超时间窗进展性前循环大动脉闭塞患者急诊血管内治疗效果分析

目的分析超时间窗前循环进展性大动脉闭塞急诊血管内治疗的安全性和效果。方法回顾性连续纳入2015年12月至2018年3月福建省漳州市医院脑血管病介入科行急诊血管内治疗的前循环大动脉闭塞患者177例,经头部CT或MRI证实为前循环大血管缺血性卒中,并排除了颅内出血。根据发病至穿刺时间的不同,将177例患者分为两组:(1)超时间窗组,即发病至血管内治疗时间>6~72 h,且病情进展;(2)时间窗内组,即发病至血管内治疗时间≤6 h。超时间窗患者通过通过多模式MR进行选择。记录两组患者的基线及临床资料,即年龄、性别、吸烟、高血压病、糖尿病、高脂血症、心房颤动、短暂性脑缺血发作、术前美国国立卫生研究院卒中量表(NIHSS)评分、静脉溶栓、CT致密征、替罗非班运用比例、急性卒中Org 10172治疗试验(TOAST)分型、血管堵塞部位、良好侧支循环比例、发病至股动脉穿刺时间等。比较两组患者术后90 d良好预后改良Rankin量表(mRS)评分≤2分]率、症状性颅内出血发生率及90 d病死率。结果(1)超时间窗组患者年龄、NIHSS评分、心房颤动比例均低于时间窗内组(59±12)岁比(65±10)岁,t=2.849;14(10,16)分比16(14,20)分,Z=3.893;15.2%(5/33)比48.6%(70/144),χ^2=12.309],发病至手术时间、吸烟比例、短暂性脑缺血发作比例及高脂血症比例均高于时间窗内组26.2(11.9,38.8)h比3.2(2.0,4.2)h,Z=8.959;57.6%(19/33)比33.3%(48/144),χ^2=6.707;6.1%(2/33)比0,χ^2=4.236;36.4%(12/33)比19.4%(28/144),χ^2=4.394],组间差异均有统计学意义(均P<0.05);两组性别、高血压病、糖尿病比例的差异均无统计学意义(均P>0.05)。(2)时间窗内组静脉溶栓、CT致密征比例均高于超时间窗组37.5%(54/144)比3.0%(1/33),χ^2=14.894;52.8%(76/144)比24.2%(8/33),χ^2=8.767],替罗非班、血流代偿>2级比例均低于超时间窗组34.0%(49/144)比84.8%(28/33),χ^2=28.212;22.2%(32/144)比48.5%(16/33),χ^2=9.369],组间差异均有统计学意义(均P<0.05)。两组卒中TOAST分型的差异有统计学意义(χ^2=27.168,P<0.01)。两组血管堵塞部位的差异无统计学意义(P>0.05)。(3)两组患者血管成功再通率、症状性出血率、异位栓塞率的差异均无统计学意义(均P>0.05)。时间窗内组mRS评分≤2分比例低于超时间窗组59.0%(85/144)比84.8%(28/33),χ^2=7.754],病死率高于超时间窗组18.8%(27/144)比3.0%(1/33),χ^2=4.982],组间差异均有统计学意义(均P<0.05)。结论通过多模式MR选择合适的超时间窗进展性前循环脑大动脉闭塞的患者进行急诊血管内治疗是安全可行的,该结果有待进一步验证。

Analysis of the effect of endovascular treatment out of time window for progressing ischemic stroke caused by acute large-vessel occlusion of anterior circulation

Objective To analyze the safety and feasibility of endovascular treatment for the progressive ischemic stroke caused by acute large-vessel occlusion of anterior circulation beyond the optimal time-window.Methods A total of 177 patients who were large-vessel occlusion of the anterior circulation and not intracranial hemorrhage confirmed by computed tomography(CT)or magnetic resonance imaging(MRI),were enrolled retrospectively in the Department of Cerebrovascular Intervention Center of Zhangzhou Hospital in Fujian Province from December 2015 to March 2018.All patients had accepted emergency endovascular treatment.According to the time from onset to mechanical thrombectomy,these patients were divided into the beyond time-window group that was beyond 6 hours among 6 to 72 hours,and the within time-window group that was less than 6 hours.The patients in the beyond time-window group were selected using multimodal magnetic resonance imaging.Demographic characteristics such as age,sex,smoking history,hypertension,diabetes mellitus,hyperlipidemia,atrial fibrillation,transient ischemic attack(TIA),baseline modified Rankin Scale(mRS),the United States National Institutes of Health Stroke Scale(NIHSS)score,intravenous thrombolysis,CT dense sign,tirofiban usage,trial of org 10172 in acute stroke treatment(TOAST)classification,location of arterial occlusion,good collateral grade(ACG),time from onset to puncture were recorded and analyzed.The rate of the favorable progressive outcome that defined mRS was less than 2 at 90 days,and the rate of symptomatic intracranial hemorrhage and mortality at 90 days were compared in the two groups.Results(1)The beyond time-window group were significantly lower than the within time-window group in the age(59±12 years vs.65±10 years,t=2.849,P<0.05),baseline NIHSS score(1410,16]vs.1614,20],Z=3.893,P<0.01),and the rate of atrial fibrillation(15.2%5/33]vs.48.6%70/144],χ^2=12.309,P<0.01),while were significantly higher in the time from onset to puncture(26.211.9,38.8]h vs.3.22.0,4.2]h,Z=8.959,P<0.01),the proportion of smoking(57.6%19/33]vs.33.3%48/133],χ^2=6.707,P<0.05),the rate of TIA(6.1%2/33]vs.0,χ^2=4.236,P<0.05),and hyperlipidemia(36.4%12/33]vs.19.4%28/144],χ^2=4.394,P<0.05),respectively.There was no significant difference in the proportion of gender,hypertension,and diabetes mellitus between the two groups(all P>0.05).(2)The within time-window group were significantly higher than the beyond time-window group in the rate of intravenous thrombolysis(37.5%54/144]vs.3.0%1/33],χ^2=14.864,P<0.01)and CT dense sign(52.8%76/144]vs.24.2%8/33],χ^2=8.767,P<0.01),while were significantly lower in the rate of tirofiban usage(34.0%49/144]vs.84.8%28/33],χ^2=28.212,P<0.01),the proportion of ACG score with more than 2(22.2%32/144]vs.48.5%16/33],χ^2=9.369,P<0.01),retrospectively.There was significant difference between the two groups in the TOAST classification(χ^2=27.168,P<0.01).There was no significant difference between the two groups in the location of arterial occlusion(P>0.05).(3)The within time-window group was lower than the beyond time-window group in the rate favorable progressive outcome(59.0%85/144]vs.84.8%28/33],χ^2=7.754,P<0.01),while was higher in the rate mortality(18.8%27/144]vs.3.0%1/33],χ^2=4.982,P<0.05).There was no significance between groups in the rate of successful recanalization,symptomatic intracranial hemorrhage,ectopic thrombus(all P>0.05).Conclusion Endovascular therapy out of time window was safe and feasible in patients who were strictly selected with acute progressing ischemic stroke caused by cerebral artery occlusion of anterior circulation using multimodal magnetic resonance imaging,which needs further verification.