| 摘要: |
| 目的 比较颅内大血管伴/不伴同侧颈内动脉闭塞的前循环大动脉粥样硬化（LAA）型脑卒中患者行血管内治疗后的结局。方法 对多中心随机临床试验DIRECT-MT亚组进行回顾性分析，比较接受血管内治疗的孤立颅内动脉闭塞LAA型卒中患者（颅内闭塞组）和伴有同侧颈内动脉颅外段闭塞的串联闭塞LAA型卒中患者（串联闭塞组）的基线特征和预后，分析不同机制学特征（动脉粥样硬化或动脉-动脉栓塞）对临床结局的影响。结果 LAA型卒中患者共108例，其中串联闭塞组63例，颅内闭塞组45例。颅内闭塞组有高血压史的患者比例高于串联闭塞组[77.8%（35/45）vs 52.4%（33/63），P=0.007]。颅内闭塞组闭塞部位最常见于大脑中动脉M1段（88.6%，39/44），而串联闭塞组颅内闭塞主要位于颈内动脉颅内段（49.2%，31/63）和大脑中动脉M1段（49.2%，31/63）（P<0.001）。两组患者在年龄、性别、术前抗栓和他汀类药物的使用、卒中史、心房颤动史、吸烟史、基线改良Rankin量表（mRS）评分、基线美国国立卫生研究院卒中量表（NIHSS）评分、是否行静脉溶栓、侧支循环以及救治流程时间等方面差异无统计学意义（P均>0.05）。两组90 d mRS评分为0~2分的患者比例差异无统计学意义[53.3%（24/45）vs 41.9%（26/62），P=0.243]。颅内闭塞组术后成功再灌注率高于串联闭塞组[93.3%（42/45）vs 77.4%（48/62），P=0.026]，但术后24~72 h血管再通率低于串联闭塞组[57.1%（24/42）vs 77.2%（44/57），P=0.034]，最终梗死体积小于串联闭塞组[20.1（0.3，65.3）mL vs 34.5（19.9，124.6）mL，P=0.025]。术后NIHSS评分、90 d欧洲五维五水平量表评分和巴塞尔指数评分为95或100分的患者比例等其他次要结局在两组间差异无统计学意义（P均>0.05）。两组90 d内的死亡率、无症状性和症状性颅内出血的发生率、5~7 d时其他血管区域脑梗死的发生率及新流域栓塞的发生率差异无统计学意义（P均>0.05）。结论 动脉粥样硬化导致的串联闭塞相较于孤立颅内闭塞，末次造影成功再灌注率较低，梗死体积更大，但术后24~72 h血管再通率较高，且神经功能良好预后率和不良事件发生率与颅内闭塞相仿。 |
| 关键词: 大动脉粥样硬化型脑卒中 串联闭塞 颅内闭塞 临床结局 |
| DOI：10.16781/j.CN31-2187/R.20230153 |
| 投稿时间：2023-03-30修订日期：2023-06-25 |
| 基金项目:国家自然科学基金（82071278），上海市浦江人才计划（2019PJD051），海军军医大学（第二军医大学）校级课题（2022QN049）. |
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| Comparison of baseline characteristics and outcomes after endovascular treatment of large artery atherosclerosis stroke with different mechanisms: retrospective subgroup analysis of DIRECT-MT trial |
| ZHU Xuan△,ZHANG Minmin△,XING Pengfei,JIANG Yi,SHEN Hongjian,ZHANG Lei,HUYAN Meihua,YUAN Hui,WU Xiongfeng,ZHANG Yongwei* |
(Neurovascular Center, The First Affiliated Hospital of Naval Medical University (Second Military Medical University), Shanghai 200433, China
△Co-first authors.
* Corresponding author) |
| Abstract: |
| Objective To compare the outcomes of patients with anterior circulation large artery atherosclerosis (LAA) stroke with or without ipsilateral internal carotid artery occlusion after endovascular treatment. Methods The subgroups of a multicenter randomized clinical trial DIRECT-MT were retrospectively analyzed. The baseline characteristics and prognoses of patients with LAA stroke with isolated intracranial artery occlusion (intracranial occlusion group) and LAA stroke with tandem occlusion (tandem occlusion group) with ipsilateral extracranial internal carotid artery occlusion were compared, and the effects of different mechanism characteristics (atherosclerosis or arterial embolism) on clinical outcomes were analyzed. Results There were 108 patients with LAA stroke, including 63 cases in the tandem occlusion group and 45 cases in the intracranial occlusion group. The proportion of patients with hypertension history in the intracranial occlusion group was higher than that in the tandem occlusion group (77.8%[35/45] vs 52.4%[33/63], P=0.007). The most common site of intracranial occlusion in the intracranial occlusion group was the middle cerebral artery M1 segment (88.6%, 39/44), while those in the tandem occlusion group were the internal carotid artery intracranial segment (49.2%, 31/63) and the middle cerebral artery M1 segment (49.2%, 31/63) (P<0.001). There were no significant differences in age, gender, preoperative use of antithrombotic drugs or statins, history of stroke, atrial fibrillation or smoking, baseline modified Rankin scale (mRS) or National Institutes of Health stroke scale (NIHSS) score, whether receiving intravenous thrombolysis or not, collateral circulation, or treatment process time between the 2 groups (all P>0.05). There was no significant difference in the proportions of patients with 90-d mRS score of 0-2 between the 2 groups (53.3%[24/45] vs 41.9%[26/62], P=0.243). The successful reperfusion rate in the intracranial occlusion group was higher than that in the tandem occlusion group (93.3%[42/45] vs 77.4%[48/62], P=0.026), but the proportion of vascular recanalization within 24-72 h after surgery was lower than that in the tandem occlusion group (57.1%[24/42] vs 77.2%[44/57], P=0.034), and the final infarct volume was smaller than that in the tandem occlusion group (20.1[0.3, 65.3] mL vs 34.5[19.9, 124.6] mL, P=0.025). There were no significant differences in other secondary outcomes such as postoperative NIHSS score, 90-d EuroQoL Group 5-dimension 5-level self-report questionnaire on health-related quality of life (EQ-5D-5L) score or Barthel index between the 2 groups (all P>0.05). The mortality within 90 d, the incidence of asymptomatic and symptomatic intracranial hemorrhage, the incidence of cerebral infarction in other vascular regions at 5-7 d, and the incidence of embolization in a new territory were similar between the 2 groups, with no significant differences (all P>0.05). Conclusion Compared with isolated intracranial occlusion, tandem occlusion caused by atherosclerosis has a lower successful reperfusion rate on the last angiography and a larger infarct volume, but the vascular recanalization rate is higher at 24-72 h after surgery, and the good prognosis rate of neurological function and the incidence of adverse events are similar to those of intracranial occlusion. |
| Key words: large artery atherosclerosis stroke tandem occlusion intracranial occlusion clinical outcomes |
