Rizzo Federica, Romoli Michele, Simonetti Luigi, Gentile Mauro, Forlivesi Stefano, Piccolo Laura, Naldi Federica, Paolucci Matteo, Galluzzo Simone, Taglialatela Francesco, Princiotta Ciro, Migliaccio Ludovica, Petruzzellis Marco, Logroscino Giancarlo, Zini Andrea
Stroke Unit, Vall d'Hebron Hospital and Vall d'Hebron Institut de Recerca, Barcelona, Spain.
Neurology and Stroke Unit, Dept. of Neuroscience, Bufalini Hospital, AUSL Romagna, Cesena, Italy.
Neurol Sci. 2024 Mar;45(3):1129-1134. doi: 10.1007/s10072-023-07089-w. Epub 2023 Oct 6.
Medium vessel occlusion (MeVO) accounts for 30% of acute ischemic stroke cases. The risk/benefit profile of endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) or the combination of the two (bridging therapy (BT)) is still unclear in MeVO. Here, we compare reperfusion strategies in MeVO for clinical and radiological outcomes.
This prospective single center study enrolled consecutive patients with AIS due to primary MeVO undergoing IVT, EVT, or BT at a comprehensive stroke center. Primary outcome was good functional status, defined as modified Rankin Scale (mRS) 0-2 at 3-month follow-up. Additional outcomes included mortality, successful recanalization, defined as mTICI ≥ 2b, stroke severity at discharge, and symptomatic intracerebral hemorrhage (sICH) according to SITS-MOST criteria. Logistic regression was modeled to define independent predictors of the primary outcome.
Overall, 180 consecutive people were enrolled (IVT = 59, EVT = 38, BT = 83), mean age 75. BT emerged as independent predictor of primary outcome (OR = 2.76, 95% CI = 1.08-7.07) together with age (OR = 0.94, 95% CI = 0.9-0.97) and baseline NIHSS (OR = 0.88, 95% CI = 0.81-0.95). BT associated with a 20% relative increase in successful recanalization compared to EVT (74.4 vs 56.4%, p = 0.049). Rates of sICH (1.1%) and procedural complications (vasospasm 4.1%, SAH in 1.7%) were very low, with no difference across groups.
BT may carry a higher chance of good functional outcome compared to EVT/IVT only in people with AIS due to MeVO, with marginally higher rates of successful recanalization. Randomized trials are needed to define optimal treatment tailoring for MeVO.
中型血管闭塞（MeVO）占急性缺血性卒中病例的30%。在MeVO中，血管内血栓切除术（EVT）和静脉溶栓（IVT）或两者联合（桥接治疗（BT））的风险/获益情况仍不明确。在此，我们比较MeVO的再灌注策略对临床和影像学结局的影响。
这项前瞻性单中心研究纳入了在一家综合卒中中心因原发性MeVO接受IVT、EVT或BT治疗的连续性急性缺血性卒中患者。主要结局为良好的功能状态，定义为3个月随访时改良Rankin量表（mRS）评分为0 - 2分。其他结局包括死亡率、成功再通（定义为脑梗死溶栓分级（mTICI）≥2b）、出院时的卒中严重程度以及根据SITS - MOST标准判定的症状性颅内出血（sICH）。采用逻辑回归模型确定主要结局的独立预测因素。
总体而言，共纳入180例连续性患者（IVT组 = 59例，EVT组 = 38例，BT组 = 83例），平均年龄75岁。BT与年龄（比值比（OR）= 0.94，95%置信区间（CI）= 0.9 - 0.97）和基线美国国立卫生研究院卒中量表（NIHSS）评分（OR = 0.88，95% CI = 0.81 - 0.95）一起，成为主要结局的独立预测因素（OR = 2.76，95% CI = 1.08 - 7.07）。与EVT相比，BT使成功再通的相对增加率达20%（74.4%对56.4%，p = 0.049）。sICH发生率（1.1%）和手术并发症（血管痉挛4.1%，蛛网膜下腔出血1.7%）非常低，各治疗组之间无差异。
在因MeVO导致急性缺血性卒中的患者中，与单纯EVT/IVT相比，BT可能带来更好功能结局的可能性更高，成功再通率略高。需要进行随机试验来确定MeVO的最佳治疗方案。
