Neurology Department, Hôpital Fondation A. de Rothschild, Paris, France (N.B., M.O., L.B., P.S.).
Neurology Department, GHU Paris Psychiatrie et Neurosciences, Sainte-Anne Hospital, Université de Paris, INSERM UMR 1266, FHU NeuroVasc, France (N.B., G.T., J.-C.B.).
Stroke. 2022 Nov;53(11):3304-3312. doi: 10.1161/STROKEAHA.122.039228. Epub 2022 Sep 8.
We recently reported a worrying 30% rate of early neurological deterioration (END) occurring within 24 hours following intravenous thrombolysis (IVT) in minor stroke with isolated internal carotid artery occlusion (ie, without additional intracranial occlusion), mainly due to artery-to-artery embolism. Here, we hypothesize that in this setting IVT-as compared to no-IVT-may foster END, in particular by favoring artery-to-artery embolism from thrombus fragmentation.
From a large multicenter retrospective database, we compared minor stroke (National Institutes of Health Stroke Scale score <6) isolated internal carotid artery occlusion patients treated within 4.5 hours of symptoms onset with either IVT or antithrombotic therapy between 2006 and 2020 (inclusion date varied among centers). Primary outcome was END within 24 hours (≥4 National Institutes of Health Stroke Scale points increase within 24 hours), and secondary outcomes were END within 7 days (END) and 3-month modified Rankin Scale score 0 to 1.
Overall, 189 patients were included (IVT=95; antithrombotics=94 [antiplatelets, n=58, anticoagulants, n=36]) from 34 centers. END within 24 hours and END occurred in 46 (24%) and 60 (32%) patients, respectively. Baseline clinical and radiological variables were similar between the 2 groups, except significantly higher National Institutes of Health Stroke Scale (median 3 versus 2) and shorter onset-to-imaging (124 versus 149min) in the IVT group. END within 24 hours was more frequent following IVT (33% versus 16%, adjusted hazard ratio, 2.01 [95% CI, 1.07-3.92]; =0.03), driven by higher odds of artery-to-artery embolism (20% versus 9%, =0.09). However, END and 3-month modified Rankin Scale score of 0 to 1 did not significantly differ between the 2 groups (END: adjusted hazard ratio, 1.29 [95% CI, 0.75-2.23]; =0.37; modified Rankin Scale score of 0-1: adjusted odds ratio, 1.1 [95% CI, 0.6-2.2]; =0.71). END occurred earlier in the IVT group: median imaging-to-END 2.6 hours (interquartile range, 1.9-10.1) versus 20.4 hours (interquartile range, 7.8-34.4), respectively, <0.01.
In our population of minor strokes with iICAO, although END rate at 7 days and 3-month outcome were similar between the 2 groups, END-particularly END due to artery-to-artery embolism-occurred earlier following IVT. Prospective studies are warranted to further clarify the benefit/risk profile of IVT in this population.
我们最近报道了一个令人担忧的现象，即在有孤立颈内动脉闭塞（即无颅内其他闭塞）的小卒中患者中，静脉溶栓（IVT）后 24 小时内早期神经功能恶化（END）的发生率为 30%，这主要是由于动脉到动脉栓塞。在此，我们假设在这种情况下，IVT 可能会导致 END，特别是通过促进血栓碎裂引起的动脉到动脉栓塞。
我们从一个大型多中心回顾性数据库中比较了在症状发作后 4.5 小时内接受治疗的孤立颈内动脉闭塞（美国国立卫生研究院卒中量表评分 <6）的小卒中患者，这些患者在 2006 年至 2020 年期间接受了 IVT 或抗血栓治疗（各中心纳入日期不同）。主要结局为 24 小时内 END（24 小时内 NIHSS 评分增加≥4 分），次要结局为 7 天内 END 和 3 个月改良 Rankin 量表评分 0 至 1。
总体而言，来自 34 个中心的 189 名患者（IVT=95；抗血栓治疗=94 [抗血小板治疗，n=58；抗凝治疗，n=36]）被纳入研究。24 小时内发生 END 和 7 天内发生 END 的患者分别为 46 名（24%）和 60 名（32%）。两组患者的基线临床和影像学变量相似，但 IVT 组的 NIHSS 评分更高（中位数为 3 分比 2 分），发病至影像学检查的时间更短（124 分钟比 149 分钟）。24 小时内 END 更常见于 IVT 组（33%比 16%，调整后的危险比为 2.01 [95%CI，1.07-3.92]；=0.03），这主要是由于动脉到动脉栓塞的可能性更高（20%比 9%，=0.09）。然而，两组患者的 END 和 3 个月改良 Rankin 量表评分 0 至 1 无显著差异（END：调整后的危险比为 1.29 [95%CI，0.75-2.23]；=0.37；改良 Rankin 量表评分 0-1：调整后的比值比为 1.1 [95%CI，0.6-2.2]；=0.71）。IVT 组的 END 发生更早：中位数影像学至 END 的时间分别为 2.6 小时（四分位间距，1.9-10.1）和 20.4 小时（四分位间距，7.8-34.4），<0.01。
在我们的孤立颈内动脉闭塞小卒中患者人群中，尽管两组患者 7 天的 END 发生率和 3 个月的结局相似，但 END，特别是由于动脉到动脉栓塞引起的 END，在 IVT 后更早发生。需要进一步开展前瞻性研究，以更明确 IVT 在该人群中的获益/风险特征。
