病请描述：DEFUSE3研究中中风发作后24小时内持续性靶点失配情况瑟伦·克里斯滕森1号、迈克尔·姆林纳什1号、斯蒂芬妮·肯普1号、阿玛纳特·延努1号、杰里米·J·海特2号、迈克尔·P·马克2号、马丁·G·兰斯堡1号、格雷戈里·W·阿尔伯斯1号隶属关系扩大PMID:30735466 DOI:10.1161/STROKEAHA.118.023392摘要背景和目的-血管内血栓切除术的有效性已被证实，在脑卒中发病后24小时内，患者选择灌注成像。我们假设一些患者在发病后24小时内存在持续良好的灌注曲线，并且可以通过较低的基线低灌注强度比来预测，这表明侧支循环良好。方法：我们从DEFUSE 3试验（缺血性卒中影像学评价后的血管内治疗）中确定对照组患者，随机分组后24小时进行弥散加权成像和灌注磁共振成像，并比较持续失配患者的影像学和临床变量与随机化后24小时不再出现不匹配的患者相比。结果-18%的对照组患者在最后一次已知的健康时间后>38小时有持续良好的外形。这些患者的基线弥散加权成像和Tmax>6秒容积与最初良好灌注曲线变得不利的患者相似（弥散加权成像病灶7 vs 17 mL；P=0.17，Tmax>6秒98 vs 100 mL；P=0.48），但梗死生长较少（15 vs 59 mL；P<0.001），随机分组后24小时梗死体积缩小3倍（15对59 mL；P<0.001）。持续良好灌注的患者在基线成像时低灌注强度比率显著降低（0.2比0.4；P<0.01）。只有10%的持续失配患者在90天时出现了良好的临床结果。结论：约20%的大脑中动脉或颈内动脉闭塞患者在延长的时间窗内出现，且未接受血栓切除术治疗，其持续失配至少持续24小时。这些患者在出现时具有良好的低灌注强度比，可能出现延迟性梗死扩大，临床预后较差。需要进行临床试验，以确定灌注情况良好的患者是否能从24小时后的再灌注中获益。临床试验注册-网址：https://www.clinicaltrials.gov。唯一标识符：NCT02586415。Stroke. 2019 Mar;50(3):754-757. doi: 10.1161/STROKEAHA.118.023392.Persistent Target Mismatch Profile >24 Hours After Stroke Onset in DEFUSE 3Søren Christensen 1, Michael Mlynash 1, Stephanie Kemp 1, Amarnath Yennu 1, Jeremy J Heit 2, Michael P Marks 2, Maarten G Lansberg 1, Gregory W Albers 1Affiliations expandPMID: 30735466 DOI: 10.1161/STROKEAHA.118.023392AbstractBackground and Purpose- Efficacy of endovascular thrombectomy has been demonstrated up to 24 hours after stroke onset in patients selected with perfusion imaging. We hypothesized that a persistent favorable perfusion profile exists in some patients beyond 24 hours from the onset and can be predicted by a lower baseline hypoperfusion intensity ratio, which indicates favorable collaterals. Methods- We identified control arm patients from the DEFUSE 3 trial (The Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) with a diffusion weighted imaging and perfusion magnetic resonance imaging performed 24 hours following randomization and compared imaging and clinical variables between patients with persistent mismatch versus patients who no longer had a mismatch 24 hours after randomization. Results- Eighteen percent of the control arm patients had a persistent favorable profile >38 hours after last known well time. These patients had similar baseline diffusion weighted imaging and Tmax >6 seconds volumes as patients whose initially favorable perfusion profile became unfavorable (diffusion weighted imaging lesion 7 versus 17 mL; P=0.17, Tmax >6 seconds 98 versus 100 mL; P=0.48) yet experienced less infarct growth (15 versus 59 mL; P<0.001) and had 3-fold smaller infarct volumes (15 versus 59 mL; P<0.001) 24 hours after randomization. Patients with a persistent favorable perfusion profile had a significantly lower hypoperfusion intensity ratio on baseline imaging (0.2 versus 0.4; P<0.01). Favorable clinical outcome at 90 days occurred in only 10% of the persistent mismatch patients. Conclusions- About 20% of patients with a middle cerebral artery or internal carotid artery occlusion who present in an extended time window and are not treated with thrombectomy have a persistent mismatch for at least an additional 24 hours. These patients have a favorable hypoperfusion intensity ratio at presentation, may experience delayed infarct expansion, and have poor clinical outcomes. Clinical trials are needed to determine if patients with a favorable perfusion profile benefit from reperfusion beyond 24 hours. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02586415.
刘建仁 2021-03-14阅读量9363
病请描述：急性缺血性中风患者的重症监护入院和管理：欧洲重症监护医学会的横断面调查摘要背景：关于危重病急性缺血性中风（AIS）患者的重症监护治疗，目前尚无具体的建议，关于该人群的最佳通气、血流动力学和普通重症监护室（ICU）治疗目标仍存在问题。我们进行了一项国际调查，以调查AIS患者的ICU入院标准和管理。方法：2019年11月1日至2020年3月30日期间，欧洲重症监护医学会网站上提供了一份电子问卷，包括25个项目，分为3个部分，并通过神经重症监护（NIC）部分时事通讯进行宣传。这项调查通过电子邮件直接发送给NIC成员，并得到了欧洲重症监护医学会的认可。结果：198个中心共有214名被调查者，应答率为16.5%（214/1296）。在大多数中心（67%），2019年入住受访医院的AIS患者人数在100至300人之间，其中每家医院需要入住ICU的患者不到50人。最广泛接受的ICU入院标准指征是插管和机械通气。88（58%）的受访者使用了动脉血压（ABP）管理的标准方案。对于符合静脉溶栓条件的患者，最常见的ABP靶点是<185/110 mm Hg（n=77[51%]），而对于接受机械血栓切除术的患者，ABP靶点是≤160/90 mm Hg（n=79[54%]）。降低ABP的首选药物是拉贝洛尔（n=84[55.6%]）。其他常用的治疗靶点包括：血糖140~180mg/dL（n=65[43%]），大多数机构通过静脉胰岛素输注维持（n=110[72.4%]）；中风发作后2~3天内开始肠内喂养（n=142[93.4%]）；血氧饱和度（SpO2）>95%（n=80[53%]），潮气量为预测体重的6至8 mL/kg（n=135[89%]）。结论：AIS的ICU管理，包括治疗目标和临床实践策略，在不同的中心有重要差异。我们的研究结果可能有助于确定未来的研究和建立一个关于AIS患者ICU治疗目标的研究议程。J Neurosurg Anesthesiol. 2021 Feb 9. doi: 10.1097/ANA.0000000000000761. Online ahead of print.Intensive Care Admission and Management of Patients With Acute Ischemic Stroke: A Cross-sectional Survey of the European Society of Intensive Care MedicineChiara Robba 1, Martina Giovannini, Geert Meyfroidt, Mathieu van der Jagt, Giuseppe Citerio, Martin Smith, CollaboratorsAffiliations expandPMID: 33587531 DOI: 10.1097/ANA.0000000000000761AbstractBackground: No specific recommendations are available regarding the intensive care management of critically ill acute ischemic stroke (AIS) patients, and questions remain regarding optimal ventilatory, hemodynamic, and general intensive care unit (ICU) therapeutic targets in this population. We performed an international survey to investigate ICU admission criteria and management of AIS patients.Methods: An electronic questionnaire including 25 items divided into 3 sections was available on the European Society of Intensive Care Medicine Web site between November 1, 2019 and March 30, 2020 and advertised through the neurointensive care (NIC) section newsletter. This survey was emailed directly to the NIC members and was endorsed by the European Society of Intensive Care Medicine.Results: There were 214 respondents from 198 centers, with response rate of 16.5% of total membership (214/1296). In most centers (67%), the number of AIS patients admitted to respondents' hospitals in 2019 was between 100 and 300, and, among them, fewer than 50 required ICU admission per hospital. The most widely accepted indication for ICU admission criteria was a requirement for intubation and mechanical ventilation. A standard protocol for arterial blood pressure (ABP) management was utilized by 88 (58%) of the respondents. For patients eligible for intravenous thrombolysis, the most common ABP target was <185/110 mm Hg (n=77 [51%]), whereas for patients undergoing mechanical thrombectomy it was ≤160/90 mm Hg (n=79 [54%]). The preferred drug for reducing ABP was labetalol (n=84 [55.6%]). Other frequently used therapeutic targets included: blood glucose 140 to 180 mg/dL (n=65 [43%]) maintained with intravenous insulin infusion in most institutions (n=110 [72.4%]); enteral feeding initiated within 2 to 3 days from stroke onset (n=142 [93.4%]); oxygen saturation (SpO2) >95% (n=80 [53%]), and tidal volume 6 to 8 mL/kg of predicted body weight (n=135 [89%]).Conclusions: The ICU management of AIS, including therapeutic targets and clinical practice strategies, importantly varies between centers. Our findings may be helpful to define future studies and create a research agenda regarding the ICU therapeutic targets for AIS patients.
刘建仁 2021-03-14阅读量1.1万
病请描述：在4.5到9小时内静脉溶栓是否会增加血栓的迁移，导致血管内取栓无法开展？摘要背景和目的：急性缺血性卒中患者静脉溶栓（IVT）后，远端血栓迁移是公认的事件。值得注意的是，最初通过血管内血栓切除术可以恢复的血栓可能会转移到远端不可恢复的位置，影响临床结果。我们调查了在4.5到9小时的时间窗内，静脉血栓移植后血栓迁移导致血栓不可接近的发生率。方法：我们对EXTEND试验（延长急诊神经功能缺损溶栓时间）的资料进行回顾性分析。根据CT血管造影或磁共振血管造影确定基线和12-24小时随访的血栓位置。两个治疗组（IVT组和安慰剂组）之间确定并比较了导致从可恢复到不可恢复位置变化的血栓迁移发生率。结果：共评估220例患者。37例患者发生了血栓从可恢复部位向不可恢复部位的转移：安慰剂组21例（19.3%），IVT组16例（14.4%）。两组之间血栓迁移率无显著差异（P=0.336）。结论：我们的研究结果没有显示在接受IVT治疗的患者中，血栓迁移增加导致无法取栓。Stroke. 2021 Mar;52(3):1083-1086. doi: 10.1161/STROKEAHA.120.030661. Epub 2021 Feb 16.Does Intravenous Thrombolysis Within 4.5 to 9 Hours Increase Clot Migration Leading to Endovascular Inaccessibility?Jeremy C Lim 1, Leonid Churilov 2, Andrew Bivard 3, Henry Ma 3, Richard J Dowling 1, Bruce C V Campbell 3, Mark W Parsons 3, Stephen M Davis 3, Geoffrey A Donnan 3, Peter J Mitchell 1, Bernard Yan 3Affiliations expandPMID: 33588590 DOI: 10.1161/STROKEAHA.120.030661AbstractBackground and purpose: Distal clot migration is a recognized event following intravenous thrombolysis (IVT) in the setting of acute ischemic stroke. Of note, clots that were initially retrievable by endovascular thrombectomy may migrate to a distal nonretrievable location and compromise clinical outcome. We investigated the incidence of clot migration leading to clot inaccessibility following IVT in the time window of 4.5 to 9 hours.Methods: We performed a retrospective analysis of the EXTEND trial (Extending the Time for Thrombolysis in Emergency Neurological Deficits) data. Baseline and 12- to 24-hour follow-up clot location was determined on computed tomography angiogram or magnetic resonance angiogram. The incidence of clot migration leading to a change from retrievable to nonretrievable location was identified and compared between the two treatment groups (IVT versus placebo).Results: Two hundred twenty patients were assessed. Clot migration from a retrievable to nonretrievable location occurred in 37 patients: 21 patients (19.3%) in the placebo group and 16 patients (14.4%) in the IVT group. No significant difference was identified in the incidence of clot migration leading to inaccessibility between groups (P=0.336).Conclusions: Our results did not show increased clot migration leading to clot inaccessibility in patients treated with IVT.Keywords: endovascular procedures; follow-up; incidence; radiology, interventional; thrombolytic therapy.
刘建仁 2021-03-13阅读量9416
病请描述：大血管缺血性卒中后血管内血栓切除术：美国的应用、结果和再入院摘要背景：在发表了证明血栓切除术有效性的试验后，2015年修订了社会指南，建议对大血管卒中采用这种方法。目的评估美国急性脑卒中大规模血栓切除术后2年内血栓切除率、不良事件、转归和再入院率。材料与方法在这项回顾性研究中，作者查询了2016年至2017年间接受血栓切除术患者的全国住院样本和全国再入院数据库。血栓切除率比较采用χ2检验。采用多变量Poisson回归和医院层面的聚类分析，获得影响常规出院、死亡率和再入院的因素的校正风险比（aRRs）。结果共收治颈内动脉或大脑中动脉卒中患者290460例（平均年龄70.5±14.2岁，女性148620例），其中30835例（10.6%）行血栓切除术。90岁或以上患者的血栓切除率较低（24090例患者中1815例，占7.5%），黑人患者（43365例患者中4280例，占9.9%），收入最低的患者（85905例患者中8520例，占9.9%）和在西南部中心区医院治疗的患者（34355例患者中2695例，占7.8%）（P<0.001）。住院病死率为12.1%（30835例中3740例），出院率为19.1%（30835例中5900例）。在校正分析中，90岁或以上的患者（aRR:0.12；95%CI:0.09,0.16；P<0.001）和80岁以上的患者（aRR:0.37；95%CI:0.33,0.41；P<0.001）常规出院的可能性较小。90岁或以上的患者（aRR:1.78；95%CI:1.48，2.14；P<0.001）、80岁以上的老人（aRR:1.76；95%CI:1.51，2.06；P<0.001）、亚洲人和/或太平洋岛民（aRR:1.21；95%CI:1.06，1.39；P=0.005）以及在教学中接受治疗的患者（aRR:1.20；95%CI:1.07，1.34；P=0.001）或在中南部接受治疗的患者（aRR:1.35；95%CI:1.14，1.60）；P<0.001）医院有较高的死亡风险。出院后，18.9%的患者（18274例中的3449例）在90天内再次入院。结论血栓切除率和结果受人口统计学、社会经济和医院相关因素的影响。不到五分之一的患者出院回家，近五分之一的患者在90天内再次入院，死亡率和预后可能不如已发表的试验。©RSNA，2021在线补充材料可用于本文。Radiology. 2021 Feb 16;203082. doi: 10.1148/radiol.2021203082. Online ahead of print.Endovascular Thrombectomy after Large-Vessel Ischemic Stroke: Utilization, Outcomes, and Readmissions across the United StatesPedram Golnari 1, Pouya Nazari 1, Sameer A Ansari 1, Michael C Hurley 1, Ali Shaibani 1, Matthew B Potts 1, Babak S Jahromi 1Affiliations expandPMID: 33591890 DOI: 10.1148/radiol.2021203082AbstractBackground Following publication of trials demonstrating the efficacy of thrombectomy, societal guidelines were revised in 2015 to recommend this procedure for large-vessel stroke. Purpose To evaluate real-world thrombectomy rates, adverse events, outcomes, and readmissions across the United States in the 2 years after large-scale adoption of thrombectomy for acute stroke. Materials and Methods In this retrospective study, the authors queried the National Inpatient Sample and Nationwide Readmissions Database for patients undergoing thrombectomy between 2016 and 2017. Thrombectomy rates were compared by using the χ2 test. Adjusted risk ratios (aRRs) were obtained for factors affecting routine discharge, mortality, and readmission by using multivariable Poisson regression with clustering at the hospital level. Results There were 290 460 admissions (mean age, 70.5 years ± 14.2 [standard deviation]; 148 620 women) for internal carotid or middle cerebral artery stroke; 30 835 (10.6%) of these patients underwent thrombectomy. Thrombectomy rates were lower in patients aged 90 years or older (1815 of 24 090 patients, 7.5%), Black patients (4280 of 43 365 patients, 9.9%), patients with the lowest income (8520 of 85 905 patients, 9.9%), and those treated in West South Central division hospitals (2695 of 34 355 patients, 7.8%) (P < .001 for all). The inpatient mortality rate was 12.1% (3740 of 30 835 patients), and 19.1% of patients (5900 of 30 835) were discharged to home. In adjusted analyses, routine discharge was less likely in patients aged 90 years or older (aRR: 0.12; 95% CI: 0.09, 0.16; P < .001) and octogenarians (aRR: 0.37; 95% CI: 0.33, 0.41; P < .001). Patients aged 90 years or older (aRR: 1.78; 95% CI: 1.48, 2.14; P < .001), octogenarians (aRR: 1.76; 95% CI: 1.51, 2.06; P < .001), Asians and/or Pacific Islanders (aRR: 1.21; 95% CI: 1.06, 1.39; P = .005), and those treated in teaching (aRR: 1.20; 95% CI: 1.07, 1.34; P = .001) or West South Central division (aRR: 1.35; 95% CI: 1.14, 1.60; P < .001) hospitals had a higher risk of death. Following discharge, 18.9% of patients (3449 of 18 274) were readmitted within 90 days. Conclusion Rates and outcomes of thrombectomy are affected by demographic, socioeconomic, and hospital-related factors. Fewer than one-fifth of patients are discharged to home, nearly one-fifth are readmitted within 90 days, and mortality and outcomes may be less favorable than in published trials. © RSNA, 2021 Online supplemental material is available for this article.Similar articles
刘建仁 2021-03-13阅读量8785
病请描述：在美国绘制血管内卒中护理的路径图及其对运输模型的影响摘要背景：这项横断面研究的目的是确定60分钟地面或空中可到达经认可或国家指定的血管内卒中中心（ECC）和非血管内卒中中心（NECC）的美国人口百分比，以及30分钟车程内有ECC的NECC百分比。方法：将脑卒中中心大致分为ECCs和NECCs。对中风中心进行地理测绘。将人口划分为普查区，并计算其质心。估计了从质心到最近的ECC和NECC的最快空中和地面旅行时间。结果：总体而言，49.6%的美国居民有60分钟的地面访问ECCs。大约37.7%（1.13亿人）缺少60分钟的地面或空中ECCs通道。大约84.4%的人有60分钟的时间进入NECC。77.9%的人有地面通道。大约738名NECC（45.4%）在30分钟车程内发生ECC。结论：近三分之一的美国人口缺乏60分钟的血管内卒中护理，但这是一个很大的变量。交通模式和额外中心的规划应根据现有设施的位置和邻近程度，针对每个州进行调整。J Neurointerv Surg. 2021 Feb 16;neurintsurg-2020-016942. doi: 10.1136/neurintsurg-2020-016942. Online ahead of print.Mapping access to endovascular stroke care in the USA and implications for transport modelsJared Aldstadt # 1, Muhammad Waqas # 2 3, Misa Yasumiishi 1, Maxim Mokin 4 5, Vincent M Tutino 2 6, Hamid H Rai 7, Felix Chin 7, Bennett R Levy 8, Ansaar T Rai 9, J Mocco 10, Kenneth V Snyder 3 11, Jason M Davies 3 12, Elad I Levy 2 3, Adnan H Siddiqui 13 3Affiliations expandPMID: 33593798 DOI: 10.1136/neurintsurg-2020-016942AbstractBackground: The purpose of this cross-sectional study was to determine the percentage of the US population with 60 min ground or air access to accredited or state-designated endovascular-capable stroke centers (ECCs) and non-endovascular capable stroke centers (NECCs) and the percentage of NECCs with an ECC within a 30 min drive.Methods: Stroke centers were identified and classified broadly as ECCs or NECCs. Geographic mapping of stroke centers was performed. The population was divided into census blocks, and their centroids were calculated. Fastest air and ground travel times from centroid to nearest ECC and NECC were estimated.Results: Overall, 49.6% of US residents had 60 min ground access to ECCs. Approximately 37.7% (113 million) lack 60 min ground or air access to ECCs. Approximately 84.4% have 60 min access to NECCs. Ground-only access was available to 77.9%. Approximately 738 NECCs (45.4%) had an ECC within a 30 min drive.Conclusion: Nearly one-third of the US population lacks 60 min access to endovascular stroke care, but this is highly variable. Transport models and planning of additional centers should be tailored to each state depending on location and proximity of existing facilities.
刘建仁 2021-03-13阅读量9037
病请描述：线粒体靶向双光子比率探针观察脑卒中时炎症诱导的有丝分裂吞噬作用 摘要 这项研究报道了一种新的，pH敏感的，以线粒体为靶点的双光子比率探针（Mito-BNO）的开发，用于实时跟踪线粒体吞噬功能，这一过程在中风期间可以在脑组织中加速。Mito-BNO具有良好的线粒体定位能力（皮尔逊相关系数，r=0.91），并能有效地将线粒体与溶酶体和内质网等其他亚细胞器区分开来（r=0.40和r=0.33）。同时，pKa值（5.23±0.03）和pH可逆性提示，有丝分裂BNO可通过共聚焦成像实时追踪有丝分裂吞噬。最重要的是，在氧-糖剥夺/再灌注（OGD/R）过程中，有丝分裂吞噬与脑卒中期间神经炎症之间的关系已经通过评估有丝分裂BNO染色的PC12细胞在有无抗炎治疗的情况下的荧光得到了成功证实。结果表明，脑卒中时有丝分裂吞噬的发生是由神经炎症引起的氧化应激所致。本研究将有助于进一步了解脑卒中的发病机制，为脑卒中的早期诊断和治疗提供潜在的新靶点，也有助于开发脑卒中的治疗药物。
刘建仁 2021-03-05阅读量9043
病请描述：普拉格雷单药治疗下表面改良血流分流器治疗远端未破裂颅内动脉瘤的初步安全性试验摘要背景：血流分流器（FDs）是治疗颈动脉瘤的有效方法。与颈动脉瘤相比，FDs治疗颅内远端动脉瘤的并发症发生率相对较高。低血栓性修饰表面FDs可减少缺血性并发症，并允许使用单一抗血小板药物。本研究的目的是评估p48 MW HPC流量调节装置（德国波鸿Phenox股份有限公司）联合普拉格雷单药治疗颅内远端动脉瘤的安全性和有效性。方法：这是一项单中心、前瞻性、关键性、开放性、单臂研究。患者于2019年12月至2020年9月被纳入本研究。主要终点是治疗后直到随访1个月（定义为美国国立卫生研究院卒中量表（NIHSS）≥1）的任何神经功能缺损的发生率，以及治疗后48小时磁共振成像（MRI）图像中急性缺血性病变的发生率。次要终点是1个月随访时动脉瘤完全闭塞的比率。结果：21例患者中有27个前循环远端动脉瘤。平均年龄57.8岁（标准差9.7），女性16例（80%）。在1个月的随访中，没有患者出现神经系统症状。4例（20%）在MRI上有无症状的急性脑缺血病变。随访1个月，9/27（33.3%）动脉瘤完全闭塞。结论：在这项初步的安全性试验中，p48mw-HPC在普拉格雷单药治疗下治疗颅内远端动脉瘤是安全的。
刘建仁 2021-03-04阅读量1.3万
病请描述：预测扩大窗血管内血栓切除术的神经影像学适用性目的：血管内血栓切除术（EVT）和组织型纤溶酶原激活剂（tPA）是早期治疗窗内有效的缺血性脑卒中治疗方法。在延长的治疗窗口期内，这些治疗可能提供益处，但CT和MR灌注可能是确定患者资格所必需的。许多医院无法使用先进的成像工具或EVT功能，进一步的患者护理需要转移到具有这些功能的设施。为了帮助转移决策，作者开发了风险指数，可以识别出符合延长窗EVT或tPA的患者。方法：作者回顾性分析了同时行CTA和灌注的脑卒中患者，并评估了三种可能的转归，这三种转归有利于患者转院。第一个结果是大血管闭塞（LVO）和靶区不匹配（TM），患者距离最后一次已知的正常（LKN）5-23小时。第二个结果是在LKN术后5-15小时出现已知LVO的患者出现TM。第三个结果是从LKN开始4.5-12小时的患者出现TM。作者用α-误差准则为0.05的反向步进法建立了多变量模型，并用C统计量进行了评估。结果：最终预测因素包括美国国立卫生研究院卒中量表（NIHSS）、艾伯塔省卒中项目早期CT评分（ASPECTS）和年龄。预测第一个结果的C统计量为0.71（n=145），第二个结果的C统计量为0.85（n=56），第三个结果的C统计量为0.86（n=54）。在不同的临界点给每个预测因子1分的情况下，得分为3分的第一、第二和第三个结果的真阳性概率分别为80%、90%和94%。结论：尽管样本量有限，但与基于灌注的检查相比，本研究确定的临床变量准确预测了在一系列临床情景和治疗截止时间内哪些卒中患者会有可挽救的半影（C统计为71%-86%）。在确诊LVO或不太严重的组织不匹配（TM<1.2）的患者中，这种预测得到改善（C统计值为85%-86%）。应使用更大的患者登记来验证和提高这些模型的预测能力。关键词：急性缺血性中风；血管内血栓切除术；大血管闭塞；灌注成像；靶点错配；组织型纤溶酶原激活剂；血管疾病。J Neurosurg. 2021 Feb 26;1-5. doi: 10.3171/2020.8.JNS20386. Online ahead of print. Predicting neuroimaging eligibility for extended-window endovascular thrombectomyAdam de Havenon 1 , Kole Mickolio 1 , Steven O'Donnell 2 , Greg Stoddard 3 , J Scott McNally 4 , Matthew Alexander 4 , Philipp Taussky 5 , Al-Wala Awad 5 Affiliations PMID: 33636705 DOI: 10.3171/2020.8.JNS20386 Abstract Objective: Endovascular thrombectomy (EVT) and tissue plasminogen activator (tPA) are effective ischemic stroke treatments in the initial treatment window. In the extended treatment window, these treatments may offer benefit, but CT and MR perfusion may be necessary to determine patient eligibility. Many hospitals do not have access to advanced imaging tools or EVT capability, and further patient care would require transfer to a facility with these capabilities. To assist transfer decisions, the authors developed risk indices that could identify patients eligible for extended-window EVT or tPA. Methods: The authors retrospectively identified stroke patients who had concurrent CTA and perfusion and evaluated three potential outcomes that would suggest a benefit from patient transfer. The first outcome was large-vessel occlusion (LVO) and target mismatch (TM) in patients 5-23 hours from last known normal (LKN). The second outcome was TM in patients 5-15 hours from LKN with known LVO. The third outcome was TM in patients 4.5-12 hours from LKN. The authors created multivariable models using backward stepping with an α-error criterion of 0.05 and assessed them using C statistics. Results: The final predictors included the National Institutes of Health Stroke Scale (NIHSS), the Alberta Stroke Program Early CT Score (ASPECTS), and age. The prediction of the first outcome had a C statistic of 0.71 (n = 145), the second outcome had a C statistic of 0.85 (n = 56), and the third outcome had a C statistic of 0.86 (n = 54). With 1 point given for each predictor at different cutoffs, a score of 3 points had probabilities of true positive of 80%, 90%, and 94% for the first, second, and third outcomes, respectively. Conclusions: Despite the limited sample size, compared with perfusion-based examinations, the clinical variables identified in this study accurately predicted which stroke patients would have salvageable penumbra (C statistic 71%-86%) in a range of clinical scenarios and treatment cutoffs. This prediction improved (C statistic 85%-86%) when utilized in patients with confirmed LVO or a less stringent tissue mismatch (TM < 1.2) cutoff. Larger patient registries should be used to validate and improve the predictive ability of these models. Keywords: acute ischemic stroke; endovascular thrombectomy; large-vessel occlusion; perfusion imaging; target mismatch; tissue plasminogen activator; vascular disorders.
刘建仁 2021-03-04阅读量1.0万
病请描述：静脉注射重组组织型纤溶酶原激活剂（iv-rtPA）治疗缺血性脑卒中已有25年的历史。然而，关于这种疗法治疗脑小血管病（SVD）所致中风的有效性和安全性的前瞻性研究很少。我们使用所有关于静脉注射rtPA对SVD相关缺血性卒中（通过神经影像学、临床特征或两者结合来定义）的影响的可用数据，评估功能结果（改良Rankin评分，mRS）和症状性脑出血（sICH）。使用固定效应和随机效应模型，我们计算了关于优秀和良好结果（3个月时mRS分别为0-1和0-2）和sICH率的综合效应估计。23项研究符合资格标准，其中11项是比较性的，只有3项随机临床试验。在调整后的分析中，与安慰剂组相比，接受静脉注射rtPA的患者的优良结果（调整后的OR=1.53，95%CI:1.29-1.82，I2:0%）或良好结果（调整后的OR=1.68，95%CI:1.31-2.15，I2:0%）的几率增加。在报道sICH的6项研究中，治疗组的sICH发病率较高（M-H RR=8.83，95%CI:2.76-28.27）。静脉注射rtPA的SVD患者sICH合并率仅为0.72%（95%CI:0.12%-1.64%）。我们的结论是，当将SVD引起的缺血性中风单独考虑时，静脉注射rtPA治疗效果的可用数据不足以达到最高推荐水平，但似乎是安全的。尽管SVD相关缺血性中风的进一步治疗试验似乎是合理的，但我们的研究结果不应妨碍其在临床实践中继续用于这组患者。关键词：脑缺血；腔隙性脑梗死；荟萃分析；小血管疾病；脑卒中；溶栓治疗。Transl Stroke Res DOI: 10.1007/s12975-021-00890-9 AbstractIntravenous recombinant tissue plasminogen activator (iv-rtPA) has been routinely used to treat ischemic stroke for 25 years, following large clinical trials. However, there are few prospective studies on the efficacy and safety of this therapy in strokes attributed to cerebral small vessel disease (SVD). We evaluated functional outcome (modified Rankin scale, mRS) and symptomatic intracerebral hemorrhage (sICH) using all available data on the effects of iv-rtPA in SVD-related ischemic stroke (defined either using neuroimaging, clinical features, or both). Using fixed-effect and random-effects models, we calculated the pooled effect estimates with regard to excellent and favorable outcomes (mRS=0-1 and 0-2 respectively, at 3 months), and the rate of sICH. Twenty-three studies fulfilled the eligibility criteria, 11 of which were comparative, and there were only 3 randomized clinical trials. In adjusted analyses, there was an increased odds of excellent outcome (adjusted OR=1.53, 95% CI: 1.29-1.82, I2: 0%) or favorable outcome (adjusted OR=1.68, 95% CI: 1.31-2.15,I2: 0%) in patients who received iv-rtPA compared with placebo. Across the six studies which reported it, the incidence of sICH was higher in the treatment group (M-H RR = 8.83, 95% CI: 2.76-28.27). The pooled rate of sICH in patients with SVD administered iv-rtPA was only 0.72% (95% CI: 0.12%-1.64%). We conclude that when ischemic stroke attributed to SVD is considered separately, available data on the effects of iv-rtPA therapy are insufficient for the highest level of recommendation, but it seems to be safe. Although further therapeutic trials in SVD-related ischemic stroke appear to be justified, our findings should not prevent its continued use for this group of patients in clinical practice. Keywords: Brain ischemia; Lacunar infarction; Meta-analysis; Small vessel disease; Stroke; Thrombolysis.
刘建仁 2021-03-04阅读量1.1万
病请描述：年龄≥90岁大血管闭塞性脑卒中患者的预后PMID:33641385 DOI:10.1161/STROKEAHA.120.031386摘要背景与目的：比较血管内治疗（EVT）与内科治疗对≥90岁大血管闭塞性脑卒中患者的疗效。方法：在日本一个前瞻性、多中心、全国注册的2420例急性缺血性卒中大血管闭塞患者中，纳入年龄≥90岁的颈内动脉或大脑中动脉M1段闭塞患者。主要疗效结果是3个月时的良好结果，定义为3个月时达到0到2的改良Rankin评分或至少恢复到prestroke改良Rankin评分。安全结果包括发病后72小时内出现症状性颅内出血。组间偏倚通过多变量调整和治疗权重的逆概率进行调整。结果：共分析了150例患者（中位年龄92[四分位区间，90-94]岁；中位prestroke改良Rankin量表评分2[四分位区间，0-4]）。49例患者（32.7%；机械血栓切除术，n=43）进行了EVT。EVT组从发病到到达医院的时间较药物治疗组短（P=0.03），Alberta卒中项目早期ct评分较高（P<0.01），静脉溶栓治疗率较高（P<0.01）。EVT组和药物治疗组的疗效分别为28.6%和6.9%（P<0.01）。EVT与良好的预后相关（调整后的优势比为8.44[95%CI，1.88-37.97]）。EVT组症状性颅内出血的发生率（0.0%）与药物治疗组（3.9%；P=0.30）相似。结论：接受EVT治疗的患者比接受内科治疗且无症状性颅内出血增加的患者表现出更好的功能结果。如果选择了合适的患者，仅仅根据患者的年龄来保留EVT可能不会提供最佳的治疗效果。注册：URL:https://www.clinicaltrials.gov；唯一标识符：NCT02419794。关键词：老年人；登记；中风；血栓切除术；治疗结果。
刘建仁 2021-03-04阅读量9043