急性缺血性卒中血管内治疗麻醉方式之选

<正>1研究介绍1.1研究背景麻醉支持通常被应用于大血管闭塞所致急性缺血性卒中患者的动脉内治疗(intra-arterialtreatment,IAT)中,其目的是减少患者运动、增加患者舒适度、促进快速治疗并降低并发症的风险。在IAT术中有几种不同的麻醉方式选择:全身麻醉(general anesthesia,GA)、镇静麻醉(conscious sedation,CS)或仅在穿刺部位     

Timing of Direct Oral Anticoagulants for Hemorrhagic Transformation After Endovascular Treatment in Acute Ischemic Stroke

ObjectivesThe purpose of this study is to investigate the relationship between the timing of starting direct oral anticoagulants (DOACs) and subsequent clinical outcomes in patients with hemorrhagic transformation (HT) after endovascular treatment (EVT).Materials and methodsThe subjects were patients with acute cardioembolic stroke who underwent EVT and received DOACs in our department from February 2017 to August 2021. Based on CT at 24 h after EVT, the patients were classified using European Collaborative Acute Stroke Study criteria into three groups: no HT, hemorrhagic infarction (HI), and parenchymal hematoma (PH). Outcomes were assessed for incidence of recurrent ischemic stroke (RIS), new intracranial hemorrhage (ICH), and worsened HT associated with DOACs.ResultsOf 111 patients, 29 (26.1%) had HT, including 16 (14.4%) with HI and 13 (11.7%) with PH. The start of DOACs was significantly delayed in the PH group (no HT: 1.0 (1.0–3.0) days vs. HI: 3.0 (2.0–5.0) days vs. PH: 7.0 (7.0–10.0) days, P < 0.01). The incidence of RIS did not differ significantly among the three groups, but tended to be higher in the PH group (no HT: 3.7% vs. HI: 6.3% vs. PH: 15.4%, p = 0.12). There were no cases of new symptomatic ICH. New asymptomatic ICH occurred in 2 cases in the no HT group. Worsened HT after initiation of DOACs did not occur in the HI or PH group.ConclusionsThe timing of starting DOACs in patients with HT after EVT may be divided by subtypes of HI and PH. In patients with HI, early initiation of DOACs can prevent RIS and is unlikely to cause new ICH or worsened HI. In PH, initiation of DOACs within 14 days appears to be safe and does not exacerbate PH. The later the start of DOACs, the higher the frequency of RIS, so early initiation of DOACs is desirable.     

Subacute Recanalization and Reocclusion in Patients with Acute Ischemic Stroke Following Endovascular Treatment

Objective  To determine the rate of subacute recanalization and reocclusion and its effect on clinical outcomes among patients with ischemic stroke treated with endovascular treatment. Subacute recanalization and reocclusion occurring hours after completion of the intravenous or intra-arterial thrombolysis for acute ischemic stroke has been reported in anecdotal cases. Methods  We performed cerebral angiography at 24 h to determine the status of occlusion after endovascular treatment (compared with immediate post-procedure angiogram) in a series of patients with ischemic stroke treated with endovascular treatment. Clinical and radiological evaluations were performed before and 24 h, and prior to discharge or 1–3 months after treatment. We performed multivariate analysis to evaluate the effect of subacute recanalization on clinical outcome graded using modified Rankin scale (mRS). Favorable outcome was defined by mRS of 0–2. Results  A total of 56 patients (mean age 66 ± 14 years; 22 were men) were analyzed. Subacute recanalization was observed in 16 (29%) patients and consisted of additional recanalization in 8 patients with early recanalization. Subacute recanalization was associated with a trend toward a higher rate of favorable outcome (Wald chi-square 3.3, P = 0.19) after adjusting for other covariates. Subacute recanalization was not associated with either neurological deterioration or symptomatic intracranial hemorrhage. Subacute reocclusion was observed in 5 (9%) patients. Subacute reocclusion was associated with a trend toward higher rate of neurological deterioration within 24 h (Wald chi-square 2.1, P = 0.15) after adjusting for other covariates. Conclusion  We found that new or additional recanalization occurs in one-fourth of the patients within 24 h of endovascular treatment and is not associated with any adverse consequences. Subacute reocclusion occurs infrequently after endovascular treatment.     

Predictors of Futile Recanalization After Endovascular Treatment in Patients with Acute Ischemic Stroke in a Multicenter Registry Study

BackgroundFutile recanalization, defined as the early recanalization of an occluded artery failing to improve neurological outcome, remains a persistent concern in the endovascular treatment of acute ischemic stroke. We investigated the occurrence and predictors of futile recanalization after endovascular treatment in a nationwide multicenter stroke registry study.MethodsThe subjects consisted of eligible patients from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment registry study (2015–2017). Subjects with acute anterior large vessel occlusion who achieved successful angiographic recanalization (defined as modified Thrombolysis in Cerebral Infarction grades 2b or 3) by endovascular treatment were dichotomized into the futile-recanalization group (with a modified Rankin Scale score of 3–6) and the favorable-recanalization group (with a modified Rankin Scale score of 0–2) according to 90-day functional independence. Logistic regression analysis was performed to investigate predictors of futile recanalization.ResultsFutile recanalization was observed in 200 (49.6%) out of 403 patients. On multivariate analysis, older age (>74 vs. ≤74; odds ratio (OR), 2.41; 95% confidence interval (CI), 1.31–4.44; P=0.005), high baseline National Institutes of Health Stroke Scale score (>21 vs. ≤13; OR, 2.52; 95% CI, 1.21–5.28; P=0.014), delayed puncture to recanalization time (>80 vs. ≤80 min; OR, 2.75; 95% CI, 1.67–4.51; P=0.000), and the use of general anesthesia (OR, 1.90; 95% CI, 1.15–3.14; P=0.012) were positively associated with futile recanalization after mechanical thrombectomy.ConclusionsThe incidence of futile recanalization is common following endovascular treatment among Asian patients with anterior circulation occlusion. Advanced age, higher baseline National Institutes of Health Stroke Scale score, delayed puncture to reperfusion, and the use of general anesthesia are associated with lower functional independence 90 days post-treatment despite successful recanalization.     

急性缺血性卒中血管内治疗中国指南2018

正引言卒中是导致人类致残和致死的主要疾病之一,急性缺血性卒中(acute ischemic stroke,AIS)约占全部卒中的80%。AIS治疗的关键在于尽早开通阻塞血管,挽救缺血半暗带。目前被证实有效的AIS早期血管再通的治疗方法主要是静脉重组组织型纤溶酶原激活剂(recombinant tissue plasminogen activator,rt-PA)溶栓~([1-3])。静脉溶栓随机对照研究的汇总分析进一步证实发病4.5 h内静脉rt-PA溶栓有明确获益,而且溶栓时间越早,获益越大~([4])。由     

院前预通知流程改善急性缺血性卒中患者血管内治疗的预后

目的 血管内治疗的效益具有时间依赖性,120急救系统（emergency medical service,EMS）通过院前预通知卒中中心可以缩短起病到治疗的时间。本研究旨在观察EMS院前预通知流程（prehospitalnotification procedure,PNP）能否减少急性大血管闭塞（large vessel occlusion,LVO）患者血管内治疗的院内延误时间,及其对预后的影响。方法 回顾性分析连续收集的行血管内治疗的LVO患者临床和影像资料。通过EMS入院并提前通知溶栓小组为PNP组,通过EMS入院但未通知溶栓小组为Non-PNP组,通过其他方式入院为Non-EMS组。预后良好定义为3个月改良Rankin量表（modified Rankin Scale,mRS）评分≤2分。比较PNP组、Non-PNP组和Non-EMS组入院到再灌注时间（door to reperfusion time,DRT）和临床结局的差异。结果 共纳入110例患者[平均年龄（68±12）岁,女性49例,占44.5%],91例（82.7%）通过EMS入院,其中21例（19.1%）为PNP组。与Non-PNP组相比,PNP组的DRT更短（145 min vs 180 mi n,t =-2.065,P =0.043）;与Non-EMS组相比,PNP组的DRT有更短的趋势（145 min vs 194 mi n,t =2.260,P =0.055）,而Non-PNP组与Non-EMS组的DRT比较差异无统计学意义（180 min vs 194 mi n,t =0.663,P =0.510）。二元Logistic回归模型显示,校正基线美国国立卫生研究院卒中量表（National Institutes of Health StrokeScale,NIHSS）、基线收缩压、高血压病史后,PNP是预后良好的独立影响因素[优势比（odds ratio,OR）3.653,95%可信区间（confi dence i nterval ,CI ）1.085～12.301,P =0.037）。若将DRT纳入二元Logistic回归模型,DRT是预后良好的独立影响因素（OR 0.981,95%CI 0.968～0.994,P =0.005）。结论 PNP可以缩短急性缺血性卒中LVO患者血管内治疗的DRT,并改善预后。     

Outcome of a Real-World Cohort of Patients Subjected to Endovascular Treatment for Acute Ischemic Stroke

ObjectivesIschemic stroke is a leading cause of death and disability worldwide. For patients with large vessel occlusion stroke, endovascular treatment is now the most effective treatment. We aimed to assess the outcome of patients undergoing endovascular treatment for large vessel occlusion stroke in a real-world setting, comparing our results with data from randomized clinical trials, and recognizing the factors associated with prognosis.Materials and methodsWe retrospectively collected data on endovascular procedures performed in one comprehensive stroke center in consecutive patients presenting with large vessel occlusion stroke from January 2017 to January 2020. Data on baseline clinical, imaging, and treatment-related characteristics were recorded. Selection of patients and treatment approach was not standardized but followed current guidelines for ischemic stroke. Functional outcome was evaluated 3 months after endovascular treatment. Clinical, imaging and treatment-related variables associated to outcome were evaluated with univariate and multivariable analyses.ResultsFour hundred twelve patients were included in our study. Three-month functional independence was achieved in 50.5% of patients (50.3% in the anterior stroke and 52.1% in the posterior stroke subgroup). Successful arterial reperfusion was observed in 84.3% of patients. Age (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.20–0.87, p = 0.020]), severe stroke at onset (OR 0.40, 95%CI 0.19–0.83), procedure related complications (OR 0.45, 95%CI 0.20–0.99), and good collateral circulation (OR 2.69, 95%CI 1.17–6.16) were associated with 3-month functional independence in multivariable model.ConclusionsOur real-world outcome results are in line with data from large randomized clinical trials on endovascular treatment for large vessel occlusion stroke.     

Improving Prognostic Evaluation by 4D CTA for Endovascular Treatment in Acute Ischemic Stroke Patients: A Preliminary Study

Objective: We aim to use 4D CTA with a comprehensive and objective scoring system to assess collateral circulation, and explore the value of prognosis prediction in endovascular treated patients. Methods: Thirty-four patients with unilateral anterior circulation large vessels occlusion were reviewed in this study retrospectively. Single-phase CTA (sCTA) and 4D CTA acquired by CT perfusion scanning were analyzed for collateral circulation assessment. The collateral vessels were scored 0-4 according to modified collateral circulation scoring based on 4D CTA. Zero to two points indicated poor collateral circulation; 3-4 points indicated good collateral circulation. Good prognosis was defined as modified Rankin scale score of 0-2. Logistic regression was used to analyze the relationship between collateral circulation and prognosis. Results: The mean age was 71.1 ± 11.5 years old. Collateral circulation on 4D CTA was an independent factor for predicting the prognosis (odds ratio = .101; 95% confidence interval: [.101-.924]; P = .042), but sCTA could not predict prognosis (P = .214). 4D CTA collateral circulation scoring had a good predicting efficacy on clinical prognosis (Area Under Curve (AUC) = .936; 95% confidence interval: [.751-.992], P < .005). Patients with good collaterals (4D CTA scores of 3-4) could obtain benefit from endovascular treatment (P = .029) compared with patients with poor collaterals (P = 1.000). Conclusions: 4D CTA could be applied to effectively evaluate cerebral collateral status. The accurate assessment of collateral circulation based on 4D CTA would be helpful to make medical decisions, especially for those patients who would undergo endovascular interventional treatment.     

急性缺血性卒中血管内治疗术后血清前白蛋白水平与预后的相关性研究

目的     探讨急性缺血性卒中血管内治疗术后低血清前白蛋白血症的发生情况及其与预后的相关性。     

急性缺血性卒中血管内治疗的术式转换和补救

急性缺血性卒中血管内治疗取得良好预后的基础是及时恢复缺血区脑组织的有效灌注，
即达到前向血流mTICI 2b/3级。当使用取栓支架取栓、抽吸导管取栓、球囊/支架成形术等方法开通
闭塞血管过程中，未能达到缺血区有效灌注时，应仔细分析原因，再度审视手术路径、病变性质、闭
塞血管特点、血栓性状及负荷量等因素，避免不必要的重复操作，减少手术延误，适时转换手术方
式，更换手术材料，或辅以药物等可行的补救措施，尽快恢复缺血区有效灌注。     

Thrombolysis Following Heparin Reversal With Protamine Sulfate in Acute Ischemic Stroke: Case Series and Literature Review

IntroductionAdministering intravenous IV tissue plasminogen activator (tPA) is the recommended standard of care in acute ischemic stroke (AIS), although it is not recommended to administer intravenous thrombolysis with tPA following heparin reversal with protamine sulfate in patients with AIS.MethodsWe describe a case series of three patients and the most comprehensive literature review published to date in this specific subset of AIS patients undergoing thrombolysis following heparin reversal with protamine sulfate. The literature review was based on a scoping review methodology performed on four databases; PubMed, CINAHL, Web of Science, and Cochrane Library. All sources were searched from the inauguration of the database until February 2019. A total of six articles involving eight patients were identified.ResultsThe primary safety outcome of no symptomatic intracranial hemorrhage (sICH) was met in all eleven patients, although only seven cases had a good functional outcome at 3 months.ConclusionsIn appropriately selected AIS patients, coagulopathy correction appears to be safe from an sICH standpoint and may be beneficial. However, given the potential for bias with observational databases, case reports and case series, extreme caution is warranted in applying these results to routine clinical practice.     

A Predictive Model for Functional Outcome in Patients with Acute Ischemic Stroke Undergoing Endovascular Thrombectomy

IntroductionEndovascular thrombectomy (EVT) is a well-established treatment of acute ischemic stroke. Variability in outcomes among thrombectomy patients results in a need for patient centered approaches to recovery. Identifying key factors that are associated with outcomes can help prognosticate and direct resources for continued improvement post-treatment. Thus, we developed a comprehensive predictive model of short-term outcomes post-thrombectomy.MethodsThis is a retrospective chart review of adult patients who underwent EVT at our institution over the last four years. Primary outcome was dichotomized 90-day mRS (mRS 0–2 v mRS 3–6). Bivariate analyses were conducted, followed by logistic regression modelling via a backward-elimination approach to identify the best fit predictive model.Results326 thrombectomies were performed; 230 cases were included in the model. In the final predictive model, adjusting for age, gender, race, diabetes, and presenting NIHSS, pre-admission mRS = 0–2 (OR 18.1; 95% 3.44–95.48; p < 0.001) was the strongest predictor of a good outcome at 90-days. Other independent predictors of good outcomes included being a non-smoker (OR 5.4; 95% CI 1.53–19.00; p = 0.01) and having a post-thrombectomy NIHSS<10 (OR 9.7; 95% CI 3.90–24.27; p < 0.001). A decompressive hemicraniectomy (DHC) was predictive of a poor outcome at 90-days (OR 0.07; 95% CI 0.01–0.72; p = 0.03). This model had a Sensitivity of 79%, a Specificity of 89% and an AUC=0.89.ConclusionOur model identified low pre-admission mRS score, low post-thrombectomy NIHSS, non-smoker status and not requiring a DHC as predictors of good functional outcomes at 90-days. Future works include developing a prognostic scoring system.     

Acute Ischemic Stroke Treatment in Infective Endocarditis: Systematic Review

Background: Ischemic stroke is a frequent neurologic complication of infective endocarditis. This systematic review aims to evaluate the efficacy and safety of thrombectomy in comparison to thrombolysis and to combined treatment in patients with infective endocarditis associated acute ischemic stroke. Methods: A systematic literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The review included case reports, cases series, cross-sectional studies, case control studies, randomized controlled trials or nonrandomized controlled trials, which reported the treatment of endocarditis-related acute ischemic stroke with mechanical thrombectomy, intravenous or intra-arterial thrombolysis in adult patients. Data sources: Scielo, b-on, Pubmed and Cochrane, from inception to April 2019. Reference lists were also checked. We compared the efficacy (independence, neurological improvement) and safety (intracranial bleeding, death) of acute ischemic stroke treatment with thrombolysis, thrombectomy and combined therapy. Results: Through systematic review 37 articles describing 52 patients met criteria. The risk of intracranial hemorrhage was 4.14 times higher in patients treated with intravenous thrombolysis (P = .001) and 4.67 times higher in patients treated with combined treatment (P = .01). There was trend for independence (P = .09) and neurological improvement (P = .07) in favor of thrombectomy, when comparing this group to the group treated with intravenous thrombolysis. Conclusions: With the limitation of the low quality of the available evidence, thrombectomy in infective endocarditis associated stroke appears to be safer than thrombolysis, or combined treatment. These results may be useful to guide clinical decisions, in selected patients.     

Acute Stenting and Concomitant Tirofiban Administration for the Endovascular Treatment of Acute Ischemic Stroke Related to Intracranial Artery Dissections: A Single Center Experience and Systematic Review of the Literature

BackgroundIntracranial artery dissection is an uncommon cause of acute ischemic stroke. Although acute stenting of the dissected arterial segment is a therapeutic option, the associated antiplatelet regimen remains a matter of debate.ObjectivesTo evaluate the efficacy and safety of acute intracranial stenting together with concomitant intravenous administration of tirofiban and to perform a systematic review of the literature.Materials and methodsA single-center, retrospective study of the clinical and radiological records of all patients treated at our center by intracranial stenting in the setting of acute ischemic stroke between January 2010 and December 2020. A systematic review of the literature was conducted according to the PRISMA-P guidelines for relevant publications from January 1976 to December 2020 on intracranial artery dissection treated by stent.ResultsSeven patients with intracranial artery dissections underwent acute stenting with concomitant tirofiban during the study period. Mid-term follow-up showed parent artery patency in 6/7 cases (85.7%). The modified Rankin Score was ≤ 0-2 at 3 months in 5/7 cases (71.4%). The literature review identified 22 patients with intracranial artery dissection treated with acute stenting in association with different antithrombotic therapies. Complete revascularization was obtained in 86.3% of cases with a modified Rankin Score of ≤ 0-2 in 68% of patients at 3-month follow-up.ConclusionsAcute intracranial stenting together with intravenous tirofiban administration could be a therapeutic option in patients with intracranial artery dissection and a small ischemic core.     

急性缺血性卒中血管内治疗的临床效果与效率评价

目的应用卒中预后特异和非特异评估体系以及卫生经济学评估体系,评价急性缺血性卒中血管内治疗的临床效果与效率。方法选择首都医科大学附属北京天坛医院于2015年1-4月收治的符合急性缺血性卒中血管内治疗的患者,分为血管内治疗组和对照组,评价指标包括:(1)特异性指标:入院后14 d神经功能缺损程度卒中量表(National Institute of Health Stroke Scale,NIHSS)评分,90 d后改良Rankin量表(modified Rankin Scale,m RS)评级,90 d及1年内卒中发生率;(2)非特异指标:1年内院内感染、急性心肌梗死、症状性脑出血的发生率;(3)卫生经济学指标:患者1年医疗总费用、总药费,1年内住院次数及累计住院日、累计重症监护病房(Intensive Care Unit,ICU)住院日。结果急性缺血性卒中患者给予血管内治疗预后较对照组在入院后14 d NIHSS评分采用秩和检验比较,血管内治疗组明显优于对照组(P0.01);90 d及1年内卒中发生率采用χ2检验,发现血管内治疗组的90 d卒中再发率(P0.05)及1年内卒中再发率(P0.01)均低于对照组。与对照组相比,血管内治疗组患者1年内院内感染、急性心肌梗死、症状性脑出血采用χ2检验,两组间差异无显著性。入院后90 d m RS评级采用秩和检验,对照组无残疾或轻度(0~1级)、中度(2~3级)、重度残疾(4~5级)及死亡人数分别为3例、15例、23例和4例,血管内治疗组分别为17例、12例、3例和5例,血管内治疗组较对照组明显改善(P0.05)。血管内治疗组在1年内累计医疗花费与对照组比较,差异无显著性,但在1年内住院次数(P0.01)、药费(P0.05)以及ICU住院日(P0.01)较对照组明显下降。结论急性缺血性卒中患者的血管内治疗可以提高患者的预后,在提高医疗质量的同时并没有增加患者的住院费用,可以减少患者的住院次数及药费。     

院内急性缺血性卒中血管内介入治疗延误的影响因素分析

目的 分析院内急性缺血性卒中（acute ischemic stroke,AIS）患者血管内介入治疗延误的影响因素。 方法 回顾性纳入2014年10月-2019年7月于南京医科大学第一附属医院住院期间发生AIS并接受血 管内介入治疗的患者,根据发病至股动脉穿刺时间（onset-to-puncture time,OTP）是否超过120 min,将 患者分为延误组和非延误组。收集两组患者相关临床资料,观察两组预后情况,良好预后定义为 90 d mRS评分≤2分,采用多因素Logistic回归分析研究院内延误的影响因素。 结果 共纳入53例院内卒中患者,平均年龄64.43±12.46岁,男性29例（54.72%）。中位OTP为150 （115～200）min,其中延误组31例,非延误组22例。非延误组良好预后比例高于延误组（63.64% vs 35.48%,P =0.043）。多因素Logistic回归分析显示,发病后立即启动绿色通道（OR 0.061,95%CI 0.007～0.532,P =0.011）及高危科室发病（OR 0.108,95%CI 0.014～0.821;P =0.031）与院内卒中血管 内介入治疗延误呈独立负相关;而家属决策时间延长（OR 1.527,95%CI 1.114～2.094,P =0.008）与院 内卒中血管内介入治疗延误呈独立正相关。 结论 家属决策时间长是院内卒中血管内介入治疗延误的独立危险因素,发病后立即启动绿色通 道及高危科室发病是院内卒中血管内介入治疗延误的独立保护因素。     

院内急性缺血性卒中血管内介入治疗延误的影响因素分析

目的 分析院内急性缺血性卒中（acute ischemic stroke，AIS）患者血管内介入治疗延误的影响因素。
方法 回顾性纳入2014年10月-2019年7月于南京医科大学第一附属医院住院期间发生AIS并接受血
管内介入治疗的患者，根据发病至股动脉穿刺时间（onset-to-puncture time，OTP）是否超过120 min，将
患者分为延误组和非延误组。收集两组患者相关临床资料，观察两组预后情况，良好预后定义为
90 d mRS评分≤2分，采用多因素Logistic回归分析研究院内延误的影响因素。
结果 共纳入53例院内卒中患者，平均年龄64.43±12.46岁，男性29例（54.72%）。中位OTP为150
（115～200）min，其中延误组31例，非延误组22例。非延误组良好预后比例高于延误组（63.64%
vs 35.48%，P =0.043）。多因素Logistic回归分析显示，发病后立即启动绿色通道（OR 0.061，95%CI
0.007～0.532，P =0.011）及高危科室发病（OR 0.108，95%CI 0.014～0.821；P =0.031）与院内卒中血管
内介入治疗延误呈独立负相关；而家属决策时间延长（OR 1.527，95%CI 1.114～2.094，P =0.008）与院
内卒中血管内介入治疗延误呈独立正相关。
结论 家属决策时间长是院内卒中血管内介入治疗延误的独立危险因素，发病后立即启动绿色通
道及高危科室发病是院内卒中血管内介入治疗延误的独立保护因素。