Honig Asaf, Hallevi Hen, Simaan Naaem, Sacagiu Tzvika, Seyman Estelle, Filioglo Andrei, Gomori Moshe J, Rotschild Ofer, Jonas-Kimchi Tali, Sadeh Udi, Horev Anat, Leker Ronen R, Cohen José E, Molad Jeremy
Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel.
Department of Stroke and Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel.
J Clin Med. 2022 Jun 26;11(13):3681. doi: 10.3390/jcm11133681.
Current guidelines advocate intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) for all patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). We evaluated outcomes with and without IVT pretreatment. Our institutional protocols allow AIS patients presenting early (<4 h from onset or last seen normal) who have an Alberta Stroke Program Early CT Score (ASPECTS) ≥6 to undergo EVT without IVT pretreatment if the endovascular team is in the hospital (direct EVT). Rates of recanalization and hemorrhagic transformation (HT) and neurological outcomes were retrospectively compared in consecutive patients undergoing IVT+EVT vs. direct EVT with subanalyses in those ≥80 years and ≥85 years. In the overall cohort (IVT+EVT = 147, direct EVT = 162), and in subsets of patients ≥80 years (IVT+EVT = 51, direct EVT = 50) and ≥85 years (IVT+EVT = 19, direct EVT = 32), the IVT+EVT cohort and the direct EVT group had similar baseline characteristics, underwent EVT after a comparable interval from symptom onset, and reached similar rates of target vessel recanalization. No differences were observed in the HT frequency, or in disability at discharge or after 90 days. Patients receiving direct EVT underwent more stenting of the carotid artery due to stenosis during the EVT procedure (22% vs. 6%, p = 0.001). Direct EVT and IVT+EVT had comparable neurological outcomes in the overall cohort and in the subgroups of patients ≥80 and ≥85 years, suggesting that direct EVT should be considered in patients with an elevated risk for HT.
目前的指南提倡，对于所有因大血管闭塞（LVO）导致急性缺血性卒中（AIS）的患者，在进行血管内血栓切除术（EVT）之前先进行静脉溶栓（IVT）。我们评估了有无IVT预处理的结果。我们机构的方案允许早期就诊（发病或最后一次正常状态后<4小时）且阿尔伯塔卒中项目早期CT评分（ASPECTS）≥6的AIS患者，若血管内治疗团队在医院，则可在不进行IVT预处理的情况下接受EVT（直接EVT）。对接受IVT+EVT与直接EVT的连续患者的再通率、出血转化（HT）率和神经功能结局进行回顾性比较，并对年龄≥80岁和≥85岁的患者进行亚组分析。在总体队列中（IVT+EVT组=147例，直接EVT组=162例），以及年龄≥80岁（IVT+EVT组=51例，直接EVT组=50例）和≥85岁（IVT+EVT组=19例，直接EVT组=32例）的患者亚组中，IVT+EVT队列和直接EVT组具有相似的基线特征，在症状发作后的相当间隔时间后接受EVT，且达到相似的目标血管再通率。在HT频率、出院时或90天后的残疾情况方面未观察到差异。接受直接EVT的患者在EVT过程中因狭窄接受颈动脉支架置入术的比例更高（22%对6%，p=0.001）。在总体队列以及年龄≥80岁和≥85岁的患者亚组中，直接EVT和IVT+EVT具有可比的神经功能结局，这表明对于HT风险较高的患者应考虑直接EVT。
