远程缺血预处理联合药物治疗或再灌注治疗急性缺血性脑卒中的系统评价和荟萃分析。
Remote Ischemic Conditioning With Medical Management or Reperfusion Therapy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.
机构信息
From the Department of Neurology (Q.L., X.F., B.J., B.L., M.Y., Z.Q., Y.D.), The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou; Intensive Care Unit of Department of Neurology (J.G.), Ningbo Medical Center Lihuili Hospital; Department of Neurology (H.-S.C.), General Hospital of Northern Theater Command, Shenyang, China; Department of Neurology (R.A.B.), Aarhus University Hospital, Denmark; Department of Neurology (D.C.H.), Medical College of Georgia, Augusta University, Augusta; Neurology and Stroke Center (F.P.), Versailles Mignot Hospital, Paris, France; Department of Neurology (P.K.), University of Cincinnati, OH; Department of Medicine and Neurology (B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Boston Medical Center (M.A., T.N.N.), Boston University Chobanian and Avedisian School of Medicine, MA; Department of Neurology (J.L.S.), University of California in Los Angeles; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh Medical Center, PA; Department of Neurology (H.S.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; and Department of Neurology (Q.Y.), Xinqiao Hospital of Army Medical University, Chongqing, China.
出版信息
Neurology. 2024 Apr 9;102(7):e207983. doi: 10.1212/WNL.0000000000207983. Epub 2024 Mar 8.
BACKGROUND AND OBJECTIVES
Remote ischemic conditioning (RIC) is a low-cost, accessible, and noninvasive neuroprotective treatment strategy, but its efficacy and safety in acute ischemic stroke are controversial. With the publication of several randomized controlled trials (RCTs) and the recent results of the RESIST trial, it may be possible to identify the patient population that may (or may not) benefit from RIC. This systematic review and meta-analysis aims to evaluate the effectiveness and safety of RIC in patients with ischemic stroke receiving different treatments by pooling data of all randomized controlled studies to date.
METHODS
We searched the PubMed, Embase, Cochrane, Elsevier, and Web of Science databases to obtain articles in all languages from inception until May 25, 2023. The primary outcome was the modified Rankin Scale (mRS) score at the specified endpoint time in the trial. The secondary outcomes were change in NIH Stroke Scale (NIHSS) and recurrence of stroke events. The safety outcomes were cardiovascular events, cerebral hemorrhage, and mortality. The quality of articles was evaluated through the Cochrane risk assessment tool. This study was registered in PROSPERO (CRD42023430073).
RESULTS
There were 7,657 patients from 22 RCTs included. Compared with the control group, patients who received RIC did not have improved mRS functional outcomes, regardless of whether they received medical management, reperfusion therapy with intravenous thrombolysis (IVT), or mechanical thrombectomy (MT). In the medical management group, patients who received RIC had decreased incidence of stroke recurrence (risk ratio 0.63, 95% CI 0.43-0.92, = 0.02) and lower follow-up NIHSS score by 1.72 points compared with the control group ( < 0.00001). There was no increased risk of adverse events including death or cerebral hemorrhage in the IVT or medical management group.
DISCUSSION
In patients with ischemic stroke who are not eligible for reperfusion therapy, RIC did not affect mRS functional outcomes but significantly improved the NIHSS score at the follow-up endpoint and reduced stroke recurrence, without increasing the risk of cerebral hemorrhage or death. In patients who received IVT or MT, the benefit of RIC was not observed.
背景与目的
远程缺血预处理（RIC）是一种低成本、可及且非侵入性的神经保护治疗策略，但在急性缺血性脑卒中中的疗效和安全性仍存在争议。随着几项随机对照试验（RCT）的发表，以及最近的 RESIST 试验结果，我们可能可以确定可能（或可能不）从 RIC 中获益的患者人群。本系统评价和荟萃分析旨在通过汇总迄今为止所有随机对照研究的数据，评估 RIC 在接受不同治疗的缺血性脑卒中患者中的有效性和安全性。
方法
我们检索了 PubMed、Embase、Cochrane、Elsevier 和 Web of Science 数据库，获取了截至 2023 年 5 月 25 日所有语种的文章。主要结局指标为试验中特定终点时间的改良 Rankin 量表（mRS）评分。次要结局指标为 NIH 卒中量表（NIHSS）变化和卒中事件复发。安全性结局指标为心血管事件、脑出血和死亡率。通过 Cochrane 风险评估工具评估文章质量。本研究已在 PROSPERO（CRD42023430073）注册。
结果
共有来自 22 项 RCT 的 7657 例患者纳入研究。与对照组相比，接受 RIC 的患者无论是否接受药物治疗、静脉溶栓（IVT）或机械取栓（MT）治疗，其 mRS 功能结局均未改善。在药物治疗组中，与对照组相比，接受 RIC 的患者卒中复发的发生率降低（风险比 0.63，95%CI 0.43-0.92，=0.02），且 NIHSS 评分在随访终点时降低 1.72 分（<0.00001）。IVT 或药物治疗组中，RIC 并未增加死亡或脑出血等不良事件的风险。
讨论
在不符合再灌注治疗条件的缺血性脑卒中患者中，RIC 并未影响 mRS 功能结局，但显著改善了随访终点的 NIHSS 评分，降低了卒中复发风险，且不增加脑出血或死亡风险。在接受 IVT 或 MT 治疗的患者中，RIC 的获益未观察到。
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