缺血持续时间对卒中预后的影响独立于梗死面积。
Duration of Ischemia Affects Outcomes Independent of Infarct Size in Stroke.
作者信息
Kim Youngran, Khose Swapnil, Zaidat Osama O, Hassan Ameer E, Fifi Johanna T, Nanda Ashish, Atchie Benjamin, Woodward Britton, Doerfler Arnd, Tomasello Alejandro, Yoo Albert J, Sheth Sunil A
机构信息
Department of Neurology, UTHealth McGovern Medical School, Houston, TX (Y.K., S.K., S.A.S.); Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX (A.E.H.); Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.); University of Missouri, Columbia, MO (A.N.); Department of Radiology, Swedish Medical Center, Englewood, CO (B.A.); Vista Radiology, Knoxville, TN (B.W.); Department of Neuroradiology, University of Erlangen-Nuremberg, Germany (A.D.); Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain (A.T.); Texas Stroke Institute, Dallas-Fort Worth, TX (A.J.Y.).
出版信息
Stroke Vasc Interv Neurol. 2022 Sep;2(5). doi: 10.1161/svin.121.000163. Epub 2022 May 20.
BACKGROUND
Delays in endovascular reperfusion for patients with large vessel occlusion stroke are known to worsen outcomes, and the mechanism is believed to be time-dependent expansion of the ischemic infarction. In this study, we hypothesize that delays in onset to reperfusion (OTR) assert an effect on outcomes independent of effects of final infarct (FI).
METHODS
We performed a subgroup analysis from the prospective multicenter COMPLETE (International Acute Ischemic Stroke Registry With the Penumbra System Aspiration Including the 3D Revascularization Device; Penumbra, Inc) registry for 257 patients with anterior circulation large vessel occlusion who underwent endovascular therapy with successful reperfusion (modified treatment in cerebral infarction score 2b/3). FI was measured by Alberta Stroke Program Early CT score and volume on 24- to 48-hour computed tomography or magnetic resonance imaging. The likelihood of 90-day good functional outcome (modified Rankin scale 0-2) was assessed by OTR and absolute risk difference (ARD) was estimated using multivariable logistic regressions adjusting for patient characteristics including FI.
RESULTS
In univariable analysis, longer OTR was associated with a decreased likelihood of good functional outcome (ARD -3% [95% CI -4.5 to -1.0]/h delay). In multivariable analysis accounting for FI, the association between OTR and functional outcome remained significant (ARD -2% [95% CI -3.5 to -0.4]/h delay) with similar ARD. This finding was maintained in the subset of patients with FI imaging using CT only, using Alberta Stroke Program Early CT Score or volumetric FI measurements, and also in patients with larger versus smaller FIs.
CONCLUSIONS
The impact of OTR on outcomes appears to be mostly through a mechanism that is independent of FI. Our findings suggest that although the field has moved toward imaging infarct core definitions of eligibility for endovascular treatment, time remains an important predictor of outcome, independent of infarct core.
背景
已知大血管闭塞性卒中患者血管内再灌注延迟会使预后恶化，其机制被认为是缺血性梗死的时间依赖性扩展。在本研究中，我们假设再灌注开始延迟（OTR）对预后有影响，且独立于最终梗死灶（FI）的影响。
方法
我们对前瞻性多中心COMPLETE（使用Penumbra系统抽吸术包括3D血管重建装置的国际急性缺血性卒中登记；Penumbra公司）登记处的257例接受血管内治疗且成功再灌注（改良脑梗死治疗评分2b/3）的前循环大血管闭塞患者进行了亚组分析。通过阿尔伯塔卒中项目早期CT评分以及24至48小时计算机断层扫描或磁共振成像上的体积来测量FI。通过OTR评估90天良好功能预后（改良Rankin量表0 - 2）的可能性，并使用多变量逻辑回归估计绝对风险差异（ARD），该回归对包括FI在内的患者特征进行了调整。
结果
在单变量分析中，较长的OTR与良好功能预后的可能性降低相关（ARD为 - 3% [95% CI - 4.5至 - 1.0]/小时延迟）。在考虑FI的多变量分析中，OTR与功能预后之间的关联仍然显著（ARD为 - 2% [95% CI - 3.5至 - 0.4]/小时延迟），ARD相似。在仅使用CT进行FI成像的患者亚组中，使用阿尔伯塔卒中项目早期CT评分或体积性FI测量时，以及在较大与较小FI的患者中，这一发现均得以维持。
结论
OTR对预后的影响似乎主要通过一种独立于FI的机制。我们的研究结果表明，尽管该领域已朝着根据梗死核心成像来定义血管内治疗的适应证发展，但时间仍然是独立于梗死核心的重要预后预测因素。
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