Rudilosso Salvatore, Ríos José, Rodríguez Alejandro, Gomis Meritxell, Vera Víctor, Gómez-Choco Manuel, Renú Arturo, Matos Núria, Llull Laura, Purroy Francisco, Amaro Sergio, Terceño Mikel, Obach Víctor, Serena Joaquim, Martí-Fàbregas Joan, Cardona Pedro, Molina Carlos, Rodríguez-Campello Ana, Cánovas David, Krupinski Jerzy, Ustrell Xavier, Torres Ferran, Román Luis San, Salvat-Plana Mercè, Jiménez-Fàbrega Francesc Xavier, Palomeras Ernest, Catena Esther, Colom Carla, Cocho Dolores, Baiges Juanjo, Aragones Josep Maria, Diaz Gloria, Costa Xavier, Almendros María Cruz, Rybyeba Maria, Barceló Miquel, Carrión Dolors, Lòpez Matilde Núria, Sanjurjo Eduard, de la Ossa Natalia Pérez, Urra Xabier, Chamorro Ángel
Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain.
Clinical and Experimental Neuroscience: Cerebrovascular Diseases, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
J Stroke. 2021 Sep;23(3):401-410. doi: 10.5853/jos.2021.00962. Epub 2021 Sep 30.
In real-world practice, the benefit of mechanical thrombectomy (MT) is uncertain in stroke patients with very favorable or poor prognostic profiles at baseline. We studied the effectiveness of MT versus medical treatment stratifying by different baseline prognostic factors.
Retrospective analysis of 2,588 patients with an ischemic stroke due to large vessel occlusion nested in the population-based registry of stroke code activations in Catalonia from January 2017 to June 2019. The effect of MT on good functional outcome (modified Rankin Score ≤2) and survival at 3 months was studied using inverse probability of treatment weighting (IPTW) analysis in three pre-defined baseline prognostic groups: poor (if pre-stroke disability, age >85 years, National Institutes of Health Stroke Scale [NIHSS] >25, time from onset >6 hours, Alberta Stroke Program Early CT Score <6, proximal vertebrobasilar occlusion, supratherapeutic international normalized ratio >3), good (if NIHSS <6 or distal occlusion, in the absence of poor prognostic factors), or reference (not meeting other groups' criteria).
Patients receiving MT (n=1,996, 77%) were younger, had less pre-stroke disability, and received systemic thrombolysis less frequently. These differences were balanced after the IPTW stratified by prognosis. MT was associated with good functional outcome in the reference (odds ratio [OR], 2.9; 95% confidence interval [CI], 2.0 to 4.4), and especially in the poor baseline prognostic stratum (OR, 3.9; 95% CI, 2.6 to 5.9), but not in the good prognostic stratum. MT was associated with survival only in the poor prognostic stratum (OR, 2.6; 95% CI, 2.0 to 3.3).
Despite their worse overall outcomes, the impact of thrombectomy over medical management was more substantial in patients with poorer baseline prognostic factors than patients with good prognostic factors.
在实际临床实践中，对于基线预后状况非常良好或较差的卒中患者，机械取栓（MT）的获益尚不确定。我们研究了MT与药物治疗相比，按不同基线预后因素分层的有效性。
对2017年1月至2019年6月在加泰罗尼亚基于人群的卒中编码激活登记系统中登记的2588例因大血管闭塞导致的缺血性卒中患者进行回顾性分析。采用治疗权重逆概率（IPTW）分析，在三个预先定义的基线预后组中研究MT对良好功能结局（改良Rankin量表评分≤2）和3个月生存率的影响：预后差组（如果存在卒中前残疾、年龄>85岁、美国国立卫生研究院卒中量表[NIHSS]>25、发病时间>6小时、阿尔伯塔卒中项目早期CT评分<6、近端椎基底动脉闭塞、国际标准化比值>3）、预后好组（如果NIHSS<6或为远端闭塞，且不存在预后差的因素）或参照组（不符合其他组标准）。
接受MT治疗的患者（n = 1996，77%）更年轻，卒中前残疾更少，全身溶栓治疗频率更低。在按预后分层的IPTW分析后，这些差异得到了平衡。MT与参照组良好的功能结局相关（优势比[OR]，2.9；95%置信区间[CI]，2.0至4.4），尤其与基线预后差的分层相关（OR，3.9；95%CI，2.6至5.9），但与预后好的分层无关。MT仅与预后差的分层的生存相关（OR，2.6；95%CI，2.0至3.3）。
尽管总体结局较差，但与预后良好的患者相比，基线预后因素较差的患者接受取栓治疗比药物治疗的影响更大。
