血管内治疗与药物治疗对伴有卒中前残疾的急性前循环大血管闭塞的疗效比较：CLEAR 和 RESCUE-Japan 研究分析
Endovascular vs Medical Management for Late Anterior Large Vessel Occlusion With Prestroke Disability: Analysis of CLEAR and RESCUE-Japan.
机构信息
From the Cooper Neurological Institute (J.E.S., A.R., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Radiology (M.M.Q., M.A., P.K., A.S., N.L.K., T.N.N.), Boston Medical Center, Boston University School of Medicine, MA; Departments of Radiation Oncology (M.M.Q.) and Neurology (T.N.N.), Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (R.G.N.), University of Pittsburgh Medical Center, PA; Division of Stroke Care Unit (Kanta Tanaka, Kazunori Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Neurology (S. Nagel), Klinikum Ludwigshafen; Departments of Neurology (S. Nagel, P.A.R.) and Neuroradiology (M.A.M., F.S.), Heidelberg University Hospital, Germany; Department of Neurology (P.M., D.S.), Lausanne University Hospital, University of Lausanne, Switzerland; Cooper Medical School of Rowan University (N.V.), Camden, NJ; Stroke Unit (M.R., M.O.-G.), Neurology, Hospital Vall D'Hebron, Barcelona, Spain; Department of Stroke Neurology (H.Y.), NHO Osaka National Hospital, Japan; Department of Neurosurgery (S.Y.), Hyogo College of Medicine, Nishinomiya, Japan; Department of Neurology (D.C.H., M.H.M.), Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA; Department of Clinical Neurosciences (S. Nannoni), University of Cambridge, United Kingdom; University of Lille (H.H., F.C., C.C.), Inserm, Centre Hospitalier Universitaire de Lille, U1172, LilNCog-Lille Neuroscience & Cognition, France; Department of Neurology (S.A.S., S.S.-M.), UTHealth McGovern Medical School, Houston, TX; Department of Neurology (S.O.G., M.F.), University of Iowa Hospitals and Clinics, Iowa City,; Department of Neurology (S.Z., A.C.), University of Toledo, OH; Department of Neurosurgery (K.U.), Hyogo College of Medicine, Nishinomiya, Japan; Department of Neurovascular Research (N.S.), Kobe City Medical Center General Hospital, Japan; Division of Neurointerventional Radiology (A.S.P., A.L.K.), University of Massachusetts Memorial Medical Center, Worcester; Department of Neurosurgery (M.T.), Seisho Hospital, Odawara, Japan; Department of Radiology (B.F., D.R., J.R.), Centre Hospitalier de L'Université de Montréal, Canada; Department of Neurology (H.E.M.), State University of New York, Upstate Medical University, Syracuse, NY; Department of Neurosurgery (M. Morimoto), Yokohama Shintoshi Neurosurgical Hospital; Department of Neurology (M.S.), Ise Red Cross Hospital; Department of Neurosurgery (T.N.), Sapporo Shiroishi Memorial Hospital, Japan; Neurology Department (J.D.), Leuven University Hospital, Belgium; Department of Neurology (P.A.R.), Heidelberg University Hospital, Germany; Neuroscience and Stroke Program (O.O.Z.), Bon Secours Mercy Health St Vincent Hospital, Toledo, OH; Institute of Diagnostic and Interventional Neuroradiology (J.K.), University of Bern, Inselspital; Institute of Diagnostic (J.K.), Interventional and Pediatric Radiology, University Hospital Bern, Inselspital; Department of Neurology (U.F.), University Hospital Basel, University of Basel; and Department of Neurology (U.F.), University Hospital Bern, University of Bern, Switzerland.
出版信息
Neurology. 2023 Feb 14;100(7):e751-e763. doi: 10.1212/WNL.0000000000201543. Epub 2022 Nov 4.
BACKGROUND AND OBJECTIVES
Current guidelines do not address recommendations for mechanical thrombectomy (MT) in the extended time window (>6 hours after time last seen well [TLSW]) for large vessel occlusion (LVO) patients with preexisting modified Rankin Scale (mRS) > 1. In this study, we evaluated the outcomes of MT vs medical management in patients with prestroke disability presenting in the 6- to 24-hour time window with acute LVO.
METHODS
We analyzed a multinational cohort (61 sites, 6 countries from 2014 to 2020) of patients with prestroke (or baseline) mRS 2 to 4 and anterior circulation LVO treated 6-24 hours from TLSW. Patients treated in the extended time window with MT vs medical management were compared using multivariable logistic regression and inverse probability of treatment weighting (IPTW). The primary outcome was the return of Rankin (ROR, return to prestroke mRS by 90 days).
RESULTS
Of 554 included patients (448 who underwent MT), the median age was 82 years (interquartile range [IQR] 72-87) and the National Institutes of Health Stroke Scale (NIHSS) was 18 (IQR 13-22). In both MV logistic regression and IPTW analysis, MT was associated with higher odds of ROR (adjusted OR [aOR] 3.96, 95% CI 1.78-8.79 and OR 3.10, 95% CI 1.20-7.98, respectively). Among other factors, premorbid mRS 4 was associated with higher odds of ROR (aOR, 3.68, 95% CI 1.97-6.87), while increasing NIHSS (aOR 0.90, 95% CI 0.86-0.94) and decreasing Alberta Stroke Program Early Computed Tomography Scale score (aOR per point 0.86, 95% CI 0.75-0.99) were associated with lower odds of ROR. Age, intravenous thrombolysis, and occlusion location were not associated with ROR.
DISCUSSION
In patients with preexisting disability presenting in the 6- to 24-hour time window, MT is associated with a higher probability of returning to baseline function compared with medical management.
CLASSIFICATION OF EVIDENCE
This investigation's results provide Class III evidence that in patients with preexisting disability presenting 6-24 hours from the TLSW and acute anterior LVO stroke, there may be a benefit of MT over medical management in returning to baseline function.
背景与目的
目前的指南并未针对存在基线改良 Rankin 量表（mRS）评分＞1 的大血管闭塞（LVO）患者，在超过时间窗（时间最后可看到正常[TLSW]后 6 小时）进行机械取栓（MT）提出建议。本研究评估了在发病前有残疾的患者，在 6-24 小时的急性 LVO 时间窗内，行 MT 与药物治疗的结局。
方法
我们分析了一个多中心队列（2014 年至 2020 年来自 6 个国家的 61 个地点）的患者数据，这些患者在发病前（或基线时）mRS 为 2-4 分，且前循环 LVO 治疗时间距离 TSLW 为 6-24 小时。采用多变量逻辑回归和逆概率治疗加权（IPTW）比较 MT 治疗与药物治疗的扩展时间窗患者。主要结局为 Rankin 恢复（ROR，90 天内恢复至发病前 mRS）。
结果
554 例患者（448 例行 MT）纳入研究，中位年龄为 82 岁（四分位距 [IQR] 72-87），美国国立卫生研究院卒中量表（NIHSS）评分为 18（IQR 13-22）。在 MV 逻辑回归和 IPTW 分析中，MT 与更高的 ROR 几率相关（校正比值比 [aOR] 3.96，95%CI 1.78-8.79 和 OR 3.10，95%CI 1.20-7.98）。在其他因素中，发病前 mRS 4 与更高的 ROR 几率相关（aOR 3.68，95%CI 1.97-6.87），而 NIHSS 升高（aOR 0.90，95%CI 0.86-0.94）和 Alberta 卒中计划早期 CT 评分降低（aOR 每点 0.86，95%CI 0.75-0.99）与 ROR 几率较低相关。年龄、静脉溶栓和闭塞部位与 ROR 无关。
讨论
在发病前有残疾且发病时间在 6-24 小时的患者中，与药物治疗相比，MT 更有可能恢复至基线功能。
证据分类
该研究结果提供了 III 级证据，表明在发病前有残疾且在 TSLW 后 6-24 小时发生急性前循环 LVO 卒中的患者中，MT 可能比药物治疗更能使患者恢复至基线功能。
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