prospective multicenter observational ETIS (Endovascular Treatment in Ischemic Stroke) and the international TITAN (Thrombectomy in Tandem Lesions) registries. TITAN enrolled patients from January 2012 to September 2016, and ETIS from January 2013 to July 2019. Patients with acute ischemic stroke due to anterior circulation tandem occlusion who were treated with endovascular therapy were included. Patients were divided based on the cervical ICA lesion treatment into stent and no-stent groups. Outcomes were compared between the two treatment groups using propensity score methods.
A total of 603 patients were included, of whom 341 were treated with acute cervical ICA stenting. In unadjusted analysis, the stent group had higher rate of favorable outcome (90-day modified Rankin Scale score, 0–2; 57% versus 45%) and excellent outcome (90-day modified Rankin Scale score, 0–1; 40% versus 27%) compared with the no-stent group. In inverse probability of treatment weighting propensity score–adjusted analyses, stent group had higher odds of favorable outcome (adjusted odds ratio, 1.09 [95% CI, 1.01–1.19]; P=0.036) and successful reperfusion (modified Thrombolysis in Cerebral Ischemia score, 2b-3; adjusted odds ratio, 1.19 [95% CI, 1.11–1.27]; P<0.001). However, stent group had higher odds of any intracerebral hemorrhage (adjusted odds ratio, 1.10 [95%, 1.02–1.19]; P=0.017) but not higher rate of symptomatic intracerebral hemorrhage or parenchymal hemorrhage type 2. Subgroup analysis demonstrated heterogeneity according to the lesion type (atherosclerosis versus dissection; P for heterogeneity, 0.01), and the benefit from acute carotid stenting was only observed for patients with atherosclerosis.
Patients treated with acute cervical ICA stenting for tandem occlusion strokes had higher odds of 90-day favorable outcome, despite higher odds of intracerebral hemorrhage; however, most of the intracerebral hemorrhages were asymptomatic.
血管内治疗前循环串联闭塞性卒中是一种有效且安全的治疗方法。目前对于颈内动脉（ICA）病变的最佳治疗方法仍不明确。本研究旨在比较目前临床实践中血管内治疗急性串联闭塞性卒中时，不同颈内动脉（ICA）病变治疗方法的功能和安全性结局。
从法国前瞻性多中心观察性 ETIS（血管内治疗缺血性卒中）和国际 TITAN（串联病变取栓）登记处汇集了个体患者的数据。TITAN 纳入了 2012 年 1 月至 2016 年 9 月的患者，ETIS 纳入了 2013 年 1 月至 2019 年 7 月的患者。纳入的患者均为前循环串联闭塞性急性缺血性卒中并接受血管内治疗。根据颈内动脉病变的治疗方法将患者分为支架组和无支架组。采用倾向评分方法比较两组治疗结果。
共纳入 603 例患者，其中 341 例接受了急性颈内动脉支架置入术。未经调整分析，支架组的预后良好（90 天改良 Rankin 量表评分 0-2）和结局极好（90 天改良 Rankin 量表评分 0-1）的比例均高于无支架组（分别为 57%比 45%，40%比 27%）。经逆概率治疗权重倾向评分调整后，支架组的预后良好的比值比（adjusted odds ratio，AOR）更高（1.09[95%CI，1.01-1.19]；P=0.036），且再通效果更好（改良脑梗死溶栓评分，2b-3；AOR，1.19[95%CI，1.11-1.27]；P<0.001）。然而，支架组颅内出血的比值比更高（AOR，1.10[95%CI，1.02-1.19]；P=0.017），但症状性颅内出血或实质内出血 2 型的发生率无显著差异。亚组分析显示，根据病变类型（动脉粥样硬化与夹层；P 异质性=0.01），急性颈内动脉支架置入的获益存在异质性，且仅在动脉粥样硬化患者中观察到急性颈动脉支架置入的获益。
对于串联闭塞性卒中患者，血管内治疗急性颈内动脉支架置入虽然颅内出血的风险更高，但能获得更好的 90 天预后；然而，大多数颅内出血是无症状的。
