大核心量急性缺血性卒中的血管内血栓切除术。最新系统综述和元分析。

IF 2 4区医学 Q3 NEUROSCIENCES

Journal of Stroke & Cerebrovascular Diseases Pub Date : 2024-11-12 DOI:10.1016/j.jstrokecerebrovasdis.2024.108135

Mishaal Hukamdad , José Biller MD , Fernando D. Testai MD, PhD , Gabriela Trifan MD

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引用次数: 0

摘要

背景：最近的几项研究评估了血管内血栓切除术（EVT）对由前循环大血管闭塞（LVO）引起的急性缺血性卒中患者的疗效和安全性：我们对迄今为止所有的随机临床试验（RCT）和观察性研究进行了系统回顾和荟萃分析，比较了EVT加最佳医疗管理（MM）与单纯MM治疗前循环大血管闭塞伴大核心急性缺血性卒中的有效性和安全性。主要疗效指标是最佳功能预后，即 90 天改良兰金量表评分（mRS）为 0-2。安全性结果为无症状性颅内出血（sICH）风险和 90 天死亡率。根据研究设计进行了分组分析。使用随机效应模型计算相对风险（RR）和 95% CI，并使用 I2 统计量评估异质性：共有16项研究、3717名参与者符合纳入标准（6项RCT研究和10项观察性研究）。证据质量为中高。与单纯 MM 相比，EVT 增加了 mRS 0-2 的结果（RR=2.91，95% CI [2.12，4.01]，I2=63%），降低了死亡率（RR=0.75 [0.63，0.88]，I2=60%），但不影响 sICH 的风险（I2=14%）。当分析仅限于RCT数据（n=1,887）时，EVT增加了mRS 0-2（RR=2.50 [1.89，3.29]，I2=8%）和sICH（RR=1.71 [1.09，2.66]，I2=0%）的结果，但不影响死亡率（I2=45%）。在观察性研究中（n=1,830），接受EVT的患者与单纯接受MM的患者相比，获得mRS 0-2的可能性更高（RR=3.39 [1.98-5.79]，I2=74%），死亡率更低（RR=0.63 [1.49-0.82]，I2=50%），但发生sICH的风险相同（I2=29）：结论：在大面积核心梗死的 LVO 患者中，EVT 与 90 天后功能预后的改善相关。当分析仅限于研究性临床试验时，EVT会增加sICH的风险，但不会影响90天的死亡率。然而，在真实世界（观察性）研究中，EVT并未改变sICH风险，但降低了90天死亡率。

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Endovascular Thrombectomy for Large Core Volume Acute Ischemic Stroke. Updated Systematic Review and Meta-Analysis

Background

Several recent studies assessed the efficacy and safety of endovascular thrombectomy (EVT) for patients with acute ischemic stroke caused by an anterior circulation large vessel occlusion (LVO) with large core infarct volumes.

Methods

We performed a systematic review and meta-analysis from inception until July 2024 of all randomized clinical trials (RCTs) and observational studies to date comparing the efficacy and safety of EVT plus best medical management (MM) for acute ischemic stroke due to anterior circulation LVO with large core, versus MM alone. Primary efficacy outcome was optimal functional outcome defined by a 90-day modified Rankin scale score (mRS) of 0-2. Safety outcomes were risk of symptomatic intracranial hemorrhage (sICH) and 90-day mortality. Subgroup analyses were done by study design. Relative risk (RR) and 95 % CIs were calculated using random-effects models and heterogeneity was assessed by I² statistics.

Results

A total of 16 studies with 3,717 participants met inclusion criteria (6 RCTs and 10 observational studies). The quality of the evidence was moderate to high. Compared with MM alone, EVT increased the outcome of mRS 0-2 (RR = 2.91, 95 % CI [2.12, 4.01], I² = 63 %), decreased mortality (RR = 0.75 [0.63, 0.88], I² = 60 %), but did not influence the risk of sICH (I² = 14 %). When the analysis was restricted to data from RCTs (n = 1,887), EVT increased the outcome of mRS 0-2 (RR = 2.50 [1.89, 3.29], I² = 8 %) and sICH (RR = 1.71 [1.09, 2.66], I² = 0 %) but did not affect mortality (I² = 45 %). In observational studies (n = 1,830), patients receiving EVT had a higher likelihood of achieving an mRS 0-2 (RR = 3.39 [1.98-5.79], I² = 74 %), lower mortality (RR = 0.63 [1.49-0.82], I² = 50 %), but equal risk of sICH (I² = 29) than those receiving MM alone.

Conclusion

Among patients with LVO with large core infarct, EVT was associated with improved functional outcome at 90 days. When the analysis was restricted to RCTs, EVT increased the risk of sICH, but did not affect 90-day mortality. However, in real-world (observational) studies, EVT did not modify the risk of sICH but reduced 90-day mortality.

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来源期刊

Journal of Stroke & Cerebrovascular Diseases Medicine-Surgery

CiteScore

5.00

自引率

4.00%

发文量

583

审稿时长

62 days

期刊介绍： The Journal of Stroke & Cerebrovascular Diseases publishes original papers on basic and clinical science related to the fields of stroke and cerebrovascular diseases. The Journal also features review articles, controversies, methods and technical notes, selected case reports and other original articles of special nature. Its editorial mission is to focus on prevention and repair of cerebrovascular disease. Clinical papers emphasize medical and surgical aspects of stroke, clinical trials and design, epidemiology, stroke care delivery systems and outcomes, imaging sciences and rehabilitation of stroke. The Journal will be of special interest to specialists involved in caring for patients with cerebrovascular disease, including neurologists, neurosurgeons and cardiologists.