Neurology:轻症的脑中风,溶栓和取栓联合治疗效果更好

2021-04-29 Freeman MedSci原创

轻症的脑中风,溶栓和取栓联合治疗效果更好

血管血栓切除术(EVT)是目前治疗急性缺血性卒中(AIS)患者前循环近端大血管闭塞(LVO)的标准治疗方法,因为它与功能的明显改善和生存率的提高有密切关系。

尽管在关键的EVT试验中,80%以上的参与者在EVT前接受了静脉注射阿替普酶(tPA),而且目前的国际建议主张对所有符合条件的LVO患者在开始EVT前进行静脉溶栓(IVT)(推荐等级I,证据等级),但人们对选择EVT的LVO患者进行tPA预处理的效用表示担忧。

支持直接EVT(dEVT)的观点包括:TPA预处理可能延迟EVT的启动,血栓切除前静脉注射tPA的总体再通率低,血栓脆性和迁移增加,远端栓子风险增加,联合治疗(bridging therapy,BT:IVT加EVT)的全身和出血性并发症风险增加,以及TPA管理成本增加。

在观察性注册数据公布后,IVT预处理的效用受到了进一步的质疑,这些数据表明,LVO患者绕过只能启动tPA治疗的初级卒中中心,直接到具有EVT能力的卒中中心就诊,其结果更好。

另一方面,支持在EVT前进行静脉溶栓的观点有:在7-8%的早期窗口EVT试验患者中观察到早期再灌注的潜力,血栓软化和促进成功再灌注,静脉tPA在EVT不能成功再灌注的患者中的潜在作用,以及EVT后对远端残留闭塞的影响。

此外,IVT的潜在益处可能不会发生在所有接受EVT的患者身上,而是特定于某些亚组,这与患者发病时的卒中严重程度有关,也与IVT是在非EVT中心 进行,还是直接进入具有EVT能力的中心有关。

SELECT(优化急性缺血性卒中血管内治疗的患者选择)研究,旨在调查前循环LVO的AIS患者在4.5小时内,dEVT与BT治疗的安全性和有效性有何区别。并评估BT治疗的潜在效果是否由受到以下因素影响:卒中严重程度、以缺血核心体积大小以及向具有EVT能力的中心的呈报状态(直接转院与二次转院)。

他们纳入226名LVO(54%:男性,平均年龄:65.6±14.6岁,NIHSS评分中位数:17,28%接受DEVT)。

BT患者从到达医院到腹股沟穿刺的中位时间,在直接就诊[dEVT:1.43(IQR=1.13-1.90)小时 vs. BT:1.58(IQR=1.27-2.02)小时,p=0.40]或转到有EVT能力的中心[dEVT:1.17(IQR:0.90-1.48)小时 vs. BT:1.27(IQR:0.97-1.87)小时,p=0.24]时没有差异。

BT与更高的90天功能独立和功能改善有关,并且90天死亡的可能性较低。

在亚组分析中,与dEVT相比,基线NIHSS评分<15的BT患者具有更高的功能独立可能性;对于NIHSS评分≥15的患者,这种关联并不明显。

在梗死体积分层的患者中,缺血性核心<50cc的亚组,和被转院治疗的亚组中,BT的功能结果改善明显。

这个研究的重要意义在于,发现了:对于NIHSS评分较轻,梗死核心体积较小以及转院治疗的患者,联合治疗具有更好的临床结果有关。但并没有观察到联合治疗对更严重的脑卒中患者有任何潜在的好处。


原文出处:
Clinical and Neuroimaging Outcomes of Direct Thrombectomy vs Bridging Therapy in Large Vessel Occlusion: Analysis of the SELECT Cohort Study
Amrou Sarraj, James Grotta, et al. Sheryl Martin-Schild, Sean Savitz, Georgios Tsivgoulis, for the SELECT investigators
Neurology Apr 2021, 10.1212/WNL.0000000000012063; DOI: 10.1212/WNL.0000000000012063

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    2021-07-24 yinhl1978
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    2021-04-29 付彬

    好好学习

    0

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    2021-04-29 内科新手

    谢谢梅斯提供这么好的信息,学到很多

    0

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    2021-04-29 guging

    中风是俗称,应该称为缺血性卒中吧

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=1894215, encodeId=2ede189421559, content=<a href='/topic/show?id=5e456463eee' target=_blank style='color:#2F92EE;'>#治疗效果#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=64637, encryptionId=5e456463eee, topicName=治疗效果)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=373a131, createdName=jxrzshh, createdTime=Wed Sep 29 19:43:40 CST 2021, time=2021-09-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2001318, encodeId=d18f2001318d3, content=<a href='/topic/show?id=d5df12695e6' target=_blank style='color:#2F92EE;'>#Neurol#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=12695, encryptionId=d5df12695e6, topicName=Neurol)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8217292, createdName=yinhl1978, createdTime=Sat Jul 24 07:43:40 CST 2021, time=2021-07-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1313826, encodeId=9a241313826f7, content=<a href='/topic/show?id=d4cc80e128f' target=_blank style='color:#2F92EE;'>#联合治疗#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=32, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=80712, encryptionId=d4cc80e128f, topicName=联合治疗)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=30bd35, createdName=一叶知秋, createdTime=Fri Apr 30 20:43:40 CST 2021, time=2021-04-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1479088, encodeId=9f4f14e9088e0, content=<a href='/topic/show?id=b97f3800ee0' target=_blank style='color:#2F92EE;'>#取栓#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=38007, encryptionId=b97f3800ee0, topicName=取栓)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=99077483919, createdName=1249862am74(暂无昵称), createdTime=Fri Apr 30 20:43:40 CST 2021, time=2021-04-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=961582, encodeId=357a961582ae, content=好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20210428/a1868a8a9259416b811d828105fac2f7/14af270b1a164b59abf5a0aa96b769f5.jpg, createdBy=4b254069157, createdName=付彬, createdTime=Thu Apr 29 18:15:26 CST 2021, time=2021-04-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1032886, encodeId=5ea2103288632, content=谢谢梅斯提供这么好的信息,学到很多, beContent=null, objectType=article, channel=null, level=null, likeNumber=44, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=内科新手, createdTime=Thu Apr 29 08:43:40 CST 2021, time=2021-04-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1046050, encodeId=2f9310460507d, content=中风是俗称,应该称为缺血性卒中吧, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=guging, createdTime=Thu Apr 29 08:43:40 CST 2021, time=2021-04-29, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1047337, encodeId=326a104e33751, content=疗效只是效果的众多方面之一,还要看对患者的获益,包括生活质量等因素共同决定效果的, beContent=null, objectType=article, channel=null, level=null, likeNumber=41, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f0620, createdName=CHANGE, createdTime=Thu Apr 29 08:43:40 CST 2021, time=2021-04-29, status=1, ipAttribution=)]
    2021-04-29 CHANGE

    疗效只是效果的众多方面之一,还要看对患者的获益,包括生活质量等因素共同决定效果的

    0

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