van Voorst Henk, Bruggeman Agnetha A E, Andriessen Jurr, Hoving Jan W, Konduri Praneeta R, Yang Wenjin, Kappelhof Manon, Arrarte Terreros Nerea, Roos Yvo B W E M, van Zwam Wim H, van der Lugt Aad, van der Hoorn Anouk, Boiten Jelis, Roosendaal Stefan, Jenniskens Sjoerd, Caan Matthan W A, Marquering Henk A, Emmer Bart J, Majoie Charles B L M
Department of Radiology and Nuclear Medicine (H.v.V., A.A.E.B., J.A., J.W.H., P.R.K., W.Y., M.K., N.A.T., S.R., H.A.M., B.J.E., C.B.L.M.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
Department of Biomedical Engineering and Physics (H.v.V., P.R.K., M.K., N.A.T., M.W.A.C., H.A.M.), Amsterdam UMC, University of Amsterdam, the Netherlands.
Stroke. 2023 Apr;54(4):1056-1065. doi: 10.1161/STROKEAHA.122.041606. Epub 2023 Mar 13.
A larger thrombus in patients with acute ischemic stroke might result in more complex endovascular treatment procedures, resulting in poorer patient outcomes. Current evidence on thrombus volume and length related to procedural and functional outcomes remains contradicting. This study aimed to assess the prognostic value of thrombus volume and thrombus length and whether this relationship differs between first-line stent retrievers and aspiration devices for endovascular treatment.
In this multicenter retrospective cohort study, 670 of 3279 patients from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) for endovascularly treated large vessel occlusions were included. Thrombus volume (0.1 mL) and length (0.1 mm) based on manual segmentations and measurements were related to reperfusion grade (expanded Treatment in Cerebral Infarction score) after endovascular treatment, the number of retrieval attempts, symptomatic intracranial hemorrhage, and a shift for functional outcome at 90 days measured with the reverted ordinal modified Rankin Scale (odds ratio >1 implies a favorable outcome). Univariable and multivariable linear and logistic regression were used to report common odds ratios (cORs)/adjusted cOR and regression coefficients (B/aB) with 95% CIs. Furthermore, a multiplicative interaction term was used to analyze the relationship between first-line device choice, stent retrievers versus aspiration device, thrombus volume, and outcomes.
Thrombus volume was associated with functional outcome (adjusted cOR, 0.83 [95% CI, 0.71-0.97]) and number of retrieval attempts (aB, 0.16 [95% CI, 0.16-0.28]) but not with the other outcome measures. Thrombus length was only associated with functional independence (adjusted cOR, 0.45 [95% CI, 0.24-0.85]). Patients with more voluminous thrombi had worse functional outcomes if endovascular treatment was based on first-line stent retrievers (interaction cOR, 0.67 [95% CI, 0.50-0.89]; =0.005; adjusted cOR, 0.74 [95% CI, 0.55-1.0]; =0.04).
In this study, patients with a more voluminous thrombus required more endovascular thrombus retrieval attempts and had a worse functional outcome. Patients with a lengthier thrombus were less likely to achieve functional independence at 90 days. For more voluminous thrombi, first-line stent retrieval compared with first-line aspiration might be associated with worse functional outcome.
急性缺血性脑卒中患者体内较大的血栓可能导致血管内治疗操作更为复杂，进而使患者预后更差。目前关于血栓体积和长度与治疗操作及功能预后之间关系的证据仍相互矛盾。本研究旨在评估血栓体积和血栓长度的预后价值，以及这种关系在用于血管内治疗的一线取栓支架和抽吸装置之间是否存在差异。
在这项多中心回顾性队列研究中，纳入了荷兰急性缺血性脑卒中血管内治疗多中心随机临床试验（MR CLEAN注册研究）中3279例接受血管内治疗的大血管闭塞患者中的670例。基于手动分割和测量得出的血栓体积（精确到0.1 mL）和长度（精确到0.1 mm）与血管内治疗后的再灌注等级（扩展脑梗死治疗评分）、取栓尝试次数、症状性颅内出血以及90天时用反向序贯改良Rankin量表测量的功能预后变化（比值比>1表示预后良好）相关。采用单变量和多变量线性及逻辑回归来报告共同比值比（cORs）/调整后的cOR以及回归系数（B/aB）及其95%置信区间。此外，使用相乘交互项来分析一线器械选择（取栓支架与抽吸装置）、血栓体积与预后之间的关系。
血栓体积与功能预后（调整后的cOR，0.83 [95%置信区间，0.71 - 0.97]）和取栓尝试次数（aB，0.16 [95%置信区间，0.16 - 0.28]）相关，但与其他预后指标无关。血栓长度仅与功能独立相关（调整后的cOR，0.45 [95%置信区间，0.24 - 0.85]）。如果血管内治疗基于一线取栓支架，血栓体积较大的患者功能预后较差（交互作用cOR，0.67 [95%置信区间，0.50 - 0.89]；P = 0.005；调整后的cOR，0.74 [95%置信区间，0.55 - 1.0]；P = 0.04）。
在本研究中，血栓体积较大的患者需要更多的血管内血栓清除尝试，且功能预后较差。血栓长度较长的患者在90天时实现功能独立的可能性较小。对于血栓体积较大的患者，与一线抽吸相比，一线取栓支架治疗可能与更差的功能预后相关。
