Stroke Thrombectomy-Capable Center, St. John Paul II Hospital, Krakow, Poland -
Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland -
J Cardiovasc Surg (Torino). 2024 Jun;65(3):231-248. doi: 10.23736/S0021-9509.24.13093-5.
Carotid-related strokes (CRS) are largely unresponsive to intravenous thrombolysis and are often large and disabling. Little is known about contemporary CRS referral pathways and proportion of eligible patients who receive emergency mechanical reperfusion (EMR).
Referral pathways, serial imaging, treatment data, and neurologic outcomes were evaluated in consecutive CRS patients presenting over 18 months in catchment area of a major carotid disease referral center with proximal-protected CAS expertise, on-site neurology, and stroke thrombectomy capability (Acute Stroke of CArotid Artery Bifurcation Origin Treated With Use oF the MicronEt-covered CGUARD Stent - SAFEGUARD-STROKE Registry; companion to SAFEGUARD-STROKE Study NCT05195658).
Of 101 EMR-eligible patients (31% i.v.-thrombolyzed, 39.5% women, age 39-89 years, 94.1% ASPECTS 9-10, 90.1% pre-stroke mRS 0-1), 57 (56.4%) were EMR-referred. Referrals were either endovascular (Comprehensive Stroke Centre, CSC, 21.0%; Stroke Thrombectomy-Capable CAS Centre, STCC, 70.2%) or to vascular surgery (VS, 1.8%), with >1 referral attempt in 7.0% patients (CSC/VS or VS/CSC or CSC/VS/STCC). Baseline clinical and imaging characteristics were not different between EMR-treated and EMR-untreated patients. EMR was delivered to 42.6% eligible patients (emergency carotid surgery 0%; STCC rejections 0%). On multivariable analysis, non-tandem CRS was a predictor of not getting referred for EMR (OR 0.36; 95%CI 0.14-0.93, P=0.03). Ninety-day neurologic status was profoundly better in EMR-treated patients; mRS 0-2 (83.7% vs. 34.5%); mRS 3-5 (11.6% vs. 53.4%), mRS 6 (4.6% vs. 12.1%); P<0.001 for all.
EMR-treatment substantially improves CRS neurologic outcomes but only a minority of EMR-eligible patients receive EMR. To increase the likelihood of brain-saving treatment, EMR-eligible stroke referral and management pathways, including those for CSC/VS-rejected patients, should involve stroke thrombectomy-capable centres with endovascular carotid treatment expertise.
颈动脉相关卒中（CRS）对静脉溶栓反应不佳，且往往较大且致残。目前对于当代 CRS 的转诊途径以及接受紧急机械再通（EMR）的合格患者比例知之甚少。
连续评估了 18 个月内在主要颈动脉疾病转诊中心的捕获区就诊的连续 CRS 患者的转诊途径、连续影像学、治疗数据和神经结局，该中心具有近端保护颈动脉内膜切除术（CAS）专业知识、现场神经科和卒中血栓切除术能力（急性颈动脉分叉起源卒中应用 MicronEt 覆盖 CGUARD 支架治疗 -SAFE-GUARD-STROKE 登记处；SAFE-GUARD-STROKE 研究的配套研究 NCT05195658）。
在 101 名 EMR 合格患者中（31%接受静脉溶栓治疗，39.5%为女性，年龄 39-89 岁，94.1% ASPECTS 9-10，90.1%卒中前 mRS 0-1），57 名（56.4%）接受了 EMR 转诊。转诊途径要么是血管内（综合卒中中心，CSC，21.0%；卒中血栓切除术能力的 CAS 中心，STCC，70.2%），要么是血管外科（VS，1.8%），7.0%的患者有>1 次转诊尝试（CSC/VS 或 VS/CSC 或 CSC/VS/STCC）。EMR 治疗和未治疗患者的基线临床和影像学特征无差异。EMR 治疗了 42.6%的合格患者（紧急颈动脉手术 0%；STCC 拒收 0%）。多变量分析显示，非串联 CRS 是未接受 EMR 转诊的预测因素（OR 0.36；95%CI 0.14-0.93，P=0.03）。EMR 治疗患者 90 天神经功能状态显著改善；mRS 0-2（83.7% vs. 34.5%）；mRS 3-5（11.6% vs. 53.4%），mRS 6（4.6% vs. 12.1%）；所有结果 P<0.001。
EMR 治疗可显著改善 CRS 的神经结局，但只有少数 EMR 合格患者接受了 EMR。为了提高挽救大脑的治疗可能性，应包括 CSC/VS 拒绝的患者，EMR 合格的卒中转诊和管理途径应涉及具有血管内颈动脉治疗专业知识的卒中血栓切除术能力中心。
