颅内动脉夹层所致急性缺血性卒中静脉溶栓的安全性及预后

Safety and outcomes of intravenous thrombolysis in acute ischemic stroke with intracranial artery dissection.

作者信息

Egashira Shuhei, Kunisawa Susumu, Koga Masatoshi, Ihara Masafumi, Tsuruta Wataro, Uesaka Yoshikazu, Fushimi Kiyohide, Toda Tatsushi, Imanaka Yuichi

机构信息

Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.

出版信息

Int J Stroke. 2025 Feb 20:17474930251317326. doi: 10.1177/17474930251317326.

DOI:10.1177/17474930251317326

PMID:39834052

Abstract

BACKGROUND

Intravenous thrombolysis (IVT) for acute ischemic stroke (AIS) related to underlying intracranial artery dissection (IAD) poses potential risks, including the exacerbation of intramural hematoma and the rupture of the dissected arterial wall. However, the safety of IVT in this specific population remains uncertain.

AIMS

This study aimed to assess whether IAD is associated with an increased risk of intracranial hemorrhage (ICH) following IVT and to evaluate its impact on functional outcomes.

METHODS

This retrospective matched-pair cohort study used a nationwide inpatient database that includes discharge abstracts and administrative claims data in Japan. We included adult patients with AIS treated with IVT between July 2010 and July 2024. We excluded patients with carotid or vertebral artery dissections due to difficulties distinguishing between intracranial and extracranial involvement, those lacking premorbid/discharge modified Rankin Scale (mRS) data, and those who received intra-arterial thrombolysis. Patients with IAD were matched 1:4 with non-IAD controls based on age, sex, premorbid mRS, endovascular treatment (EVT), and teaching hospital status. We assessed ICH, functional independence at discharge (mRS = 0-2), and in-hospital mortality using multivariable logistic regression with generalized estimating equations to account for clustering within matched pairs, adjusting for age, sex, premorbid mRS, body mass index, smoking history, hypertension, diabetes mellitus, atrial fibrillation, coagulopathy, Japan Coma Scale, EVT, and teaching hospital status.

RESULTS

Of 83,139 patients with AIS treated with IVT, 242 (0.3%) had underlying IAD (median age = 54 (46-67) years; 34% women). These patients were matched with 968 non-IAD controls. IAD was associated with a higher risk of ICH (odds ratio (OR) = 3.18; 95% confidence interval (CI) = 1.26-8.06) and a lower likelihood of functional independence at discharge (OR = 0.51; 95% CI = 0.37-0.72), but not with increased in-hospital mortality (OR = 1.09; 95% CI = 0.50-2.38).

CONCLUSION

Patients with underlying IAD may face an increased risk of ICH and a reduced chance of functional recovery following IVT compared to those without.

摘要

背景

对于与潜在颅内动脉夹层（IAD）相关的急性缺血性卒中（AIS）进行静脉溶栓（IVT）存在潜在风险，包括壁内血肿加重和夹层动脉壁破裂。然而，IVT在这一特定人群中的安全性仍不确定。

目的

本研究旨在评估IAD是否与IVT后颅内出血（ICH）风险增加相关，并评估其对功能结局的影响。

方法

这项回顾性配对队列研究使用了日本的一个全国性住院患者数据库，其中包括出院摘要和行政索赔数据。我们纳入了2010年7月至2024年7月期间接受IVT治疗的成年AIS患者。我们排除了因难以区分颅内和颅外受累而患有颈动脉或椎动脉夹层的患者、缺乏病前/出院改良Rankin量表（mRS）数据的患者以及接受动脉内溶栓的患者。IAD患者根据年龄、性别、病前mRS、血管内治疗（EVT）和教学医院状态与非IAD对照进行1:4匹配。我们使用多变量逻辑回归和广义估计方程评估ICH、出院时的功能独立性（mRS = 0 - 2）和住院死亡率，以考虑配对内的聚类情况，并对年龄、性别、病前mRS、体重指数、吸烟史、高血压、糖尿病、心房颤动、凝血障碍、日本昏迷量表、EVT和教学医院状态进行调整。

结果

在83139例接受IVT治疗的AIS患者中，242例（0.3%）有潜在IAD（中位年龄 = 54（46 - 67）岁；34%为女性）。这些患者与968例非IAD对照进行了匹配。IAD与更高的ICH风险（比值比（OR） = 3.18；95%置信区间（CI） = 1.26 - 8.06）和出院时功能独立的可能性较低（OR = 0.51；95% CI = 0.37 - 0.72）相关，但与住院死亡率增加无关（OR = 1.09；95% CI = 0.50 - 2.38）。