Stroke Research Unit, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
Department of Neurology, Danderyd Hospital, Stockholm, Sweden.
Int J Stroke. 2023 Dec;18(10):1193-1201. doi: 10.1177/17474930231180451. Epub 2023 Jun 17.
A large infarct and expanding cerebral edema (CED) due to a middle cerebral artery occlusion confers a 70% mortality unless treated surgically. There is still conflicting evidence whether reperfusion is associated with a lower risk for CED in acute ischemic stroke.
To investigate the association of reperfusion with development of early CED after stroke thrombectomy.
From the SITS-International Stroke Thrombectomy Registry, we selected patients with occlusion of the intracranial internal carotid or middle cerebral artery (M1 or M2). Successful reperfusion was defined as mTICI ⩾ 2b. Primary outcome was moderate or severe CED, defined as focal brain swelling ⩾1/3 of the hemisphere on imaging scans at 24 h. We used regression methods while adjusting for baseline variables. Effect modification by severe early neurological deficits, as indicators of large infarct at baseline and at 24 h, were explored.
In total, 4640 patients, median age 70 years and median National Institutes of Health Stroke Score (NIHSS) 16, were included. Of these, 86% had successful reperfusion. Moderate or severe CED was less frequent among patients who had reperfusion compared to patients without reperfusion: 12.5% versus 29.6%, p < 0.05, crude risk ratio (RR) 0.42 (95% confidence interval (CI): 0.37-0.49), and adjusted RR 0.50 (95% CI: 0.44-0.57). Analysis of effect modification indicated that severe neurological deficits weakened the association between reperfusion and lower risk of CED. The RR reduction was less favorable in patients with severe neurological deficits, defined as NIHSS score 15 or more at baseline and at 24 h, used as an indicator for larger infarction.
In patients with large artery anterior circulation occlusion stroke who underwent thrombectomy, successful reperfusion was associated with approximately 50% lower risk for early CED. Severe neurological deficit at baseline seems to be a predictor for moderate or severe CED also in patients with successful reperfusion by thrombectomy.
由于大脑中动脉闭塞导致的大面积梗死和不断扩大的脑水肿（CED），如果不进行手术治疗，死亡率高达 70%。目前仍然存在争议，即再灌注是否与急性缺血性卒中后 CED 的风险降低相关。
研究在卒中取栓治疗后再灌注与早期 CED 发生的相关性。
我们从 SITS-国际卒中取栓登记研究中选择了颅内颈内动脉或大脑中动脉（M1 或 M2）闭塞的患者。成功再灌注定义为 mTICI ⩾ 2b。主要结局是 24 小时时影像学检查显示中度或重度 CED，定义为局部脑肿胀 ⩾半球的 1/3。我们使用回归方法，同时调整基线变量。通过严重的早期神经功能缺损（作为基线和 24 小时时大梗死的指标）来探索效应修饰。
共纳入 4640 例患者，中位年龄为 70 岁，中位 NIHSS 评分为 16 分。其中，86%的患者再灌注成功。与未再灌注的患者相比，再灌注的患者发生中度或重度 CED 的频率较低：12.5%比 29.6%，p<0.05，粗风险比（RR）为 0.42（95%置信区间[CI]：0.37-0.49），调整后的 RR 为 0.50（95%CI：0.44-0.57）。效应修饰分析表明，严重的神经功能缺损削弱了再灌注与 CED 风险降低之间的关联。在基线和 24 小时 NIHSS 评分均为 15 或更高的患者（作为大梗死的指标）中，再灌注后 RR 的降低不太有利。
在接受取栓治疗的大动脉前循环闭塞性卒中患者中，成功再灌注与早期 CED 的风险降低约 50%相关。基线时严重的神经功能缺损似乎也是再灌注成功患者发生中重度 CED 的预测因素。
