侧支状态对急性前循环大血管闭塞性脑梗死无效再通的影响

目的 评估急性前循环大血管闭塞性脑梗死接受血管内治疗患者的侧支循环状态对3个月的临床结局的影响，分析无效再通的危险因素。方法 本研究基于急性缺血性卒中（acute ischemic stroke，AIS）再通后重症监护的登记研究（registration study for critical care of acute ischemic stroke after recanalization，RESCUE-RE）数据库，根据美国介入和治疗神经放射学协会/介入放射学协会制定的基于DSA的侧支分级方法，将符合入组标准的血管内血栓切除术（endovascular thrombectomy，EVT）成功再通的AIS患者分为侧支不良（0～1级）和侧支良好（2～4级）两组。无效再通定义为血管内治疗术后成功再通（mTICI分级≥2b级），但患者术后90 d功能预后不良（mRS评分≥3分）。比较侧支不良组和侧支良好组基线特点和预后结局的差异，采用多因素logistic回归分析侧支状态对无效再通的影响。结果 本研究共纳入748例EVT后成功再通的急性前循环大血管闭塞性脑梗死患者，其中侧支不良组323例（43.2%），374例（50.0%）发生无效再通。一般资料显示，侧支不良组合并心房颤动（27.6%?vs.?18.4%，P=0.003）、糖尿病病史（26.9%?vs.?16.0%，P<0.001）、90?d预后不良的比例更高（55.4%?vs.?45.9%，P=0.010）。多因素回归分析显示侧支不良（OR?1.75，95%CI?1.19～2.57，P=0.004）、高龄（OR?1.03，95%CI?1.02～1.05，P<0.001）、基线NIHSS评分（OR?1.09，95%CI?1.05～1.14，P<0.001）、低ASPECTS评分（OR?0.79，95%CI?0.68～0.92，P=0.003）与全身麻醉（OR?2.58，95%CI?1.71～3.89，P<0.001）是无效再通的独立危险因素。结论 侧支不良与急性前循环大血管闭塞性脑梗死接受血管内治疗后无效再通有关。在临床实践中，应该考虑将侧支状态作为手术适应证的评价因素。

Effect of Collateral Status on Futile Recanalization after Endovascular Treatment in Patients with Acute Anterior Circulation Large Vessel Occlusive Cerebral Infarction

Objective  To assess the impact of collateral circulation status on clinical outcomes at 3 months after endovascular treatment in patients with acute anterior circulation large vessel occlusive cerebral infarction, and analyze risk factors for futile recanalization. Methods  This study was based on the Registration Study for Critical Care of Acute Ischemic Stroke after Recanalization (RESCUE-RE) database. The pretreatment collateral status was evaluated using the DSA-based American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral flow grading system, then patients were divided into two groups: poor (grade 0-1) and good (grade 2-4) collateral circulation groups. Futile recanalization was defined as poor outcome (mRS score of 3-6) at 90 days after surgery despite successful angiographic recanalization (mTICI grade 2b or 3) . Multivariate logistic regression analysis was performed to identify predictors of futile recanalization. Results  Of 748 patients included in the study, 323 (43.2%) had poor collateral circulation, and 374 (50.0%) had futile recanalization. Univariate comparisons showed a higher proportion of atrial fibrillation history (27.6%?vs.?18.4%, P=0.003) , diabetes mellitus (26.9%?vs.?16.0%, P<0.001) and 90-day poor outcome (55.4%?vs.?45.9%, P=0.010) in the poor collateral circulation group. Multivariate logistic regression analysis showed that poor collateral status (OR 1.75, 95%CI 1.19-2.57, P=0.004) , advanced age (OR 1.03, 95%CI 1.02-1.05, P<0.001) , high baseline NIHSS score (OR 1.09, 95%CI 1.05-1.14, P<0.001) , low ASPECTS score (OR 0.79, 95%CI 0.68-0.92, P=0.003) , and general anesthesia (OR 2.58, 95%CI 1.71-3.89, P<0.001) were independent risk factors for futile recanalization. Conclusions  Poor collateral status is associated with futile recanalization after endovascular treatment in acute anterior circulation large vessel occlusive cerebral infarction. In clinical practice, collateral status should be taken as an evaluation factor for thrombectomy in acute ischemic stroke.