应基于CT灌注结果决定是否行机械性血栓切除

圣迭戈——在神经介入外科学会年会上公布的一项单中心研究显示，基于CT灌注结果选择进行机械性血栓切除术的卒中患者，即使在传统7~8 h治疗窗后治疗，仍能获得良好功能预后，并且安全性较好。

Jordan Magarik

在这项研究中，南卡罗莱纳医科大学的Jordan Magarik及其同事对该校卒中中心2008~2011年收治的140例卒中患者的病历进行了分析。患者的平均年龄为67岁。相关分析数据包括年龄、合用静脉组织纤溶酶原激活剂(TPA)、至治疗的时间、就诊时的国立卫生研究院卒中量表(NIHSS)评分、90天改良Rankin评分(mRS)和血管造影再通率。所用的主要动脉内器械为Penumbra System。

所有140例患者均进行机械性血栓切除术；54例在机械性血栓切除术基础上还接受静脉TPA，86例仅接受机械性血栓切除术。平均NIHSS评分为16.2分，至治疗的时间平均为11.3 h，明显超过机械器械研究中所用的传统的7~8 h时间窗。

大部分(87%)患者达到部分或完全再通，10%的患者出现颅内出血症状，与既往研究结果一致。38%患者的90天mRS为0~2分，53%为0~3分。死亡率为25%，与既往研究结果一致。

根据出现症状至治疗的平均时间对患者进行分组后分析发现，7 h时间窗内治疗组mRS 0~2分的患者比例与7 h时间窗后治疗组相应患者比例无显著差异(31% vs. 42%)，两组mRS 0~3分的患者比例也无显著差异(49% vs. 55%)。研究者表示，后一组许多患者在出现症状后15 h或18 h才就诊，但获得良好功能预后的患者比例与前组非常相似，这是基于CT灌注结果选择患者的结果。

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By: DOUG BRUNK, Cardiology News Digital Network

SAN DIEGO – An approach that uses CT perfusion findings to select patients for mechanical thrombectomy resulted in effective, safe treatment of stroke patients beyond the traditional 7- to 8-hour treatment window, results from a single-center study demonstrated.

"CT perfusion–based patient selection for endovascular therapy enables us to treat patients who would otherwise have not received such therapy based on time criteria," Jordan Magarik said at the annual meeting of the Society of Neurointerventional Surgery. "We have seen improved outcomes over historical controls and improved safety as well. The bottom line is that patient selection is paramount. When patients are selected based solely on CT perfusion imaging, we are finding very similar rates of good functional outcome regardless of when they were treated, whether it’s 8 or 18 hours after symptom onset."
 
When the Medical University of South Carolina (MUSC) in Charleston launched its Comprehensive Stroke Center in 2008, clinicians there devised an alternate method of selecting patients solely based on the CT perfusion findings, regardless of their time from symptom onset. For the current study, Mr. Magarik, who is a medical student at MUSC, and his associates reviewed the records of 140 stroke patients who were treated at the stroke center from 2008 to 2011. The mean age of the patients was 67 years. Data of interest included age, concurrent administration of IV tissue plasminogen activator (TPA), time to treatment, presenting National Institutes of Health Stroke Scale (NIHSS) score, 90-day modified Rankin score (mRS), and angiographic recanalization rates. The primary intra-arterial device used was the Penumbra System.

All 140 patients underwent mechanical thrombectomy; 54 received IV TPA in addition to mechanical thrombectomy and 86 only underwent mechanical thrombectomy. The mean NIHSS score was 16.2, and the mean time to treatment was 11.3 hours, which is well beyond the traditional 7- to 8-hour time window used in mechanical device trials, said Mr. Magarik.

The majority of patients (87%) achieved a partial or full recanalization and 10% of patients suffered symptomatic intracranial hemorrhage, which is consistent with previous trials.

More than one-third of patients (38%) achieved a 90-day mRS of 0-2, and 53% achieved a 90-day mRS of 0-3. The mortality rate was 25%, which is consistent with previous trials.

When the researchers divided patients on the basis of mean time from symptom onset to treatment, they observed no statistically significant differences in the rates of patients with mRS of 0-2 (31% among those treated within a 7-hour window vs. 42% among those treated beyond a 7-hour window) or mRS of 0-3 (49% among those treated within a 7-hour window vs. 55% among those treated beyond a 7-hour window).

"Many patients in the later time group are presenting 15 or 18 hours out from symptom onset, yet they are still achieving a very similar rate of good functional outcome," Mr. Magarik said. "We believe this is because they were selected based on their CT perfusion findings."

Mr. Magarik said that he had no relevant financial disclosures to make.