Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.).
Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.M., S.C., M.G.L., G.W.A.).
Stroke. 2022 Oct;53(10):3145-3152. doi: 10.1161/STROKEAHA.122.038560. Epub 2022 Jun 23.
Intravenous tPA (tissue-type plasminogen activator) is often administered before endovascular thrombectomy (EVT). Recent studies have questioned whether tPA is necessary given the high rates of arterial recanalization achieved by EVT, but whether tPA impacts venous outflow (VO) is unknown. We investigated whether tPA improves VO profiles on baseline computed tomography (CT) angiography (CTA) images before EVT.
Retrospective multicenter cohort study of patients with acute ischemic stroke due to large vessel occlusion undergoing EVT triage. Included patients underwent CT, CTA, and CT perfusion before EVT. VO profiles were determined by opacification of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein on CTA as 0, not visible; 1, moderate opacification; and 2, full. Pial arterial collaterals were graded on CTA, and tissue-level collaterals were assessed on CT perfusion using the hypoperfusion intensity ratio. Clinical and demographic data were determined from the electronic medical record. Using multivariable regression analysis, we determined the correlation between tPA administration and favorable VO profiles.
Seven hundred seventeen patients met inclusion criteria. Three hundred sixty-five patients received tPA (tPA+), while 352 patients were not treated with tPA (tPA-). Fewer tPA+ patients had atrial fibrillation (n=128 [35%] versus n=156 [44%]; =0.012) and anticoagulants/antiplatelet treatment before acute ischemic stroke due to large vessel occlusion onset (n=130 [36%] versus n=178 [52%]; <0.001) compared with tPA- patients. One hundred eighty-five patients (51%) in the tPA+ and 100 patients (28%) in the tPA- group exhibited favorable VO (<0.001). Multivariable regression analysis showed that tPA administration was a strong independent predictor of favorable VO profiles (OR, 2.6 [95% CI, 1.7-4.0]; <0.001) after control for favorable pial arterial CTA collaterals, favorable tissue-level collaterals on CT perfusion, age, presentation National Institutes of Health Stroke Scale, antiplatelet/anticoagulant treatment, history of atrial fibrillation and time from symptom onset to imaging.
In patients with acute ischemic stroke due to large vessel occlusion undergoing thrombectomy triage, tPA administration was strongly associated with the presence of favorable VO profiles.
静脉注射组织型纤溶酶原激活物（tPA）常于血管内血栓切除术（EVT）前使用。最近的研究对 tPA 的必要性提出了质疑，因为 EVT 可实现很高的动脉再通率，但 tPA 是否会影响静脉流出（VO）尚不清楚。我们研究了 EVT 前基线计算机断层扫描（CT）血管造影（CTA）是否可以改善 tPA 对 VO 曲线的影响。
对接受 EVT 筛选的因大血管闭塞导致急性缺血性卒中的患者进行回顾性多中心队列研究。纳入的患者接受 CT、CTA 和 CT 灌注检查。VO 曲线通过 CTA 中 Labbe 静脉、蝶顶窦和大脑中浅静脉的显影来确定，分别为 0 （不可见）、1（中度显影）和 2（完全显影）。CTA 评估软脑膜侧支循环，CT 灌注评估组织水平侧支循环使用低灌注强度比。临床和人口统计学数据从电子病历中获得。采用多变量回归分析，确定 tPA 给药与良好 VO 曲线之间的相关性。
717 名患者符合纳入标准。365 名患者接受了 tPA（tPA+）治疗，352 名患者未接受 tPA（tPA-）治疗。与 tPA-患者相比，tPA+患者心房颤动（n=128[35%]与 n=156[44%]；=0.012）和急性缺血性卒中发生前抗凝/抗血小板治疗（n=130[36%]与 n=178[52%]）较少（<0.001）。在 tPA+组中，185 名患者（51%）和 tPA-组中 100 名患者（28%）VO 曲线良好（<0.001）。多变量回归分析表明，tPA 给药是 VO 曲线良好的独立预测因素（OR，2.6[95%CI，1.7-4.0]；<0.001），校正良好的软脑膜 CTA 侧支循环、CT 灌注上良好的组织水平侧支循环、年龄、美国国立卫生研究院卒中量表（NIHSS）评分、抗血小板/抗凝治疗、心房颤动病史和症状发作至成像时间后。
在接受血栓切除术筛选的大血管闭塞性急性缺血性卒中患者中，tPA 给药与良好的 VO 曲线密切相关。
