Reperfusion therapies for ischemic stroke in dementia and cognitive impairment: A systematic review and meta-analysis.

IF 6.3 2区医学 Q1 CLINICAL NEUROLOGY

International Journal of Stroke Pub Date : 2024-10-01 Epub Date: 2023-12-27 DOI:10.1177/17474930231220186

Fouzi Bala, William Betzner, Benjamin Beland, Jennifer S McDonald, Aravind Ganesh

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引用次数: 0

Abstract

Background: Endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) have an unclear benefit in those with pre-stroke dementia or cognitive impairment, as these patients were often excluded from landmark stroke trials. We performed a systematic review and meta-analysis to assess the outcomes of IVT and EVT in these populations.

Aims: Our systematic review, conforming to the Meta-Analysis of Observational Studies in Epidemiology guidelines, investigated studies on acute ischemic stroke patients with pre-stroke dementia or cognitive impairment treated with IVT or EVT. Primary outcome was favorable 90-day outcome (mRS 0-2). Secondary outcomes included 90-day mortality, symptomatic intracranial hemorrhage (SICH), and radiographic intracranial hemorrhage (ICH).

Summary of review: Nine articles were identified, with five observational studies of IVT use in patients with (n = 1078) and without dementia (n = 2805) being selected for the meta-analysis. There were no significant differences in favorable outcome (adjusted OR: 0.61, 95% CI 0.24-1.59), mortality (unadjusted OR: 1.19, 95% CI 0.86-1.64), ICH (unadjusted OR: 1.32, 95% CI 0.79-2.19), and symptomatic ICH (unadjusted OR: 0.94, 95% CI 0.70-1.25) for patients undergoing IVT with pre-stroke dementia versus those without. One EVT study (n = 615 with dementia vs n = 9600 without) found no significant differences in outcomes apart from an increased odds of ICH for those with pre-existing dementia (adjusted OR: 1.57, 95% CI 1.03-2.40). A pooled analysis of three IVT studies showed no significant association of cognitive impairment (n = 93 vs n = 211 without) with all assessed outcomes, whereas a study of EVT found that pre-stroke cognitive impairment was associated with poor 90-day outcomes (mRS 3-6).

Conclusion: These results suggest no substantial safety issues in the use of IVT or EVT for patients with pre-existing dementia or cognitive impairment compared to those without. However, the efficacy of these therapies in this demographic remains uncertain. Further rigorous studies that include a more nuanced outcome measurement approach are warranted.

Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021240499.

查看原文本刊更多论文

再灌注治疗缺血性脑卒中痴呆和认知功能障碍:系统回顾和荟萃分析。

背景:血管内取栓(EVT)和静脉溶栓(IVT)对脑卒中前痴呆或认知障碍患者的益处尚不清楚，因为这些患者通常被排除在具有里程碑意义的脑卒中试验之外。我们进行了系统回顾和荟萃分析，以评估这些人群中IVT和EVT的结果。方法:根据流行病学指南中观察性研究的荟萃分析，我们确定了急性缺血性卒中合并卒中前痴呆或认知障碍患者接受IVT或EVT治疗的研究。主要转归为90天的有利转归(mRS 0-2)。次要结局包括90天死亡率、症状性颅内出血(SICH)和影像学颅内出血(ICH)。结果:纳入了9篇文章，其中5项观察性研究选择了IVT在有(n=1078)和无痴呆(n=2805)患者中的应用进行meta分析。接受IVT合并卒中前痴呆的患者与未接受IVT的患者在有利结局(校正OR:0.61, 95%CI 0.24-1.59)、死亡率(未校正OR: 1.19, 95%CI 0.86-1.64)、脑出血(未校正OR:1.32, 95%CI 0.79- 2.19)和症状性脑出血(未校正OR:0.94, 95%CI 0.70-1.25)方面无显著差异。一项EVT研究(n=615例痴呆患者vs n= 9600例无痴呆患者)发现，除了已存在痴呆患者脑出血的几率增加外，结果无显著差异(调整OR:1.57, 95%CI 1.03-2.40)。三项IVT研究的汇总分析显示，认知障碍与所有评估结果均无显著相关性(n=93 vs n=211)，而EVT研究发现卒中前认知障碍与较差的90天预后(mRS 3-6)相关。结论:这些结果一般表明，与没有痴呆或认知障碍的患者相比，IVT或EVT用于已有痴呆或认知障碍的患者没有实质性的安全性问题。然而，这些疗法在这一人群中的疗效仍不确定。进一步严格的研究包括更细致的结果测量方法是有必要的。注册:网址:https://www.crd.york.ac.uk/PROSPERO/;唯一标识符:CRD42021240499。缩写:EVT:血管内血栓切除术，ICH:脑出血，IVT:静脉溶栓，MCI:轻度认知障碍，mRS:改良Rankin评分，MOOSE:流行病学观察性研究荟萃分析，PRISMA:系统评价和荟萃分析的首选报告项目，QUIPS:预后质量研究，SICH:症状性脑出血。

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来源期刊

International Journal of Stroke 医学-外周血管病

CiteScore

13.90

自引率

6.00%

发文量

132

审稿时长

6-12 weeks

期刊介绍： The International Journal of Stroke is a welcome addition to the international stroke journal landscape in that it concentrates on the clinical aspects of stroke with basic science contributions in areas of clinical interest. Reviews of current topics are broadly based to encompass not only recent advances of global interest but also those which may be more important in certain regions and the journal regularly features items of news interest from all parts of the world. To facilitate the international nature of the journal, our Associate Editors from Europe, Asia, North America and South America coordinate segments of the journal.