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发病时间大于24小时急性后循环缺血性卒中血管内治疗的安全性与有效性分析

Safety and efficacy of endovascular treatment in patients with acute posterior circulation ischemic stroke over 24 hours from onset:a propensity score matched cohort study

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【作者】 岳飞学李超宋康佳石明超周杰张文彬王守春

【Author】 Yue Feixue;Li Chao;Song Kangjia;Shi Mingchao;Li Chao;Zhou Jie;Zhang Wenbin;Wang Shouchun;Stroke Center,Department of Neurology,the First Hospital of Jilin University;

【通讯作者】 王守春;

【机构】 吉林大学第一医院神经内科卒中中心

【摘要】 目的 探讨发病时间> 24 h急性后循环缺血性卒中患者行血管内治疗(EVT)的安全性与有效性。方法 回顾性连续纳入2018年6月至2023年6月于吉林大学第一医院神经内科卒中中心接受EVT的急性后循环缺血性卒中患者的临床资料。收集患者的性别、年龄等相关人口统计学信息;收集患者相关检查结果,包括入院快速血糖、入院收缩压、入院舒张压;收集患者的卒中相关危险因素,包括既往短暂性脑缺血发作、高血压病、糖尿病、心房颤动以及饮酒史、吸烟史等;收集其他相关指标,包括是否静脉溶栓、串联病变、觉醒卒中及基线美国国立卫生研究院卒中量表(NIHSS)评分、基线后循环Alberta卒中项目早期CT评分(pc-ASPECTS)、美国介入和治疗神经放射学学会/介入放射学学会(ASITN/SIR)侧支循环分级、发病至EVT穿刺时间、急性卒中Org 10172治疗试验(TOAST)分型及结局指标[有效性指标包括术后90 d改良Rankin量表(mRS)评分≤3分、术后即刻造影是否成功再通(扩展脑梗死溶栓分级2b~3级);安全性指标包括术后24 h内症状性颅内出血(sICH)及术后90 d病死率]。根据患者发病至EVT穿刺时间将患者分别纳入发病时间> 24 h组及发病时间≤24 h组。通过倾向性评分匹配(PSM)的统计方法将发病间> 24 h的患者及发病时间≤24 h的患者以1∶1的比例进行匹配。根据术后90 d mRS评分将所有患者分为预后不良(mRS评分> 3分)组和预后良好(mRS评分≤3分)组。采用单因素和多因素Logistic回归分析方法分析发病时间对术后90 d预后的影响。结果 本研究共纳入366例患者,其中男284例,女82例;年龄25~91岁,中位年龄61(55,68)岁。PSM前发病时间≤24 h组267例,发病时间> 24 h组99例,PSM后两组均为94例。未行PSM匹配前,发病时间>24 h组心房颤动比例更低[2.0%(2/99)比9.7%(26/267),P=0.025],基线NIHSS评分更低[10.0(5.0,19.0)分比14.0(10.0,35.0)分,P <0.01],两组间ASTIN/SIR侧支循环分级差异有统计学意义(P=0.018)。行PSM后,除发病至EVT穿刺时间(P <0.01)外各基线资料差异均无统计学意义(均P> 0.05)。行PSM前后,发病时间> 24 h组与发病时间≤24 h组间有效性及安全性指标差异均无统计学意义(均P> 0.05)。单因素二元Logistic回归分析显示,高血压病(OR=0.613,95%CI:0.391~0.942,P=0.025)、静脉溶栓(OR=3.235,95%CI:1.316~9.237,P=0.010)、基线NIHSS评分(OR=0.975,95%CI:0.957~0.988,P <0.01)、术前pc-ASPECTS(OR=1.281,95%CI:1.101~1.482,P=0.001)、术后24 h内sICH(OR=0.070,95%CI:0.000~0.330,P <0.01)与患者预后显著相关。将性别、年龄、高血压病、基线NIHSS评分、静脉溶栓、基线pc-ASPECTS、ASTIN/SIR侧支循环分级、发病时间> 24 h及术后24 h内sICH纳入多因素二元Logistic回归分析,结果显示,发病时间> 24 h与患者术后90 d不良预后无相关性(aOR=1.635,95%CI:0.936~2.893,P=0.087)。结论 经过严格影像学筛选的发病时间> 24h的急性后循环缺血性卒中患者行EVT的安全性和有效性与发病时间24h内患者相似。

【Abstract】 Objective To explore the safety and efficacy of endovascular treatment(EVT)in patients with acute posterior circulation ischemic stroke over 24 hours from onset. Methods This retrospective study retrospectively analyzed patients with acute posterior circulation ischemic stroke who received EVT in the Department of Neurology,First Hospital of Jilin University from June 2018 to June2023. The patient′s gender,age and other related demographic information were collected. The related examination results of patients were collected,including admission rapid blood glucose,admission systolic blood pressure,admission diastolic blood pressure. The related risk factors of stroke of patients were collected,including previous transient ischemic attack,hypertension,diabetes,atrial fibrillation,and history of drinking,smoking history,etc.;other related indicators were collected,including intravenous thrombolysis,tandem lesions,awakening stroke,baseline National Institutes of Health stroke scale(NIHSS)score,and baseline posterior circulation Alberta stroke program early CT score(pc-ASPECTS),collateral circulation grade of American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology(ASITN/SIR),onset to EVT puncture time,the trial of org 10172 in acute stroke treatment(TOAST)classification and outcome indicators(efficacy indicators included 90 days Modified Rankin scale[mRS]score ≤ 3 after EVT,successful recanalization[extended cerebral infarction thrombolytic recanalization class 2b-3];security indexes included symptomatic intracranial hemorrhage[sICH]within 24 h after EVT and 90 d mortality after EVT). According to the symptom onset to EVT puncture time,the patients were divided into two groups:≤24 h group and > 24 h group. The patients with onset time > 24 h and those with onset time ≤24 h were matched at a ratio of 1 ∶ 1 by propensity score matching(PSM). All patients were divided into poor prognosis group(mRS score > 3)and good prognosis group(mRS score ≤3)according to mRS score at 90 days after EVT. Using univariate and multivariate Logistic regression was used to analyze the effect of onset time on clinical outcomes at 90 days after EVT. Results A total of 366 patients were enrolled in this study,including 284 males and82 females. The median age was 61(55,68)years old,ranging from 25 to 91 years old. Before PSM,the> 24 h group had lower prevalence of atrial fibrillation(2. 02%[2/99]vs. 9. 74%[26/267],P =0. 025)and lower baseline NIHSS score(10. 0[5. 0,19. 0]vs. 14. 0[10. 0,35. 0],P < 0. 01)and higher ASTIN/SIR collateral grade(P = 0. 018). After PSM,we did not find statistical difference between the two groups in baseline characteristics except for the onset to EVT puncture time. Before and after PSM,there was no significant difference in efficacy and safety between the onset time > 24 h group and the onset time ≤24 h group. Univariate binary Logistic regression analysis showed that hypertension(OR,0. 613,95% CI 0. 391-0. 942,P = 0. 025),intravenous thrombolysis(OR,3. 235,95% CI 1. 316-9. 237,P =0. 010),baseline NIHSS score(OR,0. 975,95% CI 0. 957-0. 988,P < 0. 01),baseline pc-ASPECTS(OR,1. 281,95% CI 1. 101-1. 482,P = 0. 001)and sICH within 24 h after EVT(OR,0. 070,95% CI0. 000-0. 330,P < 0. 01)were significantly correlated with prognosis. Gender,age,hypertension,baseline NIHSS score,intravenous thrombolysis,baseline pc-ASPECTS,ASTIN/SIR collateral grade,onset time > 24 h and sICH within 24 h after EVT were included in the multivariate binary Logistic regression analysis. The multivariate binary Logistic regression analysis showed that the onset time > 24 h was not associated with poor prognosis 90 d after EVT(aOR,1. 635,95% CI 0. 936-2. 893,P = 0. 087).Conclusion EVT for acute posterior circulation ischemic stroke more than 24 hours after onset is feasible under strict imaging screening,and its safety and efficacy are similar to those in patients with onset under24 hours.

  • 【文献出处】 中国脑血管病杂志 ,Chinese Journal of Cerebrovascular Diseases , 编辑部邮箱 ,2023年12期
  • 【分类号】R743.3
  • 【下载频次】9
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