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

doi:10.3969/j.issn.1673-5765.2023.04.011

摘要/Abstract

摘要： 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。

文章导读：

虽然侧支状态对EVT后功能结局具有重要意义，但在临床实践中，尚未将其作为EVT的决策依据。本研究证实了侧支状态不良是无效再通的独立危险因素。未来需要进一步的随机对照试验来评价在EVT前完善侧支循环评估的风险和益处。

关键词: 侧支状态; 大血管闭塞; 脑梗死; 血管内治疗; 无效再通

Abstract: 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.

Key words: Collateral status; Large vessel occlusion; Cerebral infarction; Endovascular treatment; Futile recanalization

魏娜, 刘欣, 聂曦明, 严鸿伊, 温淼, 杨中华, 刘丽萍. 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[J]. 中国卒中杂志, 2023, 18(04): 450-455.

WEI Na, LIU Xin, NIE Ximing, YAN Hongyi, WEN Miao, YANG Zhonghua, LIU Liping.

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

[J]. Chinese Journal of Stroke, 2023, 18(04): 450-455.

参考文献

[1] POWERS W J，RABINSTEIN A A，ACKERSON T，et al. Guidelines for the early management of patients with acute ischemic stroke：2019 update to the 2018 guidelines for the early management of acute ischemic stroke：a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J/OL]. Stroke，2019，50（12）：e344-e418[2022-10-15]. https://doi.org/10.1161/STR.0000000000000211.
[2] POWERS W J，DERDEYN C P，BILLER J，et al. American Heart Association Stroke Council. 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment：a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke，2015，46（10）：3020-3035.
[3] POWERS W J，RABINSTEIN A A，ACKERSON T，et al. American Heart Association Stroke Council. 2018 guidelines for the early management of patients with acute ischemic stroke：a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J/OL]. Stroke，2018，49（3）：e46-e110[2022-10-15]. https://doi.org/10.1161/STR.0000000000000158.
[4] YANG P F，ZHANG Y W，ZHANG L，et al. Endovascular thrombectomy with or without intravenous alteplase in acute stroke[J]. N Engl J Med，2020，21，382（21）：1981-1993.
[5] XU H F，JIA B X，HUO X C，et al. Predictors of futile recanalization after endovascular treatment in patients with acute ischemic stroke in a multicenter registry study[J]. J Stroke Cerebrovasc Dis，2020，29（10）：105067.
[6] HUSSEIN H M，SALEEM M A，QURESHI A I. Rates and predictors of futile recanalization in patients undergoing endovascular treatment in a multicenter clinical trial[J]. Neuroradiology，2018，60（5）：557-563.
[7] LIEBESKIND D S，TOMSICK T A，FOSTER L D，et al. Collaterals at angiography and outcomes in the interventional management of stroke（IMS）III trial[J]. Stroke，2014，45（3）：759-764.
[8] ROMÁN L S，MENON B K，BLASCO J，et al. Imaging features and safety and efficacy of endovascular stroke treatment：a meta-analysis of individual patient-level data[J]. Lancet Neurol，2018，17（10）：895-904.
[9] GOYAL M，DEMCHUK A M，MENON B K，et al. ESCAPE trial investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke[J]. N Engl J Med，2015，372（11）：1019-1030.
[10] MENDELSON S J，PRABHAKARAN S. Diagnosis and management of transient ischemic attack and acute ischemic stroke：a review[J]. JAMA，2021，16，325（11）：1088-1098.
[11] TOMSICK T，BRODERICK J，CARROZELLA J，et al. Revascularization results in the interventional management of stroke II trial[J]. AJNR Am J Neuroradiol，2008 ，29（3）：582-587.
[12] AWADH M，MACDOUGALL N，SANTOSH C，et al. Early recurrent ischemic stroke complicating intravenous thrombolysis for stroke：incidence and association with atrial fibrillation[J]. Stroke，2010，41（9）：1990-1995.
[13] VON KUMMER R，BRODERICK J P，CAMPBELL B C，et al. The Heidelberg bleeding classification：classification of bleeding events after ischemic stroke and reperfusion therapy[J]. Stroke，2015，46（10）：2981-2986.
[14] DENG G，XIAO J，YU H H，et al. Predictors of futile recanalization after endovascular treatment in acute ischemic stroke：a meta-analysis[J]. J Neurointerv Surg，2022，14（9）：881-885.
[15] GUGLIELMI V，LECOUFFE N E，ZINKSTOK S M，et al. MR-CLEAN registry investigators. Collateral circulation and outcome in atherosclerotic versus cardioembolic cerebral large vessel occlusion[J]. Stroke，2019，50（12）：3360-3368.
[16] VAN HORN N，KNIEP H，LEISCHNER H，et al. Predictors of poor clinical outcome despite complete reperfusion in acute ischemic stroke patients[J]. J Neurointerv Surg，2021，13（1）：14-18.
[17] LIEBESKIND D S，JAHAN R，NOGUEIRA R G，et al. Early arrival at the emergency department is associated with better collaterals，smaller established infarcts，and better clinical outcomes with endovascular stroke therapy：SWIFT study[J]. J Neurointerv Surg，2016，8（6）：553-558.
[18] GUGLIELMI V，LECOUFFE N E，ZINKSTOK S M，et al. Collateral circulation and outcome in atherosclerotic versus cardioembolic cerebral large vessel occlusion[J]. Stroke，2019，50（12）：3360-3368.
[19] UNIKEN VENEMA S M，DANKBAAR J W，WOLFF L，et al. Collateral status and recanalization after endovascular treatment for acute ischemic stroke[J/OL]. J Neurointerv Surg，2022：neurintsurg-2021-018545[2022-10-15]. https://doi.org/10.1136/neurintsurg-2021-018545.
[20] BROOCKS G，KEMMLING A，MEYER L，et al. Computed tomography angiography collateral profile is directly linked to early edema progression rate in acute ischemic stroke[J]. Stroke，2019，50（12）：3424-3430.
[21] FLORES A，RUBIERA M，RIBÓ M，et al. Poor collateral circulation assessed by multiphase computed tomographic angiography predicts malignant middle cerebral artery evolution after reperfusion therapies[J]. Stroke，2015，46（11）：3149-3153.
[22] GALEGO O，JESUS-RIBEIRO J，BAPTISTA M，et al. Collateral pial circulation relates to the degree of brain edema on CT 24 hours after ischemic stroke[J]. Neuroradiol J，2018，31（5）：456-463.
[23] NIE X M，PU Y H，ZHANG Z，et al. Futile recanalization after endovascular therapy in acute ischemic stroke[J/OL]. Biomed Res Int，2018：5879548[2022-10-15]. https://doi.org/10.1155/2018/5879548.
[24] EKER O F，SAVER J L，GOYAL M，et al. Impact of anesthetic management on safety and outcomes following mechanical thrombectomy for ischemic stroke in SWIFT PRIME Cohort[J/OL]. Front Neurol，2018，9：702[2022-10-15]. https://doi.org/10.3389/fneur.2018.00702.