血管内治疗对前循环大面积缺血性卒中患者去骨瓣减压术需求和功能转归的影响

Effect of endovascular therapy on the requirement for decompressive craniectomy and functional outcomes in patients with large anterior circulation ischemic stroke

目的探讨血管内治疗(endovascular treatment,EVT)对前循环大面积缺血性卒中患者去骨瓣减压术(decompressive craniectomy,DC)需求及功能转归的影响。方法纳入四川大学华西医院神经内科在2017年9月至2019年12月期间收治的发病24 h内的前循环大面积脑梗死患者。转归指标包括DC需求和3个月时转归不良,后者定义为改良Rankin量表评分>2分。应用多变量logistic回归分析确定DC需求和3个月时功能转归的独立影响因素。结果共纳入381例前循环大面积脑梗死患者,男性203例(53.3%),年龄(70.7±14.3)岁,中位发病至入院时间4.5 h,中位基线美国国立卫生研究院卒中量表评分17分,中位基线阿尔伯塔卒中项目早期CT评分(Alberta Stroke Program Early Computed Tomography Score,ASPECTS)为7分,139例(36.5%)接受EVT,64例(16.8%)有DC需求;376例(98.7%)完成3个月随访(5例未完成3个月随访者均无DC需求,其中2例接受了EVT),312例(83.0%)3个月时转归不良,146例(38.8%)死亡。多变量logistic回归分析显示,EVT是增加DC需求的独立预测因素[优势比(odds ratio,OR)4.42,95%置信区间(confidence interval,CI)1.81~10.81;P=0.001],基线ASPECTS较高(OR 0.80,95%CI 0.71~0.89;P<0.001)和血管成功再通(OR 0.37,95%CI 0.15~0.90;P=0.028)是降低DC需求的独立保护因素;血管成功再通(OR 0.09,95%CI 0.01~0.72;P=0.023)和抗血小板治疗(OR 0.29,95%CI 0.11~0.76;P=0.012)是降低转归不良的独立预测因素。在139例接受EVT的患者中,27例(19.4%)接受静脉溶栓,96例(69.1%)血管成功再通,88例(63.3%)发生出血性转化,61例(43.9%)发生有症状出血性转化,34例(24.5%)有DC需求;137例(98.6%)完成3个月随访,116例(84.7%)3个月时转归不良,67例(48.9%)死亡。对于接受EVT患者,基线ASPECTS较高(OR 0.72,95%CI 0.60~0.88;P=0.001)和血管成功再通(OR 0.35,95%CI 0.14~0.90;P=0.029)是降低DC需求的独立预测因素,血管成功再通(OR 0.09,95%CI 0.01~0.71;P=0.022)是降低3个月转归不良的独立预测因素。在64例有DC需求的患者中,22例(34.4%)接受了DC治疗。接受DC可显著降低3个月内病死率(OR 0.25,95%CI 0.07~0.86;P=0.028),但对3个月时功能转归无显著影响(OR 0.35,95%CI 0.03~4.38;P=0.412)。EVT或血管再通与DC对病死率的降低不存在交互影响(P均>0.05)。结论EVT后血管成功再通可减少前循环大面积脑梗死患者对DC的需求并改善3个月时的功能转归。DC可降低有DC需求患者3个月内的病死率,且与EVT或血管成功再通无交互影响。

Objective To investgate the effect of endovascular therapy(EVT)on the requirement for decompressive craniectomy(DC)and functional outcomes in patients with large anterior circulation ischemic stroke.Methods Patients with large anterior circulation ischemic stroke within 24 hours of onset admitted to the Department of Neurology,West China Hospital,Sichuan University between September 2017 and December 2019 were included.Outcome indicators included DC demand and poor outcome at 3 months.The latter was defined as a modified Rankin Scale score>2.Multivariate logistic regression analysis was used to determine independent factors of DC requirement and functional outcomes at 3 months.Results A total of 381 patients with large anterior circulation ischemic stroke were enrolled,including 203 males(53.3%),and the mean age was 70.7±14.3 years.The median time from onset to admission was 4.5 hours.The median baseline National Institutes of Health Stroke Scale score was 17 and median baseline Alberta Stroke Program Early Computed Tomography Score(ASPECTS)was 7.Totally 139 patients(36.5%)received EVT,and 64(16.8%)required DC;376 patients(98.7%)completed a 3-month follow-up(5 who did not complete follow-up did not require DC,of which 2 received EVT),312(83.0%)had poor outcome at 3 months,and 146(38.8%)died.Multivariate logistic regression analysis showed that EVT was an independent predictor for the requiremet of DC(odds ratio[OR]4.42,95%confidence interval[CI]1.81-10.81;P=0.001),higher baseline ASPECTS(OR 0.80,95%CI 0.71-0.89;P<0.001)and successful recanalization(OR 0.37,95%CI 0.15-0.90;P=0.028)were independent protective factors of reducing the requirement of DC.Successful recanalization(OR 0.09,95%CI 0.01-0.72;P=0.023)and antiplatelet therapy(OR 0.29,95%CI 0.11-0.76;P=0.012)were independent predictors for reduced risk of poor outcome.In 139 patients who received EVT,27(19.4%)received intravenous thrombolysis,96(69.1%)achieved successful recanalization,88(63.3%)had hemorrhagic transformation,61(43.9%)had symptomatic hemorrhagic transformation,and 34(24.5%)required DC;137(98.6%)completed a 3-month follow-up,116(84.7%)had poor outcome at 3 months,and 67(48.9%)died.For patients receiving EVT,a higher baseline ASPECTS(OR 0.72,95%CI 0.60-0.88;P=0.001)and successful recanalization(OR 0.35,95%CI 0.14-0.90;P=0.029)were independent predictors of reducing the requirement of DC,while successful recanalization(OR 0.09,95%CI 0.01-0.71;P=0.022)was an independent predictor for reduced risk of poor outcome.Among 64 patients who required DC,22(34.4%)received DC.Receiving DC significantly reduced the mortality within 3 months(OR 0.25,95%CI 0.07-0.86;P=0.028),but had no significant effect on functional outcome at 3 months(OR 0.35,95%CI 0.03-4.38;P=0.412).There was no significant interaction of either EVT or successful recanalization in the effect of DC on 3-month death(P for interaction>0.05).Conclusions Successful recanalization after EVT reduces requirement for DC in patients with large anterior circulation ischemic stroke and improves functional outcome at 3 months.DC can reduce the mortality in patients required DC,and have no interactive effect with EVT or successful recanalization.