From the Department of Diagnostic and Interventional Neuroradiology (A.M., C.C.K., B.L.S., T.D., D.W., L.G., S.P.-P., E.I.P., J.G., J.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.
Department of Diagnostic, Interventional and Pediatric Radiology (C.C.K.), University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.
AJNR Am J Neuroradiol. 2023 Sep;44(9):1050-1056. doi: 10.3174/ajnr.A7943. Epub 2023 Jul 27.
Intra-arterial thrombolytics may be used to treat distal vessel occlusions, which cause incomplete reperfusion following mechanical thrombectomy. Because immediate reperfusion after intra-arterial thrombolytics occurs rarely, the aim of this study was to assess the delayed effect of intra-arterial thrombolytics using follow-up perfusion imaging.
We included patients from a prospective stroke registry (February 2015 to September 2022) who had undergone mechanical thrombectomy and had incomplete reperfusion (expanded TICI 2a-2c) and available 24 hour perfusion imaging. Perfusion imaging was rated as delayed reperfusion if time-sensitive perfusion maps did not show wedge-shaped delays suggestive of persisting occlusions corresponding to the post-mechanical thrombectomy angiographic deficit. Patients treated with intra-arterial thrombolytics were compared with controls using multivariable logistic regression and inverse probability of treatment weighting matching for baseline differences and factors associated with delayed reperfusion.
The median age of the final study population ( = 459) was 74 years (interquartile range, 63-81 years), and delayed reperfusion occurred in 61% of cases. Patients treated with additional intra-arterial thrombolytics ( = 40) were younger and had worse expanded TICI scores. After matching was performed, intra-arterial thrombolytics was associated with higher rates of delayed reperfusion (adjusted OR = 2.7; 95% CI, 1.1-6.4) and lower rates of new infarction in the residually hypoperfused territory after mechanical thrombectomy (adjusted OR = 0.3; 95% CI, 0.1-0.7). No difference was found in the rates of functional independence (90-day mRS, 0-2; adjusted OR = 1.4; 95% CI, 0.4-4.1).
Rescue intra-arterial thrombolytics is associated with delayed reperfusion of remaining vessel occlusions following incomplete mechanical thrombectomy. The value of intra-arterial thrombolytics as a potential therapy for incomplete reperfusions after mechanical thrombectomy should be assessed in the setting of randomized controlled trials.
动脉内溶栓治疗可用于治疗机械取栓后仍存在不完全再通的远端血管闭塞。由于动脉内溶栓后即刻再通的情况很少见，本研究旨在通过随访灌注成像来评估动脉内溶栓的延迟效应。
我们纳入了 2015 年 2 月至 2022 年 9 月期间前瞻性卒中登记研究中接受机械取栓治疗但存在不完全再通（扩大的 TICI 2a-2c）且有 24 小时灌注成像的患者。如果时间敏感的灌注图没有显示楔形延迟，提示与机械取栓后血管造影缺损相对应的持续性闭塞，则将灌注成像评定为延迟再通。通过多变量逻辑回归和逆概率治疗加权匹配来比较接受动脉内溶栓治疗的患者和对照组之间的差异，以及与延迟再通相关的因素。
最终研究人群（n=459）的中位年龄为 74 岁（四分位距，63-81 岁），61%的患者发生延迟再通。接受额外动脉内溶栓治疗的患者（n=40）年龄较小，且扩大的 TICI 评分较差。匹配后，动脉内溶栓与更高的延迟再通率（校正比值比=2.7；95%置信区间，1.1-6.4）和机械取栓后残留灌注不足区域新梗死发生率较低（校正比值比=0.3；95%置信区间，0.1-0.7）相关。机械取栓后 90 天功能独立率（mRS 0-2）无差异（校正比值比=1.4；95%置信区间，0.4-4.1）。
补救性动脉内溶栓与机械取栓后不完全再通的残余血管闭塞的延迟再通有关。动脉内溶栓作为机械取栓后不完全再通的潜在治疗方法的价值应在随机对照试验中进行评估。
