Hassan Ameer E, Abraham Michael G, Blackburn Spiros, Hussain Muhammad S, Ortega-Gutierrez Santiago, Chen Michael, Hu Yin C, Pujara Deep K, Herial Nabeel A, Tsai Jenny P, Budzik Ronald F, Manning Nathan W, Kozak Osman, Hanel Ricardo A, Aghaebrahim Amin N, Gandhi Chirag D, Al-Mufti Fawaz, Cheung Andrew, Yan Bernard, Mitchell Peter, Blasco Jordi, Manzanera Luis San Román, Vora Nirav, Gibson Daniel, Wallace Adam, Sahlein Daniel, Elijovich Lucas, Arenillas Juan F, Wu Teddy Y, Portela Pere Cardona, de la Ossa Natalia Pérez, Schaafsma Joanna D, Hicks William J, Cordato Dennis J, Sangha Navdeep, Warach Steven, Kleinig Timothy J, Shaker Faris, Johns Hannah, Tekle Wondwossen, Dannenbaum Mark J, Ebersole Koji, Toth Gabor, Gooch Michael, Alhajeri Abdulnasser, Amuluru Krishna, Ray Abhishek, Burkhardt Jan-Karl, Abdulrazzak Mohammad A, Rosenbaum-Halevi David P, Kamal Haris, Duncan Kelsey R, Sitton Clark W, Churilov Leonid, Pereira Vitor Mendes, Sunshine Jeffrey, Nguyen Thanh N, Fifi Johanna T, Samaniego Edgar A, Arthur Adam, Tjoumakaris Stavropoula, Jabbour Pascal, Davis Stephen M, Wechsler Lawrence, Bambakidis Nicholas, Kasner Scott E, Grotta James C, Hill Michael D, Campbell Bruce C, Ribo Marc, Sarraj Amrou
Valley Baptist Medical Center, Harlingen, TX.
University of Kansas Medical Center, Kansas City, KS.
Ann Neurol. 2024 Nov 7. doi: 10.1002/ana.27104.
Endovascular thrombectomy (EVT) was shown to be safe and efficacious in patients with large core stroke in multiple randomized controlled trials. However, the impact of reperfusion and other procedural metrics on EVT outcomes in this population has not been well-characterized.
From the SELECT2 trial, we evaluated the association between reperfusion status, first-pass effect (near-complete or complete reperfusion [extended thrombolysis in cerebral infarction (eTICI) 2c-3] in 1 pass), procedure time and primary technique (aspiration vs stent-retriever) with functional outcomes in patients receiving EVT across ASPECTS (3 vs 4 vs 5) and core estimate strata (<70 vs ≥70ml, <100 vs ≥100ml, and <150 vs ≥150ml).
Of 180 patients who received thrombectomy, 144 (80%) achieved successful reperfusion (eTICI 2b-3) and demonstrated better clinical outcomes (adjusted generalized odds ratios [aGenOR]: 1.48, 95% confidence interval [CI]: 1.01-2.15), compared with unsuccessful reperfusion. Results were consistent across ASPECTS and core estimate strata. Additionally, complete or near-complete reperfusion (eTICI 2c-3) was associated with better functional outcome (aGenOR: 1.99, 95% CI: 1.33-2.97) in patients achieving successful reperfusion. Functional outcome point estimates favored those with first-pass-effect (42 of 167 (25%), aGenOR: 1.46, 95% CI: 0.96-2.24). Longer procedure time was associated with worse modified Rankin scale (mRS) distribution (aGenOR: 0.92, 95% CI: 0.87-0.96, p-value = 0.001 for 10 minutes increment). Aspiration-first technique was used in 43 of 154 (25%) patients and was not associated with higher reperfusion (88% vs 78%, p = 0.18) or better functional outcome (aGenOR: 0.74, 95% CI: 0.50-1.10) as compared with stent-retriever first.
Successful reperfusion resulted in improved clinical outcomes in large core patients across baseline ischemic core strata. Near complete or complete reperfusion was further associated with better outcomes, whereas prolonged procedures were associated with worse outcomes. Results were consistent regardless of the technique used. ANN NEUROL 2024.
多项随机对照试验表明，血管内血栓切除术（EVT）对大面积梗死核心的卒中患者安全有效。然而，再灌注及其他手术指标对该人群EVT治疗效果的影响尚未得到充分描述。
在SELECT2试验中，我们评估了接受EVT治疗的患者中，再灌注状态、首过效应（一次通过即实现接近完全或完全再灌注[脑梗死扩展溶栓（eTICI）2c - 3级]）、手术时间和主要技术（抽吸与取栓支架）与不同ASPECTS评分（3分对4分对5分）以及梗死核心估计分层（<70ml对≥70ml、<100ml对≥100ml、<150ml对≥150ml）下功能结局的相关性。
在180例接受血栓切除术的患者中，144例（80%）实现了成功再灌注（eTICI 2b - 3级），与未成功再灌注相比，其临床结局更好（校正广义优势比[aGenOR]：1.48，95%置信区间[CI]：1.01 - 2.15）。在不同ASPECTS评分和梗死核心估计分层中结果一致。此外，在实现成功再灌注的患者中，完全或接近完全再灌注（eTICI 2c - 3级）与更好的功能结局相关（aGenOR：1.99，95% CI：1.33 - 2.97）。功能结局的点估计值有利于具有首过效应的患者（167例中的42例（25%），aGenOR：1.46, 95% CI：0.96 - 2.24）。手术时间越长，改良Rankin量表（mRS）分布越差（aGenOR：0.92，95% CI：0.87 - 0.96，每增加10分钟p值 = 0.001）。154例患者中有43例（25%）采用了先抽吸技术，与先使用取栓支架相比，其再灌注率（88%对78%，p = 0.18）或功能结局更好（aGenOR：0.74，95% CI：0.50 - 1.10）无关。
成功再灌注使不同基线缺血核心分层的大面积梗死核心患者临床结局得到改善。接近完全或完全再灌注进一步与更好的结局相关，而手术时间延长与更差的结局相关。无论采用何种技术，结果均一致。《神经病学年鉴》2024年
