Zhongguo cuzhong zazhi (Apr 2023)
急性后循环大血管闭塞性脑梗死桥接治疗与直接血管内治疗的疗效和安全性对比研究 A Comparative Study on the Efficacy and Safety of Bridging Therapy and Direct Endovascular Therapy for Acute Posterior Circulation Large Vessel Occlusive Cerebral Infarction
Abstract
目的 探讨桥接治疗和直接血管内治疗对急性后循环大血管闭塞性脑梗死患者的安全性和有效性。 方法 本研究采用回顾性、多中心研究方法，应用Epidata数据库，收集2020年1月—2021年12月江苏省4家医疗中心急性后循环大血管闭塞性脑梗死患者动脉取栓数据，根据治疗方式分为桥接治疗组（急诊血管内治疗前给予阿替普酶静脉溶栓）和直接血管内治疗组。收集患者一般基线数据和结局指标，比较两组患者基线特征和治疗后预后情况。使用术后90 d mRS评分评估患者预后，0～2分为预后良好，3～6分为预后不良；主要有效性结局指标为90 d mRS评分和90 d血管性死亡率；主要安全性指标为术后48 h内出现症状性颅内出血（symptomatic intracerebral hemorrhage，sICH）、再灌注损伤、造影剂渗漏。采用logistic回归分析影响后循环取栓术预后的独立危险因素。 结果 共纳入125例急性后循环大血管闭塞性脑梗死患者，其中接受桥接治疗28例，直接血管内治疗97例。入院时，桥接治疗组丙氨酸转氨酶（alanine aminotransferase，ALT）[13.9（11.3～23.2）U/L vs. 20.0（13.0～27.8）U/L，P=0.024]低于直接取栓组。桥接治疗组和直接血管内治疗组的单因素分析发现，桥接治疗组发病到医院的时间[120（82.5～180.0）min vs. 270（180.0～360.0）min，P<0.001]、发病到血管内治疗的时间[232（180.0～363.8）min vs. 334（255.0～443.5）min，P<0.013]、穿刺至灌注的时间[67.5（44.3～95.0）min vs. 90（60.0～137.5）min，P=0.009]、发病至灌注的时间[348.5（272.5～421.3）min vs. 460（335.0～577.5）min，P=0.002]均短于直接取栓组；而入院至动脉穿刺的时间，桥接治疗组的时间延误较长[117.5（70.0～160.0）min vs. 60（25.0～120.0）min，P=0.002]。桥接治疗组90 d预后良好比例高于直接取栓组（57.1% vs. 28.9%，P=0.006）。sICH（7.1% vs. 17.5%，P=0.178）、再灌注损伤（25.0% vs. 41.2%，P=0.118）、造影剂渗漏（10.7% vs. 15.5%，P=0.528）和90 d血管性死亡率（28.6% vs. 43.3%，P=0.161），桥接治疗组均低于直接取栓组，差异无统计学意义。 结论 桥接治疗可明显改善急性后循环大血管闭塞性脑梗死患者90 d的临床预后，疗效显著优于直接血管内治疗组，且不增加症状性颅内出血的发生风险。 Objective To investigate the safety and efficacy of bridging therapy and direct endovascular therapy in patients with acute posterior circulation large vessel occlusive cerebral infarction. Methods In this retrospective multicenter study, all the clinical data were collected from the arterial thrombectomy data of patients with acute posterior circulation large vessel occlusive cerebral infarction of 4 medical centers in Jiangsu Province of the Epidata database from January 2020 to December 2021. The patients were divided into bridging treatment group (intravenous thrombolysis with alteplase before emergency endovascular treatment) and direct endovascular treatment group. The baseline characteristics and prognosis after treatment were compared between the two groups. The efficacy evaluation indexes were mRS score (score of 0-2 for good prognosis and 3-6 for poor prognosis) and vascular mortality at 90 days after surgery. The main safety indexes were symptomatic intracerebral hemorrhage (sICH) , reperfusion injury and contrast leakage within 48 hours after surgery. Multivariate logistic regression was used to analyze the independent risk factors for the prognosis after thrombectomy in post circulation. Results A total of 125 eligible patients were enrolled, with 28 in bridging treatment group and 97 in direct endovascular treatment group. At admission, alanine aminotransferase (ALT) [13.9 (11.3-23.2) U/L vs. 20.0 (13.0-27.8) U/L, P=0.024] in bridging treatment group was lower than that in direct thrombectomy group. The time from onset to hospital [120 (82.5-180.0) min vs. 270 (180.0-360.0) min, P<0.001], the time from onset to endovascular treatment [232 (180.0-363.8) min vs. 334 (255.0-443.5) min, P<0.013], the time from puncture to perfusion [67.5 (44.3-95.0) min vs. 90 (60.0-137.5) min, P=0.009], the time from onset to perfusion [348.5 (272.5-421.3) min vs. 460 (335.0-577.5) min, P=0.002] in bridging treatment group were shorter than those in direct thrombectomy group. The time from admission to arterial puncture was longer in bridging treatment group [117.5 (70.0-160.0) min vs. 60 (25.0-120.0) min, P=0.002] than that in direct thrombectomy group. The proportion of good prognosis at 90 days in bridging treatment group was higher than that in direct thrombectomy group (57.1 % vs. 28.9 %, P=0.006) . The proportion of sICH (7.1 % vs. 17.5 %, P=0.178) , reperfusion injury (25.0 % vs. 41.2 %, P=0.118) , contrast leakage (10.7 % vs. 15.5 %, P=0.528) and 90-day vascular mortality (28.6 % vs. 43.3 %, P=0.161) in bridging treatment group was lower than those in direct thrombectomy group, without statistical differences. Conclusions Bridging therapy can significantly improve the 90-day clinical prognosis of patients with acute posterior circulation large vessel occlusive cerebral infarction, and the efficacy was significantly better than that of direct endovascular therapy, without increasing the risk of sICH.
Keywords
