Stroke :卒中后取栓,侧枝血管循环提示预后更佳

2022-01-03 Freeman MedSci原创

DAWN受试者在发病后6至24小时入院,梗死核心有限

颈动脉支配着脑缺血的速度和严重程度,区分了快速或缓慢的进展者和相应的治疗机会。先前的研究表明,有良好的侧枝循环的急性缺血性卒中患者对静脉阿替普酶和血管血栓切除术(EVT)的反应更好,卒中进展更慢,神经系统的预后也更好。

大多数先前的文献都集中在早期治疗窗口(距最后已知井6小时内)的急性缺血性卒中患者,而在晚期窗口(距最后已知井>6小时),持续侧枝灌注或侧枝失败的命运特征不明显。

意外的是,在最近的DEFUSE-3试验(缺血性卒中成像评估后的血管内治疗)的事后分析中,卒中后晚期治疗窗口期,单相计算机断层扫描(CT)血管造影(CTA)上的良好侧支与基线时较小的缺血核心体积和减少缺血核心增长有关,但与更好的功能结果、血管内治疗的成功、出血性并发症或死亡无关。

DAWN试验(Diffusion-Weighted Imaging or Computed Tomography Perfusion Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo)显示,在大血管闭塞导致的中风患者中,最后已知的时间是6至24小时前,临床功能障碍的严重程度与梗塞体积不匹配,与单纯的医疗护理相比,90天时血栓切除的功能结果更好。

藉此,UCLA的David S. Liebeskind等人,对DAWN试验的事后分析,探究了急性卒中患者晚期时间窗内附属物的特点和影响。并假设,基线CTA或数字减影血管造影(DSA)上良好的旁路状态与该患者群体中较慢的梗死核心和梗死进展、更大的再灌注率和更有利的临床结果有关。

DAWN成像核心实验室对基线计算机断层扫描血管成像(CTA;血管内和对照组)和数字减影血管成像(DSA;仅血管内组),对CTA旁路用Tan评分,DSA旁路用ASITN评分(美国介入和治疗神经放射学协会旁路评分)。描述性统计学描述了所有DAWN受试者的CTA侧枝等级和血管内侧枝的DSA侧枝的特点。对每个治疗组分别分析了侧枝评分等级与第90天结果之间的关系。


161名DAWN受试者(平均年龄69.8±13.6岁;55.3%为女性;91名血管内治疗,70名对照组)在血栓切除前通过CTA(n=144;中位数2,0-3)和DSA(n=57;中位数2,1-4)对缺血区的侧支循环进行了评估。CTA显示了广泛的侧枝循环(Tan 3级,n=64[44%];2级,n=45[31%];1级,n=31[22%];0,n=4[3%])。


DSA也显示了各种不同的侧枝等级(ASITN 4级,n=4;3,n=22;2,n=27;1,n=4)。在各治疗组中,基线人口统计学、除心房颤动外的临床变量(41.6%的血管内科对25.0%的对照组,P=0.04),以及CTA等级都是平衡的。

在3个级别的侧支流(好、一般、差)中,基线NIHSS、血糖<150、糖尿病、既往缺血性卒中、基线和24小时核心梗死体积、基线和24小时阿尔伯塔卒中计划早期CT评分、梗死急剧进展、最终脑梗死溶栓治疗2b+以及死亡都有差异。

在血管内治疗组中,侧支血流是90天改良的Rankin量表评分为0至2分的重要预测因素,43.7%(31/71)有良好侧支流的受试者,30.8%(16/52)有一般侧支流的受试者,以及17.7%(6/34)有不良侧支流的受试者在90天达到改良Rankin量表评分为0至2分(P=0.026)。

该研究的重要意义在于发现了:DAWN受试者在发病后6至24小时入院,梗死核心有限,在CTA和DSA上都有广泛的侧枝等级。即使在这个较晚的时间窗口,较好的侧支会导致较慢的卒中进展和较好的功能结果。

原文出处:
  Liebeskind DS, Saber H, Xiang B, et al. Collateral Circulation in Thrombectomy for Stroke After 6 to 24 Hours in the DAWN Trial. Stroke. Published online November 3, 2021:STROKEAHA.121.034471. doi:10.1161/STROKEAHA.121.034471

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