Chen Huanwen, Chaturvedi Seemant, Gandhi Dheeraj, Colasurdo Marco
From the National Institute of Neurological Disorders and Stroke (H.C.), National Institutes of Health, Bethesda, Maryland.
Department of Neurology (H.C.), MedStar Georgetown University Hospital, Washington DC.
AJNR Am J Neuroradiol. 2025 May 2;46(5):915-920. doi: 10.3174/ajnr.A8553.
Recent randomized trials have suggested that endovascular thrombectomy (EVT) is superior to medical management (MM) for stroke patients with large infarcts. However, whether or how perfusion metrics should be used to guide optimal patient selection for treatment is unknown.
To synthesize trial results to provide more definitive guidance on the role of EVT for stroke patients with large infarcts based on perfusion metrics.
MEDLINE database from inception up to July 8, 2024. Randomized controlled trials that report the efficacy and safety of EVT for patients with large infarcts (defined by either infarct core volume greater than 50cc or Alberta Stroke Program Early CT Score [ASPECTS] less than 6) stratified by mismatch profile were included.
Five trials were identified - SELECT2 and ANGEL-ASPECT.
The primary outcome was odds of acceptable outcomes (90-day modified Rankin scale [mRS] 0 to 3). Secondary outcome was 90-day mRS 5 or 6. Patients where then subdivided into those with mismatch ratio 1.2-1.8 or penumbra volume 10-15cc (intermediate mismatch) and those with mismatch ratio <1.2 or volume <10cc (low mismatch).
A total of 140 intermediate mismatch (75 EVT and 65 MM) and 60 low mismatch patients (23 EVT and 37 MM) were identified. EVT was significantly associated with higher odds of mRS 0-3 for intermediate mismatch (OR 2.77 [95% CI 1.11-6.89], = .028), but not low mismatch (OR 1.47 [95% CI 0.44-4.94], = .54). Similarly, in terms of 90-day poor outcomes (mRS 5-6), EVT for intermediate mismatch patients was significantly associated with lower odds (OR 0.49 [95% CI 0.24 to 0.99], = .046), while EVT for the low mismatch cohort was not (OR 0.66 [95% CI 0.22 to 1.96], = .45). There was no significant inter-study heterogeneity observed across study estimates.
For stroke patients with large infarcts, EVT was beneficial for patients with perfusion mismatch ratio and volume of at least 1.2 and 10cc, but not for those with mismatch ratio <1.2 or volume <10cc.
近期的随机试验表明，对于大面积梗死的中风患者，血管内血栓切除术（EVT）优于药物治疗（MM）。然而，是否以及如何使用灌注指标来指导最佳的患者治疗选择尚不清楚。
综合试验结果，以基于灌注指标为大面积梗死的中风患者提供关于EVT作用的更明确指导。
截至2024年7月8日的MEDLINE数据库。纳入了报告EVT对大面积梗死患者（梗死核心体积大于50cc或阿尔伯塔卒中项目早期CT评分[ASPECTS]小于6定义）疗效和安全性的随机对照试验，并按不匹配情况分层。
确定了五项试验——SELECT2和ANGEL - ASPECT。
主要结局是可接受结局（90天改良Rankin量表[mRS]为0至3）的几率。次要结局是90天mRS为5或6。然后将患者分为不匹配率为1.2 - 1.8或半暗带体积为10 - 15cc（中度不匹配）的患者以及不匹配率<1.2或体积<10cc（低度不匹配）的患者。
共确定了140例中度不匹配患者（75例接受EVT，65例接受MM）和60例低度不匹配患者（23例接受EVT，37例接受MM）。对于中度不匹配患者，EVT与mRS 0 - 3的较高几率显著相关（比值比[OR] 2.77 [95%置信区间1.11 - 6.89]，P = 0.028），但与低度不匹配患者无关（OR 1.47 [95%置信区间0.44 - 4.94]，P = 0.54）。同样，就90天不良结局（mRS 5 - 6）而言，中度不匹配患者接受EVT与较低几率显著相关（OR 0.49 [95%置信区间0.24至0.99]，P = 0.046），而低度不匹配队列接受EVT则不然（OR 0.66 [95%置信区间0.22至1.96]，P = 0.45）。在各研究估计值中未观察到显著的研究间异质性。
对于大面积梗死的中风患者，EVT对灌注不匹配率和体积至少为1.2和10cc的患者有益，但对不匹配率<1.2或体积<10cc的患者无益。
