中型血管闭塞性卒中的血管内治疗

Endovascular Treatment of Stroke Due to Medium-Vessel Occlusion.

作者信息

Goyal Mayank, Ospel Johanna M, Ganesh Aravind, Dowlatshahi Dar, Volders David, Möhlenbruch Markus A, Jumaa Mouhammad A, Nimjee Shahid M, Booth Thomas C, Buck Brian H, Kennedy James, Shankar Jai J, Dorn Franziska, Zhang Liqun, Hametner Christian, Nardai Sandor, Zafar Atif, Diprose William, Vatanpour Shabnam, Stebner Alexander, Bosshart Salome, Singh Nishita, Sebastian Ivy, Uchida Kazutaka, Ryckborst Karla J, Fahed Robert, Hu Sherry X, Vollherbst Dominik F, Zaidi Syed F, Lee Vivien H, Lynch Jeremy, Rempel Jeremy L, Teal Rachel, Trivedi Anurag, Bode Felix J, Ogungbemi Ayokunle, Pham Mirko, Orosz Peter, Abdalkader Mohamad, Taschner Christian, Tarpley Jason, Poli Sven, Singh Ravinder-Jeet, De Leacy Reade, Lopez George, Sahlas Demetrios, Chen Michael, Burns Paul, Schaafsma Joanna D, Marigold Richard, Reich Arno, Amole Adewumi, Field Thalia S, Swartz Richard H, Settecase Fabio, Lenzsér Gábor, Ortega-Gutierrez Santiago, Asdaghi Negar, Lobotesis Kyriakos, Siddiqui Adnan H, Berrouschot Joerg, Mokin Maxim, Ebersole Koji, Schneider Hauke, Yoo Albert J, Mandzia Jennifer, Klostranec Jesse, Jadun Changez, Patankar Tufail, Sauvageau Eric, Lenthall Robert, Peeling Lissa, Huynh Thien, Budzik Ronald, Lee Seon-Kyu, Makalanda Levansri, Levitt Michael R, Perry Richard J, Hlaing Thant, Jahromi Babak S, Singh Paul, Demchuk Andrew M, Hill Michael D

机构信息

Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, AB, Canada.

Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, AB, Canada.

出版信息

N Engl J Med. 2025 Apr 10;392(14):1385-1395. doi: 10.1056/NEJMoa2411668. Epub 2025 Feb 5.

DOI:10.1056/NEJMoa2411668

PMID:39908448

Abstract

BACKGROUND

Whether the large effect size of endovascular thrombectomy (EVT) for stroke due to large-vessel occlusion applies to stroke due to medium-vessel occlusion is unclear.

METHODS

In a multicenter, prospective, randomized, open-label trial with blinded outcome evaluation, we assigned patients with acute ischemic stroke due to medium-vessel occlusion who presented within 12 hours from the time that they were last known to be well and who had favorable baseline noninvasive brain imaging to receive EVT plus usual care or usual care alone. The primary outcome was the modified Rankin scale score (range, 0 [no symptoms] to 6 [death]) at 90 days, reported as the percentage of patients with a score of 0 or 1.

RESULTS

A total of 530 patients from five countries were enrolled between April 2022 and June 2024, with 255 patients assigned to the EVT group and 275 to the usual-care group. Most patients (84.7%) had primary occlusions in a middle-cerebral-artery branch. A modified Rankin scale score of 0 or 1 at 90 days occurred in 106 of 255 patients (41.6%) in the EVT group and in 118 of 274 (43.1%) in the usual-care group (adjusted rate ratio, 0.95; 95% confidence interval [CI], 0.79 to 1.15; P = 0.61). Mortality at 90 days was 13.3% in the EVT group and 8.4% in the usual-care group (adjusted hazard ratio, 1.82; 95% CI, 1.06 to 3.12). Symptomatic intracranial hemorrhage occurred in 14 of 257 patients (5.4%) in the EVT group and in 6 of 272 (2.2%) in the usual-care group.

CONCLUSIONS

Endovascular treatment for acute ischemic stroke due to medium-vessel occlusion within 12 hours did not lead to better outcomes at 90 days than usual care. (Funded by the Canadian Institutes for Health Research and Medtronic; ESCAPE-MeVO ClinicalTrials.gov number, NCT05151172.).

摘要

背景

血管内血栓切除术（EVT）对大血管闭塞所致中风的显著疗效是否适用于中等血管闭塞所致中风尚不清楚。

方法

在一项多中心、前瞻性、随机、开放标签且结局评估设盲的试验中，我们将发病12小时内、最后一次情况良好时起病、基线无创脑成像结果良好的中等血管闭塞所致急性缺血性中风患者随机分为两组，分别接受EVT联合常规治疗或单纯常规治疗。主要结局为90天时的改良Rankin量表评分（范围为0[无症状]至6[死亡]），以评分为0或1的患者百分比表示。

结果

2022年4月至2024年6月期间，来自五个国家的530例患者入组，其中255例患者被分配至EVT组，275例患者被分配至常规治疗组。大多数患者（84.7%）的主要闭塞部位在大脑中动脉分支。EVT组255例患者中有106例（41.6%）在90天时改良Rankin量表评分为0或1，常规治疗组274例患者中有118例（43.1%）达到该评分（校正率比为0.95；95%置信区间[CI]为0.79至1.15；P = 0.61）。EVT组90天死亡率为13.3%，常规治疗组为8.4%（校正风险比为1.82；95%CI为1.06至3.12）。EVT组257例患者中有14例（5.4%）发生有症状性颅内出血，常规治疗组272例患者中有6例（2.2%）发生。