大血管卒中:静脉溶栓搭桥在血管内治疗时代仍然有益吗?

Harshit Shah, S. Dighe, A. Mowla
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While the efficacy of IV tPA in AIS has been well validated, recently and in the era of effective EVT, its use in AIS with large vessel occlusion (LVO) has been debated. We are at a critical juncture in the ever evolving and exciting field of AIS care, the question on every neurologist’s mind remains whether to bypass IV tPA for EVT in AIS with LVO. Is it the end of the road for IV tPA in AIS with LVO? It has been largely recognized that IV tPA has a low rate of recanalization in AIS with LVO. In a computed tomography (CT) angiogram-based retrospective study, only 21% of the AIS patients with LVO who received IV tPA within 4.5 h of symptom onset achieved complete recanalization [10]. The same study noted much lower rates of recanalization in the case of proximal internal carotid artery and basilar artery occlusions, approximately 4% [9]. Rai et al concluded that administration of IV tPA before EVT for large vessel strokes single handedly increased the total length of hospital stay and the health care costs [11]. It is well known that early recanalization of an occluded intracranial large vessel leads to better functional outcome. Combination therapy increases the door to groin puncture time of EVT that may lead to delayed recanalization time and subsequently worse functional outcomes [12]. Furthermore, the results of the recently published SKIP trial [13], comparing EVT with versus without IV tPA in AIS with internal carotid artery (ICA) and M1 occlusions, showed a lower rate of intracranial hemorrhage in the EVT only group (34% vs. 50%, P = 0.02). There is also a concern that IV tPA administration might fragment a blood clot targeted for extraction and potentially propagate the fragments downstream, making it non-amenable to EVT [14]. Kamal et al [15] also reported the possibility of recurrent AIS early after IV tPA administration due to disintegration of a pre-existing intracardiac, valvular or aortic thrombus and subsequent systemic embolization. Since health care providers usually think of intracranial hemorrhage as the cause of neurological deterioration during or shortly after IV thrombolysis (IVT), this might cause a delay in the timely diagnosis of recurrent AIS and subsequently EVT in the case of large vessel stroke. Despite the concerns associated with IV tPA administration before EVT in large vessel strokes, it continues to remain as the standard of care. Current American Heart Association/American Stroke Association (AHA/ASA) guidelines set against withholding IV tPA administration in eligible patients regardless of the LVO status [16]. The Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaborative group performed a pooled data analysis of the five landmark LVO stroke trials and showed that patients who underwent EVT after IV tPA administration had better functional outcomes and less mortality [9]. In a prospective observational study, Ferrigno et al [17] showed that IV tPA plus EVT group had higher chance of having a favorable outcome compared to EVT only group (35% vs. 22%, P = 0.007) along with lower rate of mortality at 3 months (32% vs. 14%, P < 0.0001) in the case of anterior circulation large vessel strokes. In addition, a post-hoc analysis of the ASTER trial [18], which included 381 patients, showed that 90-day mortality rate in the IV tPA plus EVT group was lower compared to EVT alone (fully-adjusted risk ratio: 0.59; 95% confidence interval (CI): 0.39 0.88). 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Rai et al concluded that administration of IV tPA before EVT for large vessel strokes single handedly increased the total length of hospital stay and the health care costs [11]. It is well known that early recanalization of an occluded intracranial large vessel leads to better functional outcome. Combination therapy increases the door to groin puncture time of EVT that may lead to delayed recanalization time and subsequently worse functional outcomes [12]. Furthermore, the results of the recently published SKIP trial [13], comparing EVT with versus without IV tPA in AIS with internal carotid artery (ICA) and M1 occlusions, showed a lower rate of intracranial hemorrhage in the EVT only group (34% vs. 50%, P = 0.02). There is also a concern that IV tPA administration might fragment a blood clot targeted for extraction and potentially propagate the fragments downstream, making it non-amenable to EVT [14]. Kamal et al [15] also reported the possibility of recurrent AIS early after IV tPA administration due to disintegration of a pre-existing intracardiac, valvular or aortic thrombus and subsequent systemic embolization. Since health care providers usually think of intracranial hemorrhage as the cause of neurological deterioration during or shortly after IV thrombolysis (IVT), this might cause a delay in the timely diagnosis of recurrent AIS and subsequently EVT in the case of large vessel stroke. Despite the concerns associated with IV tPA administration before EVT in large vessel strokes, it continues to remain as the standard of care. Current American Heart Association/American Stroke Association (AHA/ASA) guidelines set against withholding IV tPA administration in eligible patients regardless of the LVO status [16]. The Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaborative group performed a pooled data analysis of the five landmark LVO stroke trials and showed that patients who underwent EVT after IV tPA administration had better functional outcomes and less mortality [9]. In a prospective observational study, Ferrigno et al [17] showed that IV tPA plus EVT group had higher chance of having a favorable outcome compared to EVT only group (35% vs. 22%, P = 0.007) along with lower rate of mortality at 3 months (32% vs. 14%, P < 0.0001) in the case of anterior circulation large vessel strokes. In addition, a post-hoc analysis of the ASTER trial [18], which included 381 patients, showed that 90-day mortality rate in the IV tPA plus EVT group was lower compared to EVT alone (fully-adjusted risk ratio: 0.59; 95% confidence interval (CI): 0.39 0.88). 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引用次数: 0

摘要

2020年是具有里程碑意义的美国国家神经疾病和中风研究所(NINDS)试验的50周年纪念,该试验使静脉注射组织型纤溶酶原激活剂(IV tPA)成为迄今为止唯一获得美国食品和药物管理局(FDA)批准的急性缺血性卒中(AIS)治疗方法[1]。多年来,静脉注射tPA已变得更加安全且普遍[2-8]。2020年也是五项大型随机临床试验(RCTs)的五周年纪念日,它们通过认可在大血管卒中中同时使用静脉tPA和血管内治疗(EVT)与支架回收器相比单独使用静脉tPA的益处,彻底改变了急性卒中的护理[9]。经证实,无论是否采用静脉tPA,采用支架置换器的EVT均可改善大血管卒中患者的整体功能结局并降低死亡率[9]。虽然静脉tPA在AIS中的疗效已经得到了很好的验证,但最近在有效EVT的时代,它在大血管闭塞(LVO)的AIS中的应用一直存在争议。我们正处于不断发展和令人兴奋的AIS护理领域的关键时刻,每个神经科医生心中的问题仍然是是否在患有LVO的AIS患者中绕过静脉tPA进行EVT。这是LVO AIS患者静脉tPA治疗的终点吗?人们普遍认为,静脉tPA在合并LVO的AIS中具有较低的再通率。在一项基于CT血管造影的回顾性研究中,在症状出现后4.5小时内接受静脉tPA治疗的伴有LVO的AIS患者中,只有21%的患者实现了完全再通[10]。同一项研究指出,近段颈内动脉和基底动脉闭塞的再通率要低得多,约为4%[9]。Rai等人得出结论,大血管卒中EVT前单独给予静脉注射tPA会增加总住院时间和医疗费用[11]。众所周知,颅内大血管闭塞的早期再通可以带来更好的功能结果。联合治疗增加了EVT到腹股沟穿刺的时间,可能导致再通时间延迟,从而导致更差的功能预后[12]。此外,最近发表的SKIP试验[13]的结果显示,在合并颈内动脉(ICA)和M1闭塞的AIS患者中,EVT组颅内出血发生率较低(34% vs. 50%, P = 0.02)。还有一种担忧是,静脉注射tPA可能会使用于提取的血凝块破碎,并可能将碎片向下游传播,使其不适合EVT[14]。Kamal等[15]也报道了静脉注射tPA后早期AIS复发的可能性,这是由于先前存在的心内、瓣膜或主动脉血栓的解体以及随后的全身栓塞。由于医疗保健提供者通常认为颅内出血是静脉溶栓(IVT)期间或之后不久神经功能恶化的原因,这可能会导致大血管卒中时复发性AIS和随后的EVT的及时诊断延迟。尽管在大血管卒中EVT前静脉注射tPA存在问题,但它仍然是标准的治疗方法。目前美国心脏协会/美国卒中协会(AHA/ASA)的指南反对在符合条件的患者中不给予静脉tPA治疗,无论LVO状态如何[16]。HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials)合作小组对5项具有里程碑意义的LVO卒中试验进行了汇总数据分析,结果显示,静脉注射tPA后接受EVT的患者具有更好的功能结局和更低的死亡率[9]。在一项前瞻性观察性研究中,Ferrigno等[17]表明,在前循环大血管卒中的病例中,静脉tPA + EVT组较单纯EVT组有更高的预后机会(35% vs 22%, P = 0.007),且3个月死亡率较低(32% vs. 14%, P < 0.0001)。此外,一项包括381例患者的ASTER试验的事后分析[18]显示,静脉tPA加EVT组的90天死亡率低于单纯EVT组(完全调整风险比:0.59;95%置信区间(CI): 0.39 0.88)。这两项研究都显示了在脑梗死(TICI) 2b级中实现溶栓的更好机会的趋势。论文提交于2020年6月8日,接受于2020年6月15日
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Large Vessel Strokes: Is Bridging With Intravenous Thrombolysis Still Beneficial in the Era of Endovascular Treatment?
The year 2020 marks the silver jubilee of the landmark National Institute of Neurological Disorders and Stroke (NINDS) trial which made intravenous tissue plasminogen activator (IV tPA) the only Food and Drug Administration (FDA)-approved treatment for acute ischemic stroke (AIS) management thus far [1]. Over the years, the use of IV tPA has become safer and ubiquitous [2-8]. 2020 also marks the fifth anniversary of the five large randomized clinical trials (RCTs) which revolutionized acute stroke care by endorsing the benefits of concomitant use of IV tPA and endovascular treatment (EVT) with stent retrievers over IV tPA alone in large vessel strokes [9]. EVT with stent retrievers have demonstrated to improve the overall functional outcome and reduce mortality in large vessel strokes, with or without IV tPA [9]. While the efficacy of IV tPA in AIS has been well validated, recently and in the era of effective EVT, its use in AIS with large vessel occlusion (LVO) has been debated. We are at a critical juncture in the ever evolving and exciting field of AIS care, the question on every neurologist’s mind remains whether to bypass IV tPA for EVT in AIS with LVO. Is it the end of the road for IV tPA in AIS with LVO? It has been largely recognized that IV tPA has a low rate of recanalization in AIS with LVO. In a computed tomography (CT) angiogram-based retrospective study, only 21% of the AIS patients with LVO who received IV tPA within 4.5 h of symptom onset achieved complete recanalization [10]. The same study noted much lower rates of recanalization in the case of proximal internal carotid artery and basilar artery occlusions, approximately 4% [9]. Rai et al concluded that administration of IV tPA before EVT for large vessel strokes single handedly increased the total length of hospital stay and the health care costs [11]. It is well known that early recanalization of an occluded intracranial large vessel leads to better functional outcome. Combination therapy increases the door to groin puncture time of EVT that may lead to delayed recanalization time and subsequently worse functional outcomes [12]. Furthermore, the results of the recently published SKIP trial [13], comparing EVT with versus without IV tPA in AIS with internal carotid artery (ICA) and M1 occlusions, showed a lower rate of intracranial hemorrhage in the EVT only group (34% vs. 50%, P = 0.02). There is also a concern that IV tPA administration might fragment a blood clot targeted for extraction and potentially propagate the fragments downstream, making it non-amenable to EVT [14]. Kamal et al [15] also reported the possibility of recurrent AIS early after IV tPA administration due to disintegration of a pre-existing intracardiac, valvular or aortic thrombus and subsequent systemic embolization. Since health care providers usually think of intracranial hemorrhage as the cause of neurological deterioration during or shortly after IV thrombolysis (IVT), this might cause a delay in the timely diagnosis of recurrent AIS and subsequently EVT in the case of large vessel stroke. Despite the concerns associated with IV tPA administration before EVT in large vessel strokes, it continues to remain as the standard of care. Current American Heart Association/American Stroke Association (AHA/ASA) guidelines set against withholding IV tPA administration in eligible patients regardless of the LVO status [16]. The Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaborative group performed a pooled data analysis of the five landmark LVO stroke trials and showed that patients who underwent EVT after IV tPA administration had better functional outcomes and less mortality [9]. In a prospective observational study, Ferrigno et al [17] showed that IV tPA plus EVT group had higher chance of having a favorable outcome compared to EVT only group (35% vs. 22%, P = 0.007) along with lower rate of mortality at 3 months (32% vs. 14%, P < 0.0001) in the case of anterior circulation large vessel strokes. In addition, a post-hoc analysis of the ASTER trial [18], which included 381 patients, showed that 90-day mortality rate in the IV tPA plus EVT group was lower compared to EVT alone (fully-adjusted risk ratio: 0.59; 95% confidence interval (CI): 0.39 0.88). Both studies showed a trend towards better chance of achieving thrombolysis in cerebral infarction (TICI) scale 2b 3 for Manuscript submitted June 8, 2020, accepted June 15, 2020 Published online August 12, 2020
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