Departments of Clinical Neurosciences (K.T., M.G., B.K.M., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, Canada.
Hotchkiss Brain Institute (M.G., B.K.M., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, Canada.
Stroke. 2022 Dec;53(12):3564-3571. doi: 10.1161/STROKEAHA.122.039774. Epub 2022 Nov 7.
Age and infarct volume are strong predictors of outcome in patients with ischemic stroke who underwent endovascular therapy (EVT). We aimed to investigate the impact of ischemic core volume (ICV) on stroke outcome after EVT in elderly.
Using the HERMES (Highly Effective Reperfusion Using Multiple Endovascular Devices) collaboration, a patient-level meta-analysis of 7 randomized trials in which patients were enrolled from December 2010 to April 2015) dataset, we categorized patients into those aged <75 and ≥75 years. ICV was calculated on computed tomography perfusion or magnetic resonance diffusion-weighted imaging. The association between ICV and the benefit of EVT over best medical treatment on outcome (modified Rankin Scale [mRS] at 90 days) and an ICV threshold for high likelihood (≥90%) of very poor outcome (mRS score ≥5) after EVT were investigated.
A total of 899 patients who had baseline ICV data, 247 patients aged ≥75 years, of which 118 were randomized in the EVT arm. Patients aged ≥75 years required smaller ICV to achieve mRS score ≤3 than those aged <75 years in the EVT arm (median 10.7 mL versus 23.9 mL, <0.001). In patients aged ≥75 years, modeling of outcome in both treatment arms revealed potential loss of effect for EVT at ICV of ≥50 mL or ≥85 mL for achieving mRS score ≤3 or ≤4, respectively. Treatment effect of EVT was significant in ICV <50 mL for mRS ≤3 (odds ratio 2.38, 95% confidence interval 1.35-4.22). ICV ≥132 mL was a threshold for high likelihood of very poor outcome after EVT. However, EVT still predicted at least 30% rate of mRS ≤3 at 150 mL ICV if near-complete or complete reperfusion was achieved.
Baseline ICV has an impact on stroke outcome after EVT in the elderly, but elderly patients with large ICV may still benefit from EVT if near-complete or complete reperfusion is achieved. Young patients seem to benefit from EVT regardless of ICV status.
在接受血管内治疗 (EVT) 的缺血性脑卒中患者中，年龄和梗死体积是预后的强有力预测因素。我们旨在研究在老年人中，缺血核心体积 (ICV) 对 EVT 后卒中结局的影响。
利用 HERMES（使用多种血管内装置实现高效再灌注）协作，对 2010 年 12 月至 2015 年 4 月期间纳入的 7 项随机试验的患者进行了一项基于个体患者水平的荟萃分析，我们将患者分为年龄<75 岁和≥75 岁。在 CT 灌注或磁共振弥散加权成像上计算 ICV。研究了 ICV 与 EVT 优于最佳药物治疗对结局（90 天时改良 Rankin 量表 [mRS]）的获益之间的关联，以及 EVT 后非常差结局（mRS 评分≥5）的高可能性（≥90%）的 ICV 阈值。
共纳入 899 例基线 ICV 数据患者，247 例年龄≥75 岁，其中 EVT 组 118 例随机分组。与 EVT 组年龄<75 岁的患者相比，年龄≥75 岁的患者需要更小的 ICV 才能达到 mRS 评分≤3（中位数 10.7 mL 比 23.9 mL，<0.001）。在≥75 岁的患者中，对两个治疗组的结局进行建模显示，EVT 在 ICV 为≥50 mL 或≥85 mL 时，分别获得 mRS 评分≤3 或≤4 的治疗效果丧失。EVT 在 ICV<50 mL 时对 mRS≤3 的治疗效果显著（比值比 2.38，95%置信区间 1.35-4.22）。ICV≥132 mL 是 EVT 后非常差结局的高可能性阈值。然而，如果实现了近乎完全或完全再灌注，ICV 为 150 mL 时仍预测 EVT 至少有 30%的 mRS≤3 率。
基线 ICV 对老年 EVT 后的卒中结局有影响，但如果实现了近乎完全或完全再灌注，大 ICV 的老年患者仍可能从 EVT 中获益。年轻患者似乎无论 ICV 状态如何都能从 EVT 中获益。
