Section of Vascular/Endovascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA.
Ochsner Center for Outcomes Research, Ochsner Clinic Foundation, New Orleans, LA.
J Vasc Surg. 2023 Sep;78(3):702-710. doi: 10.1016/j.jvs.2023.04.031. Epub 2023 Jun 16.
Carotid interventions are increasingly performed in select patients following acute stroke. We aimed to determine the effects of presenting stroke severity (National Institutes of Health Stroke Scale [NIHSS]) and use of systemic thrombolysis (tissue plasminogen activator [tPA]) on discharge neurological outcomes (modified Rankin scale [mRS]) after urgent carotid endarterectomy (uCEA) and urgent carotid artery stenting (uCAS).
Patients undergoing uCEA/uCAS at a tertiary Comprehensive Stroke Center (January 2015 to May 2022) were divided into two cohorts: (1) no thrombolysis (uCEA/uCAS only) and (2) use of thrombolysis before the carotid intervention (tPA + uCEA/uCAS). Outcomes were discharge mRS and 30-day complications. Regression models were used to determine an association between tPA use and presenting stroke severity (NIHSS) and discharge neurological outcomes (mRS).
Two hundred thirty-eight patients underwent uCEA/uCAS (uCEA/uCAS only, n = 186; tPA + uCEA/uCAS, n = 52) over 7 years. In the thrombolysis cohort compared with the uCEA/uCAS only cohort, the mean presenting stroke severity was higher (NIHSS = 7.6 vs 3.8; P = .001), and more patients presented with moderate to severe strokes (57.7% vs 30.2% with NIHSS >4). The 30-day stroke, death, and myocardial infarction rates in the uCEA/uCAS only vs tPA + uCEA/uCAS were 8.1% vs 11.5% (P = .416), 0% vs 9.6% (P < .001), and 0.5% vs 1.9% (P = .39), respectively. The 30-day stroke/hemorrhagic conversion and myocardial infarction rates did not differ with tPA use; however, the difference in deaths was significantly higher in the tPA + uCEA/uCAS cohort (P < .001). There was no difference in neurological functional outcome with or without thrombolysis use (mean mRS, 2.1 vs 1.7; P = .061). For both minor strokes (NIHSS ≤4 vs NIHSS >4: relative risk, 1.58 vs 1.58, tPA vs no tPA, respectively, P = .997) and moderate strokes (NIHSS ≤10 vs NIHSS >10: relative risk, 1.94 vs 2.08, tPA vs no tPA, respectively; P = .891), the likelihood of discharge functional independence (mRS score of ≤2) was not influenced by tPA.
Patients with a higher presenting stroke severity (NIHSS) had worse neurological functional outcomes (mRS). Patients presenting with minor and moderate strokes were more likely to have discharge neurological functional independence (mRS of ≤2), regardless of whether they received tPA or not. Overall, presenting NIHSS is predictive of discharge neurological functional autonomy and is not influenced by the use of thrombolysis.
在选择的急性卒中患者中，颈动脉介入治疗的应用日益增多。我们旨在确定发病严重程度（国立卫生研究院卒中量表 [NIHSS]）和使用全身溶栓治疗（组织型纤溶酶原激活剂 [tPA]）对紧急颈动脉内膜切除术（uCEA）和紧急颈动脉支架置入术（uCAS）后出院神经功能结局（改良 Rankin 量表 [mRS]）的影响。
在三级综合卒中中心（2015 年 1 月至 2022 年 5 月）接受 uCEA/uCAS 的患者分为两组：（1）无溶栓治疗（仅 uCEA/uCAS）和（2）在颈动脉介入前使用溶栓治疗（tPA+uCEA/uCAS）。结局为出院 mRS 和 30 天并发症。回归模型用于确定 tPA 使用与发病严重程度（NIHSS）和出院神经功能结局（mRS）之间的关联。
7 年内，238 例患者接受 uCEA/uCAS（仅 uCEA/uCAS，n=186；tPA+uCEA/uCAS，n=52）。与仅 uCEA/uCAS 组相比，溶栓组的平均发病严重程度更高（NIHSS=7.6 比 3.8；P=0.001），且更多患者出现中重度卒中（NIHSS>4 者占 57.7%比 30.2%）。仅 uCEA/uCAS 组与 tPA+uCEA/uCAS 组的 30 天卒中、死亡和心肌梗死发生率分别为 8.1%比 11.5%（P=0.416）、0%比 9.6%（P<0.001）和 0.5%比 1.9%（P=0.39）。tPA 使用与 30 天卒中/出血转化率和心肌梗死率无差异；然而，tPA+uCEA/uCAS 组的死亡率差异显著更高（P<0.001）。是否使用溶栓治疗与神经功能结局无差异（平均 mRS，2.1 比 1.7；P=0.061）。对于轻度卒中（NIHSS≤4 与 NIHSS>4：相对风险，1.58 比 1.58，tPA 与无 tPA，分别，P=0.997）和中度卒中（NIHSS≤10 与 NIHSS>10：相对风险，1.94 比 2.08，tPA 与无 tPA，分别；P=0.891），tPA 对出院功能独立性（mRS 评分≤2）的可能性没有影响。
发病严重程度（NIHSS）较高的患者神经功能结局（mRS）较差。轻度和中度卒中患者出院时更有可能实现神经功能独立（mRS≤2），无论是否使用 tPA。总体而言，发病 NIHSS 可预测出院时的神经功能自主能力，不受溶栓治疗的影响。
