急性前循环大血管闭塞性轻型卒中血管内治疗的临床预后及手术时机选择

Clinical prognosis and timing of endovascular treatment for minor stroke patients with acute anterior circulation large vessel occlusive

目的探讨急性前循环大血管闭塞性轻型卒中患者行血管内治疗(EVT)的有效性、安全性及影响预后的因素,并分析比较不同时机手术的临床预后。方法回顾性连续纳入自2020年1月至2022年3月于临沂市人民医院神经内科卒中中心就诊的急性前循环大血管闭塞性轻型卒中患者(美国国立卫生研究院卒中量表评分<5分)177例,按初始治疗方案分为直接EVT组(39例)和最佳药物治疗组(138例),比较2组患者的临床预后。对最佳药物治疗后病情恶化再行补救EVT的患者(43例),计为补救EVT组,比较直接EVT组与补救EVT组患者的疗效和安全性。评估的主要终点事件(主要有效性指标)为治疗后90d良好预后[改良Rankin量表(mRS)评分<2分],次要终点事件(主要安全性指标)为早期神经功能恶化、症状性颅内出血及90 d死亡。依据90dmRS评分将所有患者分为预后良好组(mRS评分2分)与预后不良组(mRS评分>2分),采用单因素及多因素Logistic回归分析筛选影响急性前循环大血管闭塞性轻型卒中患者预后的因素。结果与最佳药物治疗组相比,直接EVT组患者有更高的90d良好预后率(92.3%vs78.3%),早期神经功能恶化的比例显著降低(7.7%vs41.3%),差异均具有统计学意义(X^(2)=3.955、15.331,P=0.047、<0.001)。与补救EVT组相比,直接EVT组患者有更高的良好预后率(92.3%vs74.4%),差异具有统计学意义(X^(2)=4.623,P=0.032)。直接EVT(OR=0.070,95%CI:0.013~0.382,P=0.002)、高侧支循环等级(OR=0.096,95%CI:0.024~0.385,P=0.001)是急性前循环大血管闭塞性轻型卒中患者良好预后的独立影响因素。结论急性前循环大血管闭塞性轻型卒中患者行EVT是安全的,对该类患者尽早行EVT可明显改善预后,高侧支循环等级患者获益可能性更大。

Objective To investigate the efficacy,safety,and prognostic factors of endovascular treatment(EVT)in patients with minor stroke caused by acute anterior circulation large vessel occlusion(LVO),and to further compare the clinical prognosis of operation at different times.Methods A total of 177 patients with minor stroke with acute anterior circulation LVO and National Institutes of Health Stroke Scale(NIHSS)score≤5,admitted to the Stroke Center of Department of Neurology,Linyi people's Hospital from January 2020 to March 2022 were consecutively collected in our study.According to the initial treatment regimen,177 patients were divided into the direct endovascular treatment group(39 cases)and theoptimal drug treatment group(138 cases),and the clinical prognosis of the two groups of patients was compared.The patients(43 cases)who underwent endovascular remedial therapy after the deterioration after the optimal drug treatment were regarded as the remedial endovascular treatment group,And the efficacy and safety of patients in the two groups of patients with direct endovascular therapy and remedial endovascular therapy were compared.The primary endpoint events were the prognosis at 90 days after treatment[modified Rankin scale(mRS)score≤2],and secondary endpoint events were early neurological deterioration,symptomatic intracranial hemorrhage,and 90 d mortality.Based on the 90 d mRS score,all patients were divided into a good prognosis group(mRS score≤2)and a poor prognosis group(mRS score>2)Univariate and multivariate logistic regression analysis was used to screen for factors affecting the prognosis of patients with minor stroke with acute anterior circulation LVO.Results Compared with the optimal drug treatment group,patients in the direct endovascular treatment group had a higher proportion of good prognosis of 90 days,and the difference was statistically significant(92.3%vs 78.3%,X^(2)=3.955,P-0.047).The proportion of early neurological deterioration was significantly reduced,and the difference was statistically significant(7.7%vs 41.3%,X^(2)=15.331,P<0.001).Patients treated with direct endovascular therapy had a significantly higher prognosis than remedial endovascular therapy(92.3%vs 74.4%,X^(2)=4.623,P-0.032).Direct endovascular therapy(OR=0.070,95%CI:0.013-0.382,P-=0.002),and high collateral circulation grade(OR=0.096,95%CI:0.024-0.385,P=0.001)are independent influencing factors for EVT prognosis in patients with minor stroke caused by acute anterior circulation LVO.Conclusion Endovascular therapy is safe for patients with minor stroke caused by acute anterior circulation LVO.Early endovascular treatment for such patients can significantly improve the prognosis,and patients with a high grade of collateral circulation are more likely to benefit.