背景:急性基底动脉闭塞(BAO)引起的卒中具有高依赖性和死亡率。最近的试验已经证明了血管内治疗(EVT)对急性BAO的疗效,而治疗前侧支可能是EVT后结局的有价值的预后指标。
目的:系统评价和综合急性BAO治疗前侧支状态与EVT后结局之间的相关性。
方法:我们检索了自2010年1月1日以来以英文发表的相关全文文章,报告了治疗前抵押品状态与BAOEVT后结果之间的关联,通过搜索MEDLINE和Embase。主要结局是90天功能结局良好或良好(改良Rankin量表[mRS]0-2或0-3);次要结局包括成功再通,症状性颅内出血,最终梗死体积,90天死亡率。使用随机效应模型合成了具有95%置信区间(CI)的好抵押品和差抵押品对结果的风险比(RR)。对主要结局进行亚组和敏感性分析。
结果:总体而言,29项主要研究(2,995名参与者)被纳入定性审查,其中16项研究(1,447名参与者)进行了荟萃分析.用不同的成像方式和方法对侧支状态进行分级,在个别主要研究中,33-85%的患者发现了良好的络脉(I2=95.2%,p<0.001),所有研究的合并比例为51%(95%CI40-62%)。良好的治疗前侧支与良好/良好的90天功能结局的比率加倍相关(RR=2.03,95%CI1.63-2.51,p<0.001),成功再通率较高(RR=1.23,95%CI1.04-1.45,p=0.015),BAOEVT后90天死亡率降低(RR=0.59,95%CI0.43-0.81,p=0.001)。没有一项主要研究报告了良好的侧支与其他次要结果的关联。亚组分析显示,与主要结局相比,良好的预处理侧支可能更突出的保护作用。在EVT患者资格标准中时间窗较长的研究中(亚组间异质性p=0.028).
结论:在接受EVT的BAO患者中,良好的治疗前侧支状态与良好的90天功能结局的机会较高相关,尽管对侧支循环进行分级的方法多种多样。需要努力在BAO进行更标准化的抵押品评估,对其临床意义进行更可靠和可推广的研究。
Stroke caused by acute basilar artery occlusion (BAO) is devastating with high dependency and mortality. Recent trials have demonstrated the efficacy of endovascular treatment (EVT) for acute BAO, while pretreatment collaterals may be a valuable prognostic indicator for post-EVT outcomes.
To systematically
review and synthesize evidence on the associations between pretreatment collateral status and outcomes after EVT in acute BAO.
We retrieved relevant full-text articles published in English since 1 January 2010, reporting associations between pretreatment collateral status and outcomes after EVT for BAO, by searching MEDLINE and Embase. The primary outcome was favorable or good 90-day functional outcome (modified Rankin Scale [mRS] 0-2 or 0-3); secondary outcomes included successful recanalization, symptomatic intracranial hemorrhage, final infarct volume, and 90-day mortality. Risk ratios (RRs) with 95% confidence intervals (CIs) for good versus poor collaterals on the outcomes were synthesized using random-effects models. Subgroup and sensitivity analyses were conducted for the primary outcome.
Overall, 29 primary studies (2995 participants) were included in qualitative
review, among which 16 studies (1447 participants) were meta-analyzed. With different imaging modalities and methods to grade the collateral status, good collaterals were found in 33-85% of patients in the individual primary studies (I2 = 95.2%, p < 0.001), with a pooled proportion of 51% (95% CI: 40-62%) across all studies. Good pretreatment collaterals were associated with a doubled rate of favorable/good 90-day functional outcome (RR = 2.03, 95% CI: 1.63-2.51, p < 0.001), a higher rate of successful recanalization (RR = 1.23, 95% CI: 1.04-1.45, p = 0.015), and reduced 90-day mortality (RR = 0.59, 95% CI: 0.43-0.81, p = 0.001) after EVT for BAO. None of the primary studies reported the associations of good collaterals with the other secondary outcomes. Subgroup analyses revealed possibly more prominent protective effect of good pretreatment collaterals over the primary outcome, in studies with longer time windows in patient eligibility criteria for EVT (p = 0.028 for between-subgroup heterogeneity).
In patients with BAO receiving EVT, good pretreatment collateral status was associated with a higher chance of favorable 90-day functional outcome, despite the various methods in grading the collateral circulation. Efforts are needed for more standardized collateral assessment in BAO, for more reliable and generalizable investigations of its clinical implications.