Neurology Department, GHU Paris psychiatrie et neurosciences, Sainte-Anne Hospital, Université de Paris, INSERM U1266, FHU NeuroVasc, France (P.S., J.-C.B., G.T.).
Neurology Department, Hôpital Fondation A. de Rothschild, Paris, France (P.S.).
Stroke. 2022 Nov;53(11):3429-3438. doi: 10.1161/STROKEAHA.122.039182. Epub 2022 Jul 12.
Whether bridging therapy (intravenous thrombolysis [IVT] followed by mechanical thrombectomy) is superior to IVT alone in minor stroke with large vessel occlusion is unknown. Perfusion imaging may identify subsets of large vessel occlusion-related minor stroke patients with distinct response to bridging therapy.
We conducted a multicenter international observational study of consecutive IVT-treated patients with minor stroke (National Institutes of Health Stroke Scale score ≤5) who had an anterior circulation large vessel occlusion and perfusion imaging performed before IVT, with a subset undergoing immediate thrombectomy. Propensity score with inverse probability of treatment weighting was used to account for baseline between-groups differences. The primary outcome was 3-month modified Rankin Scale score 0 to 1. We searched for an interaction between treatment group and mismatch volume (critical hypoperfusion-core volume).
Overall, 569 patients were included (172 and 397 in the bridging therapy and IVT groups, respectively). After propensity-score weighting, the distribution of baseline variables was similar across the 2 groups. In the entire population, bridging was associated with lower odds of achieving modified Rankin Scale score 0 to 1: odds ratio, 0.73 [95% CI, 0.55-0.96]; =0.03. However, mismatch volume modified the effect of bridging on clinical outcome (=0.04 for continuous mismatch volume); bridging was associated with worse outcome in patients with, but not in those without, mismatch volume <40 mL (odds ratio, [95% CI] for modified Rankin Scale score 0-1: 0.48 [0.33-0.71] versus 1.14 [0.76-1.71], respectively). Bridging was associated with higher incidence of symptomatic intracranial hemorrhage in the entire population, but this effect was present in the small mismatch subset only (=0.002).
In our population of large vessel occlusion-related minor stroke patients, bridging therapy was associated with lower rates of good outcome as compared with IVT alone. However, mismatch volume was a strong modifier of the effect of bridging therapy over IVT alone, notably with worse outcome with bridging therapy in patients with mismatch volume ≤40 mL. Randomized trials should consider adding perfusion imaging for patient selection.
在小卒伴大血管闭塞患者中，桥接治疗（静脉溶栓后行机械取栓）是否优于单纯静脉溶栓尚不明确。灌注成像可能可以识别出对桥接治疗有不同反应的大血管闭塞相关小卒患者亚组。
我们开展了一项多中心国际观察性研究，连续纳入了接受静脉溶栓治疗的小卒患者（美国国立卫生研究院卒中量表评分≤5 分），这些患者的前循环大血管闭塞且在溶栓前进行了灌注成像，其中一部分患者进行了即刻取栓。采用逆概率治疗加权法来校正组间基线差异。主要结局为 3 个月时改良 Rankin 量表评分 0-1 分。我们对治疗组与不匹配体积（关键低灌注-核心体积）之间是否存在交互作用进行了探索。
共有 569 例患者纳入分析（桥接治疗组 172 例，静脉溶栓组 397 例）。经倾向评分加权后，两组间基线变量的分布相似。在全人群中，桥接治疗与较低的改良 Rankin 量表评分 0-1 分相关：比值比为 0.73（95%CI，0.55-0.96）；P=0.03。然而，不匹配体积改变了桥接治疗对临床结局的影响（连续不匹配体积的 P 值=0.04）；在存在不匹配体积＜40ml 的患者中，桥接治疗与较差的结局相关（改良 Rankin 量表评分 0-1 分的比值比为 0.48[95%CI，0.33-0.71]，而不匹配体积≥40ml 的患者比值比为 1.14[95%CI，0.76-1.71]）。在全人群中，桥接治疗与症状性颅内出血的发生率升高相关，但这一效应仅在小不匹配体积亚组中存在（P=0.002）。
在本项纳入大血管闭塞相关小卒患者的研究中，与单纯静脉溶栓相比，桥接治疗与较低的良好结局相关。然而，不匹配体积是桥接治疗与单纯静脉溶栓比较的一个重要调节因素，特别是在不匹配体积≤40ml 的患者中，桥接治疗的结局更差。随机试验应考虑加入灌注成像以进行患者选择。
