大脑中动脉远端急性缺血性卒中的血管内治疗与最佳药物治疗：一项多国多中心倾向评分匹配研究
Endovascular therapy versus best medical management in distal medium middle cerebral artery acute ischaemic stroke: a multinational multicentre propensity score-matched study.
作者信息
Salim Hamza Adel, Yedavalli Vivek, Musmar Basel, Adeeb Nimer, E L Naamani Kareem, Henninger Nils, Sundararajan Sri Hari, Kühn Anna Luisa, Khalife Jane, Ghozy Sherief, Scarcia Luca, Tan Benjamin Yong Qiang, Heit Jeremy J, Regenhardt Robert W, Cancelliere Nicole M, Bernstock Joshua D, Rouchaud Aymeric, Fiehler Jens, Essibayi Muhammed Amir, Sheth Sunil A, Puri Ajit S, Barreau Xavier, Colasurdo Marco, Renieri Leonardo, Dyzmann Christian, Marotta Thomas, Spears Julian, Mowla Askan, Jabbour Pascal, Filipe João Pedro, Biswas Arundhati, Harker Pablo, Clarençon Frédéric, Radu Răzvan Alexandru, Siegler James E, Nguyen Thanh N, Varela Ricardo, Ota Takahiro, Gonzalez Nestor, Moehlenbruch Markus A, Altschul David, Gory Benjamin, Costalat Vincent, Stracke Christian Paul, Aziz-Sultan Mohammad Ali, Hecker Constantin, Shaikh Hamza, Liebeskind David S, Baker Amanda, Pedicelli Alessandro, Alexandre Andrea, Faizy Tobias D, Tancredi Illario, Kalsoum Erwah, Lubicz Boris, Patel Aman B, Mendes Pereira Vitor, Guenego Adrien, Dmytriw Adam A
机构信息
Radiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA.
出版信息
J Neurol Neurosurg Psychiatry. 2024 Jul 23. doi: 10.1136/jnnp-2024-333669.
BACKGROUND
The efficacy of endovascular treatment (EVT) in acute ischaemic stroke due to distal medium vessel occlusion (DMVO) remains uncertain. Our study aimed to evaluate the safety and efficacy of EVT compared with the best medical management (BMM) in DMVO.
METHODS
In this prospectively collected, retrospectively reviewed, multicentre cohort study, we analysed data from the Multicentre Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy registry. Patients with acute ischaemic stroke due to DMVO in the M2, M3 and M4 segments who underwent EVT or received BMM were included. Primary outcome measures comprised 10 co-primary endpoints, including functional independence (mRS 0-2), excellent outcome (mRS 0-1), mortality (mRS 6) and haemorrhagic complications. Propensity score matching was employed to balance the cohorts.
RESULTS
Among 2125 patients included in the primary analysis, 1713 received EVT and 412 received BMM. After propensity score matching, each group comprised 391 patients. At 90 days, no significant difference was observed in achieving mRS 0-2 between EVT and BMM (adjusted OR 1.00, 95% CI 0.67 to 1.50, p>0.99). However, EVT was associated with higher rates of symptomatic intracerebral haemorrhage (8.4% vs 3.0%, adjusted OR 3.56, 95% CI 1.69 to 7.48, p<0.001) and any intracranial haemorrhage (37% vs 19%, adjusted OR 2.61, 95% CI 1.81 to 3.78, p<0.001). Mortality rates were similar between groups (13% in both, adjusted OR 1.48, 95% CI 0.87 to 2.51, p=0.15).
CONCLUSION
Our findings suggest that while EVT does not significantly improve functional outcomes compared with BMM in DMVO, it is associated with higher risks of haemorrhagic complications. These results support a cautious approach to the use of EVT in DMVO and highlight the need for further prospective randomised trials to refine treatment strategies.
背景
血管内治疗（EVT）在远端中等血管闭塞（DMVO）所致急性缺血性卒中中的疗效仍不确定。我们的研究旨在评估与最佳药物治疗（BMM）相比，EVT治疗DMVO的安全性和疗效。
方法
在这项前瞻性收集、回顾性分析的多中心队列研究中，我们分析了来自原发性远端中等血管闭塞多中心分析：机械取栓登记处的数据。纳入了在M2、M3和M4段因DMVO接受EVT或接受BMM治疗的急性缺血性卒中患者。主要结局指标包括10个共同主要终点，包括功能独立（改良Rankin量表评分0 - 2分）、良好结局（改良Rankin量表评分0 - 1分）、死亡率（改良Rankin量表评分6分）和出血并发症。采用倾向评分匹配法平衡队列。
结果
在纳入初步分析的2125例患者中，1713例接受了EVT治疗，412例接受了BMM治疗。倾向评分匹配后，每组各有391例患者。在90天时，EVT组和BMM组在达到改良Rankin量表评分0 - 2分方面未观察到显著差异（调整后的比值比为1.00，95%置信区间为0.67至1.50，p>0.99）。然而，EVT与较高的症状性脑出血发生率相关（8.4%对3.0%，调整后的比值比为3.56，95%置信区间为1.69至7.48，p<0.001）以及任何颅内出血发生率相关（37%对19%，调整后的比值比为2.61，95%置信区间为1.81至3.78，p<0.001）。两组的死亡率相似（均为13%，调整后的比值比为1.48，95%置信区间为0.87至2.51，p = 0.15）。
结论
我们的研究结果表明，虽然在DMVO中与BMM相比，EVT并未显著改善功能结局，但它与更高的出血并发症风险相关。这些结果支持在DMVO中谨慎使用EVT，并强调需要进一步进行前瞻性随机试验以优化治疗策略。
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