机械取栓治疗轻中度症状急性基底动脉闭塞患者的结局。
Outcomes of Mechanical Thrombectomy in Patients With Acute Basilar Artery Occlusion With Mild to Moderate Symptoms.
机构信息
From the Department of Human Neuroscience (E.N., S.L., D.T.), Sapienza University of Rome; Stroke Unit (E.N., F.S.), Ospedale dei Castelli, Ariccia (RM); Department of NEUROFARBA (G.P.), Neuroscience Section, University of Florence; Stroke Unit (A.C., M.D.M.), Policlinico Umberto I, Sapienza University of Rome; Neurology and Stroke Unit (V.S., T.T.), S. Corona Hospital, Pietra Ligure, Italy; Interventional Neurovascular Unit (N. Limbucci), Careggi University Hospital; Careggi University Hospital (P.N.), Florence; AUSL Romagna Cesena (M.R.); Neurologia e Stroke Unit Ospedale Bufalini Cesena (M.L.); UO Neuroradiologia (M. Cosottini); Neurological Institute (G.O.), Azienda Ospedaliero Universitaria Pisana; Dipartimento di Neuroscienze (M.B.), Universitá di Torino; A.O. Cittá della Salute (P.C.), Torino; UO Neuroradiologia (S.V.); Neurologia-Stroke Unit (G. Bigliardi), Ospedale Civile di Baggiovara - AOU di Modena; UOC Neuroradiologia diagnostica e terapeutica AOU Senese (S.C.); UOC Stroke Unit AOU Senese (R.T.), Siena; Dipartimento di Biomedicina e Prevenzione - UOSD radiologia interventistica (V.D.R.); Department of Systems Medicine (M.D.), University of Rome Tor Vergata; IRCCS Istituto di Scienze Neurologiche di Bologna - UOC Neuroradiologia Ospedale Bellaria (L.S.); IRCCS Istituto di Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; UOC Neuroradiologia AOU "G. Martino" Messina (M.V.); UOSD Stroke Unit AOU "G. Martino"-Messina (P.L.L.S.); UO Neuroradiologia Ospedale Policlinico San Martino (L.C.); UO Neurologia Ospedale Policlinico San Martino (M.D.S.), Genova, Italy; Neurology Unit (I.C.), University Hospital Arcispedale S. Anna, Ferrara; Dipartimento di Scienze Biomediche (E.F.), Sperimentali e Cliniche, Neuroradiologia, Università degli Studi di Firenze, Ospedale Universitario Careggi; Unità Complessa di Neuroradiologia (R.M.), Azienda Ospedaliero-Universitaria; Dipartimento di Medicina e Chirurgia (A.P.), Università degli Studi di Parma - Programma Stroke Care, Dipartimento di Emergenza-Urgenza, Azienda Ospedaliero-Universitaria, Parma; UOSD Interventistica AOU Salerno (D.G.R.); UOC Neuroradiologia AOU Salerno (G.F.); Radiologia e Neuroradiologia diagnostica e interventistica (S.N.), IRCCS Policlinico San Matteo; UO Neurologia d'Urgenza e Stroke Unit (N. Loizzo), IRCCS Fondazione Mondino, Pavia; UO Neuroradiologia Dip Neuroscienze AZOU Ferrara (A.S.); UO Neurologia Dip Neuroscienze AZOU Ferrara (A.D.V.); Neuroradiology department ospedale di circolo- ASST Settelaghi Varese (R.A.); Stroke Unit - Azienda Ospedaliera Universitaria Integrata Verona (M. Cappellari); UO Neuroradiologia AOU Consorziale Policlinico Bari (D.S.Z.); UOC Neurologia e Stroke Unit "Puca" AOU Consorziale Policlinico Bari (M.P.); SC Neuroradiologia Diagnostica e Interventistica (L.A.), S. Corona Hospital, Pietra Ligure; UO Neuroradiologia interventistica (D.A.); Neurologia d'urgenza e Stroke Unit (S. Marcheselli), IRCCS Humanitas Research Hospital, Rozzano; UOC Neuroradiologia (M.P.G.); UOC Neurologia (G. Boero), Ospedale "SS. Annunziata", Taranto; IRCCS Neuromed (S. Mangiafico), Pozzilli (IS), Italy; Department of Clinical Neuroscience (N.A.), Karolinska Institutet, Stockholm, Sweden; Stroke Center EOC (C.W.C.), Neurocentre of Southern Switzerland; and Faculty of Biomedical Sciences (C.W.C.), Università della Svizzera Italiana, Lugano, Switzerland.
出版信息
Neurology. 2024 Dec 24;103(12):e210086. doi: 10.1212/WNL.0000000000210086. Epub 2024 Nov 21.
BACKGROUND AND OBJECTIVES
The benefit of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) with basilar artery occlusion (BAO) and a baseline National Institute of Health Stroke Scale (NIHSS) score <10 is unclear because this subpopulation has been substantially excluded from large clinical trials. The aim of our study was to determine whether MT ± IV thrombolysis (IVT) improves functional outcomes compared with IVT alone in patients with BAO and a NIHSS score <10.
METHODS
We emulated a hypothetical trial including adult patients with BAO, a baseline NIHSS score <10, and prestroke modified Rankin scale (mRS) scores 0-2, comparing MT (±IVT) with IVT alone. We acquired data from patients receiving MT (±IVT) within 24 hours of onset from the Italian Registry of Endovascular Treatment in Acute Stroke and data from patients treated only with IVT within 9 hours of symptom onset from the SITS International Stroke Thrombolysis Register, from 2011 until 2021. We used inverse probability weighting (IPW) adjusted for prespecified covariates to weight each individual's contribution to the outcome. The primary outcome was 90-day mRS scores 0-2. Secondary outcomes included 90-day mRS scores 0-1, 90-day mRS scores 4-5, mortality at 90 days, in-hospital death, and symptomatic intracerebral hemorrhage.
RESULTS
Among the 764 patients recruited from the 2 databases (477 men [62.4%]; mean age [±SD] 67.88 [±13.9] years), 410 (53.7%) received MT±IVT and 354 (46.3%) only IVT. After applying IPW, our population was composed of 710 MT and 707 IVT patients. Of these, 454 MT-treated (63.9%) and 383 IVT-treated (54.2%) patients had a 90-day mRS score of 0-2 (adjusted odds ratio (aOR) 1.56 [95% CI 1.04-2.03]). MT was also associated with a higher rate of mRS scores 0-1 (aOR 2.01 [95% CI 1.37-2.95]) and a lower rate of in-hospital death (aOR 0.45 [95% CI 0.25-0.78]). Among the subgroups tested, MT had a larger effect on 90-day mRS scores 0-2 for patients with NIHSS scores 6-9 than for patients with a NIHSS score <6 ( for interaction 0.02).
DISCUSSION
In a large-scale target trial emulation on patients with stroke from BAO and a NIHSS score <10, MT was associated with better functional outcomes compared with IVT alone. Further research is needed to confirm the benefit of MT in patients with a NIHSS score <6.
CLASSIFICATION OF EVIDENCE
This study provides Class III evidence that MT ± intravenous thrombolysis is associated with better 90-day functional outcomes in patients with BAO and a NIHSS score < 10 compared with intravenous thrombolysis alone.
背景与目的
机械取栓术（MT）在伴有基底动脉闭塞（BAO）且基线国立卫生研究院卒中量表（NIHSS）评分＜10 的急性缺血性卒中（AIS）患者中的获益尚不清楚，因为这一亚组人群已被大量临床试验排除在外。我们的研究旨在确定 MT±静脉溶栓（IVT）是否比单独 IVT更能改善伴有 BAO 和 NIHSS 评分＜10 的患者的功能结局。
方法
我们模拟了一项假设性试验，纳入了基线 NIHSS 评分＜10 且发病前改良 Rankin 量表（mRS）评分 0-2 的伴有 BAO 的成年患者，比较 MT（±IVT）与单独 IVT。我们从意大利急性卒中血管内治疗登记处接受 MT（±IVT）治疗的患者（发病后 24 小时内）和 SITS 国际卒中溶栓登记处仅接受 IVT 治疗的患者（症状发作后 9 小时内）中获取数据，时间范围为 2011 年至 2021 年。我们使用逆概率加权（IPW）方法调整了预设协变量，以调整每个个体对结局的贡献。主要结局为 90 天 mRS 评分 0-2。次要结局包括 90 天 mRS 评分 0-1、90 天 mRS 评分 4-5、90 天死亡率、住院期间死亡率和症状性颅内出血。
结果
从 2 个数据库（477 例男性[62.4%]；平均年龄[±标准差]67.88[±13.9]岁）中招募的 764 例患者中，410 例（53.7%）接受了 MT±IVT，354 例（46.3%）仅接受了 IVT。应用 IPW 后，我们的人群由 710 例 MT 治疗和 707 例 IVT 治疗的患者组成。其中，454 例 MT 治疗（63.9%）和 383 例 IVT 治疗（54.2%）患者 90 天 mRS 评分为 0-2（调整后的优势比[aOR]1.56[95%置信区间 1.04-2.03]）。MT 还与更高的 mRS 评分 0-1 率（aOR 2.01[95%置信区间 1.37-2.95]）和更低的住院期间死亡率（aOR 0.45[95%置信区间 0.25-0.78]）相关。在测试的亚组中，对于 NIHSS 评分 6-9 的患者，MT 对 90 天 mRS 评分 0-2 的影响大于 NIHSS 评分＜6 的患者（交互检验 P 值为 0.02）。
讨论
在一项对伴有 NIHSS 评分＜10 的 BAO 和 NIHSS 评分＜10 的卒中患者进行的大规模目标试验模拟中，与单独 IVT 相比，MT 与更好的功能结局相关。需要进一步的研究来证实 MT 在 NIHSS 评分＜6 的患者中的获益。
证据分类
本研究提供了 III 级证据，表明与单独 IVT 相比，MT±静脉溶栓治疗伴有基底动脉闭塞且 NIHSS 评分＜10 的急性缺血性卒中患者可改善 90 天的功能结局。
Zotero 插件