提示: 手机请竖屏浏览!

血管内治疗经灌注成像选择的缺血性卒中
Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection


Bruce C.V. Campbell ... 心脑血管疾病 • 2015.03.12

摘要


背景

缺血性卒中血管内治疗的试验产生了差异较大的结果。我们实施本研究以检验更先进的影像选择、新近开发的设备及更早期的干预是否能够改善结局。

 

方法

我们将缺血性卒中发病4.5小时内接受阿替普酶(0.9 mg/kg体重)治疗的患者随机分配到使用Solitaire FR(流量恢复[Flow Restoration])支架取栓器的血管内血栓切除术组或继续接受单独阿替普酶组。所有患者均存在颈内动脉或大脑中动脉闭塞,具备可挽救的脑组织的证据,且在计算机断层扫描(CT)灌注成像上缺血核心小于70 mL。主要复合终点是24小时再灌注和早期神经功能改善(美国国家卫生研究院卒中量表[National Institutes of Health Stroke Scale]评分下降≥8分,或在第3天得分为0或1分)。次要结局包括90天时的改良Rankin量表功能评分。

 

结果

该试验在70名患者(每组35人)接受随机化后因有效性而提前终止。血管内治疗组在24小时接受再灌注的缺血区域百分比高于阿替普酶单药组(中位数,100%对37%;P<0.001)。血管内治疗组,开始于卒中发作后的中位时间210分钟时,和阿替普酶单药组相比增加了3天时的早期神经功能改善(80% 对37%,P= 0.002),提高了90天时的功能结局,且更多患者获得功能独立(改良的Rankin评分为0~2, 71%对 40%;P­= 0.01)。两组患者在死亡或有症状脑内出血方面无显著差异。

 

结论

对于存在近端脑动脉闭塞且CT灌注成像中存在可挽救组织的缺血性卒中患者,使用Solitaire FR支架取栓比阿替普酶单药治疗更能促进再灌注、早期神经功能恢复以及功能结局。(本研究由澳大利亚国家卫生与医学研究委员会[Australian National Health and Medical Research Council]等资助;EXTEND-IA在ClinicalTrials.gov注册号为NCT01492725,澳大利亚新西兰临床研究[Australian New Zealand Clinical Trials Registry]注册号为ACTRN12611000969965。)





作者信息

Bruce C.V. Campbell, M.D., Peter J. Mitchell, M.D., Timothy J. Kleinig, M.D., Helen M. Dewey, M.D., Leonid Churilov, Ph.D., Nawaf Yassi, M.D., Bernard Yan, M.D., Richard J. Dowling, M.D., Mark W. Parsons, M.D., Thomas J. Oxley, M.D., Teddy Y. Wu, M.D., Mark Brooks, M.D., Marion A. Simpson, M.D., Ferdinand Miteff, M.D., Christopher R. Levi, M.D., Martin Krause, M.D., Timothy J. Harrington, M.D., Kenneth C. Faulder, M.D., Brendan S. Steinfort, M.D., Miriam Priglinger, M.D., Timothy Ang, M.D., Rebecca Scroop, M.D., P. Alan Barber, M.D., Ben McGuinness, M.D., Tissa Wijeratne, M.D., Thanh G. Phan, M.D., Winston Chong, M.D., Ronil V. Chandra, M.D., Christopher F. Bladin, M.D., Monica Badve, M.D., Henry Rice, M.D., Laetitia de Villiers, M.D., Henry Ma, M.D., Patricia M. Desmond, M.D., Geoffrey A. Donnan, M.D., and Stephen M. Davis, M.D., for the EXTEND-IA Investigators*
The authors' affiliations are listed in the Appendix. Address reprint requests to Dr. Campbell at the Department of Neurology, Royal Melbourne Hospital, Grattan St., Parkville, VIC 3050, Australia, or at bruce.campbell@mh.org.au. *A complete list of investigators in the Extending the Time for Thrombolysis in Emergency Neurological Deficits — Intra-Arterial (EXTEND-IA) trial is provided in the Supplementary Appendix, available at NEJM.org.

 

参考文献

1. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015;372:11-20

2. Broderick JP, Palesch YY, Demchuk AM, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 2013;368:893-903[Erratum, N Engl J Med 2013;368:1265.]

3. Ciccone A, Valvassori L, Nichelatti M, et al. Endovascular treatment for acute ischemic stroke. N Engl J Med 2013;368:904-913

4. Kidwell CS, Jahan R, Gornbein J, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 2013;368:914-923

5. Pereira VM, Gralla J, Davalos A, et al. Prospective, multicenter, single-arm study of mechanical thrombectomy using Solitaire Flow Restoration in acute ischemic stroke. Stroke 2013;44:2802-2807

6. Saver JL, Jahan R, Levy EI, et al. Solitaire Flow Restoration Device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 2012;380:1241-1249

7. Nogueira RG, Lutsep HL, Gupta R, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet 2012;380:1231-1240

8. Bivard A, Levi C, Spratt N, Parsons M. Perfusion CT in acute stroke: a comprehensive analysis of infarct and penumbra. Radiology 2013;267:543-550

9. Bivard A, Spratt N, Levi C, Parsons M. Perfusion computer tomography: imaging and clinical validation in acute ischaemic stroke. Brain 2011;134:3408-3416

10. Campbell BCV, Christensen S, Levi CR, et al. Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core. Stroke 2011;42:3435-3440

11. Campbell BCV, Christensen S, Levi CR, et al. Comparison of computed tomography perfusion and magnetic resonance imaging perfusion-diffusion mismatch in ischemic stroke. Stroke 2012;43:2648-2653

12. Campbell BCV, Yassi N, Ma H, et al. Imaging selection in ischemic stroke: feasibility of automated CT-perfusion analysis. Int J Stroke 2015;10:51-54

13. Straka M, Albers GW, Bammer R. Real-time diffusion-perfusion mismatch analysis in acute stroke. J Magn Reson Imaging 2010;32:1024-1037

14. Campbell BC, Mitchell PJ, Yan B, et al. A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA). Int J Stroke 2014;9:126-132

15. Lansberg MG, Straka M, Kemp S, et al. MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study. Lancet Neurol 2012;11:860-867

16. Wintermark M, Albers GW, Broderick JP, et al. Acute Stroke Imaging Research Roadmap II. Stroke 2013;44:2628-2639

17. Wahlgren N, Ahmed N, Davalos A, et al. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet 2007;369:275-282

18. Holm S. A simple sequentially rejective multiple test procedure. Scand J Stat 1979;6:65-70

19. Churilov L, Arnup S, Johns H, et al. An improved method for simple, assumption-free ordinal analysis of the modified Rankin Scale using generalized odds ratios. Int J Stroke 2014;9:999-1005

20. Howard G, Waller JL, Voeks JH, et al. A simple, assumption-free, and clinically interpretable approach for analysis of modified Rankin outcomes. Stroke 2012;43:664-669

21. Zaidat OO, Yoo AJ, Khatri P, et al. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 2013;44:2650-2663

22. Quinn TJ, Dawson J, Lees JS, Chang TP, Walters MR, Lees KR. Time spent at home poststroke: “home-time” a meaningful and robust outcome measure for stroke trials. Stroke 2008;39:231-233

23. Davis SM, Donnan GA, Parsons MW, et al. Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET): a placebo-controlled randomised trial. Lancet Neurol 2008;7:299-309

24. Inoue M, Mlynash M, Straka M, et al. Patients with the malignant profile within 3 hours of symptom onset have very poor outcomes after intravenous tissue-type plasminogen activator therapy. Stroke 2012;43:2494-2496

25. Kimura K, Iguchi Y, Shibazaki K, et al. Recanalization between 1 and 24 hours after t-PA therapy is a strong predictor of cerebral hemorrhage in acute ischemic stroke patients. J Neurol Sci 2008;270:48-52

26. Bang OY, Saver JL, Kim SJ, et al. Collateral flow predicts response to endovascular therapy for acute ischemic stroke. Stroke 2011;42:693-699

27. Campbell BCV, Christensen S, Tress BM, et al. Failure of collateral blood flow is associated with infarct growth in ischemic stroke. J Cereb Blood Flow Metab 2013;33:1168-1172

28. Meretoja A, Weir L, Ugalde M, et al. Helsinki model cut stroke thrombolysis delays to 25 minutes in Melbourne in only 4 months. Neurology 2013;81:1071-1076

29. Menezes NM, Ay H, Wang Zhu M, et al. The real estate factor: quantifying the impact of infarct location on stroke severity. Stroke 2007;38:194-197

服务条款 | 隐私政策 | 联系我们