From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Hamilton, Ontario; Department of Clinical Neurosciences (E.E.S., B.K.M., A.G., P. Barber, S.B.C., A.D., M.G., M.D.H.), Hotchkiss Brain Institute, Departments of Radiology (E.E.S., B.K.M., A.G., A.D., M.G., M.D.H.), and Medicine (M.D.H.), Cumming School of Medicine, and Department of Community Health Sciences (E.E.S., B.K.M., A.G., M.D.H.), University of Calgary, Alberta; Department of Clinical Neurological Sciences (J.M.), Western University and London Health Sciences Center, Ontario; Departments of Radiology (J.L.R.), and Medicine (Neurology) (A.S.), University of Alberta Hospital, Edmonton, Canada; Department of Radiology (J.T.), Beaumont Hospital, Dublin, Ireland; Department of Radiology (D.R.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec, Canada; Department of Neurology (T.G.J.), Cooper University Health Care, Camden, NJ; Department of Medicine (Neurology) (D.D.), University of Ottawa, Ottawa Hospital, Ontario, Canada; Radiology Imaging Associates (D.F.F.), Swedish Medical Centre, Englewood, CO; Division of Neurology (F.L.S.), Department of Medicine and Department of Radiology (A.B.), University of Toronto, St. Michael's Hospital, Ontario; Department of Neurosciences (A.P.), Université de Montréal, Centre Hospitalier de l'Université de Montréal (CHUM), Québec; Department of Neurology (J.S.T.), Montreal Neurological Institute, Québec, Canada; Department of Neurology (D.W.), Royal College of Surgeons Ireland, Beaumont Hospital, Dublin; Department of Neurology (O.Y.B.), Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Providence Neurological Specialties (B.L.S.), Providence Health Care, Portland, OR; Department of Neuroradiology (P. Burns), Royal Victoria Hospital, Belfast, United Kingdom; Department of Neuroradiology (H.C.), Community Regional Medical Centre, Fresno, CA; Department of Neurology (J.-H.H.), Severance Medical Centre, Yonsei University, Seoul, South Korea; Department of Surgery (Neurosurgery) (M.E.K.), University of Saskatoon, Royal Saskatoon Hospital, Saskatchewan, Canada; St. Louis University (G.L.), Souers Stroke Institute, MO; Department of Radiology (J.J.S.), University of Manitoba, Health Sciences Centre, Winnipeg, Canada; Department of Neurology (S.-I.S.), Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea; and Department of Medicine (Neurology) (R.H.S.), University of Toronto, Sunnybrook Health Sciences Centre, Ontario, Canada.
Neurology. 2024 May 28;102(10):e209270. doi: 10.1212/WNL.0000000000209270. Epub 2024 May 13.
The effect of endovascular therapy (EVT) for large vessel occlusion stroke on cognitive outcomes is not well understood. We evaluated the effect of EVT on cognitive function in the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial.
Patient data from the ESCAPE randomized trial were analyzed. Cognitive assessments completed at 90 days after stroke were the Montreal Cognitive Assessment (MoCA), the Sunnybrook Neglect Assessment Procedure (SNAP), the Boston Naming Test (BNT), Trail-making test A (Trails A), and Trail-making test B (Trails B). We used logistic regression to evaluate the association between EVT and favorable cognitive outcome on the 5 separate tests, adjusting for demographic and clinical factors. We used generalized estimating equations and ordinal regression to determine the odds of favorable outcome with EVT on global cognition incorporating the 5 tests. We added final infarct volume (FIV) to the models to assess the relationship of FIV with cognitive outcome.
The ESCAPE trial included 315 patients, 165 randomized to EVT and 150 randomized to control. There was higher odds of favorable outcome with EVT for MoCA (adjusted odds ratio [aOR] 2.32, 95% CI 1.30-4.16), SNAP (aOR 3.85, 95% CI 2.00-7.45), BNT (aOR 2.33, 95% CI 1.30-4.17), trails A (aOR 3.50, 95% CI 1.93-6.36), and trails B (aOR 2.56, 95% CI 1.46-4.48). There was higher odds of favorable outcome with EVT on global binary (aOR 2.57, 95% CI 1.67-3.94) and ordinal analyses (aOR 2.83, 95% CI 1.68-4.76) of cognitive function. After adding FIV to the models, both FIV and EVT were significantly associated with cognitive outcome. There was a significant correlation between global cognitive performance and mRS at day 90 ( = -0.78, < 0.001), with the largest reductions in favorable cognitive outcome from mRS score 4 to 5 and from mRS 2 to 3.
In this secondary analysis of the ESCAPE trial, EVT was associated with favorable outcome on 5 separate cognitive tests and in global analyses of cognitive benefit. These results provide novel evidence for the effect of EVT on cognition and support the global benefit of treatment with EVT.
This study provides Class II evidence that in patients with acute ischemic stroke due to intracranial internal carotid artery (ICA) or M1 segment MCA occlusion, including tandem extracranial ICA occlusions, EVT compared with best medical therapy increased odds of favorable cognitive outcome.
血管内治疗（EVT）对大血管闭塞性卒中患者认知结局的影响尚未得到充分了解。我们评估了血管内治疗对 ESCAPE 试验中小核心和前循环近端闭塞患者认知功能的影响，该试验重点在于尽量减少 CT 至再通时间。
分析 ESCAPE 随机试验的患者数据。卒中后 90 天完成的认知评估包括蒙特利尔认知评估（MoCA）、森尼布鲁克忽视评估程序（SNAP）、波士顿命名测验（BNT）、连线测验 A（Trails A）和连线测验 B（Trails B）。我们使用逻辑回归来评估 EVT 与 5 项单独测试中认知结局良好的相关性，调整了人口统计学和临床因素。我们使用广义估计方程和有序回归来确定 EVT 对全球认知的有利结果的可能性，纳入了 5 项测试。我们将最终梗死体积（FIV）添加到模型中，以评估 FIV 与认知结局的关系。
ESCAPE 试验纳入了 315 例患者，其中 165 例随机接受 EVT 治疗，150 例随机接受对照治疗。EVT 治疗后 MoCA（调整后的优势比 [aOR] 2.32，95%CI 1.30-4.16）、SNAP（aOR 3.85，95%CI 2.00-7.45）、BNT（aOR 2.33，95%CI 1.30-4.17）、Trails A（aOR 3.50，95%CI 1.93-6.36）和 Trails B（aOR 2.56，95%CI 1.46-4.48）的有利结局的可能性更高。EVT 治疗在全球二分类（aOR 2.57，95%CI 1.67-3.94）和有序分析（aOR 2.83，95%CI 1.68-4.76）中对认知功能也有更好的结果。将 FIV 添加到模型中后，FIV 和 EVT 均与认知结局显著相关。90 天 mRS 与全球认知表现呈显著负相关（ = -0.78，<0.001），mRS 评分从 4 分到 5 分和从 2 分到 3 分的认知结局改善幅度最大。
在 ESCAPE 试验的二次分析中，EVT 与 5 项单独的认知测试和认知获益的总体分析中良好的认知结局相关。这些结果为 EVT 对认知的影响提供了新的证据，并支持 EVT 治疗的整体获益。
本研究提供了 II 级证据，表明对于因颅内颈内动脉（ICA）或 M1 段 MCA 闭塞引起的急性缺血性卒中患者，包括串联性颅外 ICA 闭塞患者，与最佳药物治疗相比，血管内治疗增加了认知结局良好的可能性。
