机械取栓与动脉溶栓治疗急性脑动脉闭塞单中心回顾性对照研究

Mechanical thrombectomy versus Intra-arterial Thrombolysis in Patients with Stroke Caused by Acute cerebral Arterial Occlusions:A Single-center study

目的对比分析机械取栓与动脉溶栓血管再通方法对于治疗急性脑动脉闭塞的有效性及安全性。方法回顾比较分析2005年5月至2014年5月期间行动脉溶栓及机械取栓患者,比较其发病到入院时间、入院到穿刺时间以及穿刺到获得再通时间、血管再通率TICI评分、患者术前及出院时NIHSS评分变化、90d时MRS评分、颅内出血发生率、死亡率。结果机械取栓组102例,动脉溶栓组50例,两组在发病入院时间(300 min vs.120 min,Z=-5.704,P=0.000),穿刺到再通时间(30 min vs.65 min,Z=-5.011,P=0.001)存在统计学差异,机械取栓组明显优于动脉溶栓组。两组在血管再通率(91.2%vs.60.0%,P=0.01)、总出血率(21.7%vs.36.0%,P=0.046)、死亡率(16.6%vs.26.0%,P=0.043)比较存在统计学差异,机械取栓组明显优于动脉溶栓组。两组90d时症状性出血率(12%vs.16%,P=0.055)、NIHSS评分变化(3 vs.4,Z=-0.236,P=0.823)、90d时良好预后率(48.2%vs.46.0%,P=0.823)比较无统计学差异。机械取栓组的支架放置率高于动脉溶栓组(22.5%vs.8.0%,P=0.018)。两组责任血管分层比较:机械取栓组颈内动脉(81.8%vs.55.6%,P=0.048)、基底动脉(93.1%vs.55.6%,P=0.032)、大脑中动脉(97.5%vs.60%,P=0.026)的血管再通率明显高于动脉溶栓组,机械取栓组颈内动脉(13.8%vs.33.3%,P=0.001)、基底动脉(13.8%vs.22.2%,P=0.011)的症状性出血率明显低于动脉溶栓组。机械取栓组大脑中动脉死亡率显著低于动脉溶栓组(2.5%vs.20.0%,P=0.000)。机械取栓组基底动脉良好预后率明显高于动脉溶栓组(41.3%vs.22.2%,P﹤0.01)。结论对于急性脑动脉闭塞患者的血管内治疗,机械取栓相比动脉溶栓有更宽的时间窗,更高的再通率和更好的预后。

Objective To investigate the safety and efficacy of mechanical thrombectomy （MT） compared with Intra-arterial Thrombolysis （IAT） treatment in patients with severe acute ischemic stroke （AIS） caused by large cerebral artery occlusion. Method The patients with AIS caused by large cerebral artery occlusion and underwent MT or IAT from 2005 May to 2014 May was included. A retrospective analysis was conducted on the onset to emergency （OTE）time, emergency to acupuncture （ETA）time, acupuncture to recanalization （ATR） time, stroke severity as measured by the National Institutes of Health Stroke Scale （NIHSS） score, and site of arterial occlusion on magnetic resonance angiography （MRA）. A comparison was made between MT and IAT patients in rates of recanalization, symptomatic intracranial bleeding （SIB）, mortality, and functional outcome. Three-month favourable outcome was defined as a modified Rankin Scale （mRS） score≤2. Result One hundred and two AIS patients were treated with MT and 50 with IAT. There was no difference between MT and IAT groups with regard to demographics, onset NIHSS score （13.37±6.95 vs. 12.70±6.11; P=0.572） and discharge NIHSS score （8.40±6.69 vs. 7.53±7.28, P= 0.522） and the change of NIHSS score （3.87±7.14 vs. 4.26± 5.42, P =0.766）. There were significantly differences between MT and IAT groups in the OTE time （Median 300 min vs. 120 min, Z=-5.704, P =0.000）, ATR time （Median 30 min vs. 65 min, Z=-5.011, P =0.001） , recanalization （91.2% vs. 60.0%, P =0.01）, the rate of AIB（21.7% vs. 36.0%, P =0.046）,3-month mortality （16.6% vs. 26.0%, P =0.043）. The above parameters were better in MT group than in the IAT group. There were no significant differences between MT and IAT groups in the rate of SIB （12% vs. 16%, P =0.055）, the NIHSS change（Median 3 vs. 4, Z =-0.236, P =0.823） and mRS score on 90d （ 48.2% vs. 46.0%, P =0.823）. MT patients had significantly higher percentages of stent use （22.5% vs. 8%, P =0.018）. The Recanalization for ICA （81.8% vs. 55.6%, P =0.048 ）, BA （93.1% vs. 55.6%, P =0.032） and MCA （ 97.5% vs. 60.0%, P =0.026）was higher in MT group than in IAT group .The SIB rate for ICA （13.8% vs. 33.3%, P = 0.000）, BA （13.8% vs. 33.3%, P =0.000）was lower in MT group than in IAT group. The mortality rate of was significantly lower in MT than in IAT group for MCA （2.5% vs. 20.0%, P =0.000） . the good outcome rate for BA was higher in MT group than in IAT group（41.3% vs. 22.2% ,P 〈 0.01 ）. Conclusions Compared to IAT, MT can provide broader time window, higher recanalization rate and better outcome in patients with severe acute ischemic stroke （AIS） caused by large cerebral artery occlusion.