背景:孤立性大脑后动脉闭塞患者的最佳治疗方法尚不确定。我们比较了孤立性大脑后动脉闭塞患者的血管内治疗(EVT)与药物治疗(MM)的临床结果。
方法:这项多国病例对照研究在欧洲和北美的27个地点进行,纳入了2015年1月至2022年8月在24小时内出现孤立性大脑后动脉闭塞的连续患者。用多变量逻辑回归和治疗加权的逆概率比较接受EVT或MM治疗的患者。共同主要结果是90天的改良Rankin量表序数移位和美国国立卫生研究院卒中量表下降≥2分。
结果:在1023名患者中,589(57.6%)为男性,中位(四分位距)年龄为74(64-82)岁。美国国立卫生研究院卒中量表的中位数(四分位范围)为6(3-10)。闭塞节段为P1(41.2%),P2(49.2%),和P3(7.1%)。总的来说,静脉溶栓占43%,EVT占37%.在90天改良的Rankin量表移位中,EVT组和MM组之间没有差异(aOR,1.13[95%CI,0.85-1.50];P=0.41)。在EVT的情况下,美国国立卫生研究院卒中量表下降≥2分的可能性更高(aOR,1.84[95%CI,1.35-2.52];P=0.0001)。与MM相比,EVT与良好结局的可能性更高(aOR,1.50[95%CI,1.07-2.09];P=0.018),完全恢复视力,和相似的功能独立性率(改良的Rankin量表评分,0-2),尽管SICH和死亡率较高(症状性颅内出血,6.2%对1.7%;P=0.0001;死亡率,10.1%对5.0%;P=0.002)。
结论:在孤立性大脑后动脉闭塞患者中,通过顺序改良的Rankin量表,EVT与相似的残疾几率相关,早期美国国立卫生研究院卒中量表改善的几率更高,与MM相比,视力完全恢复。尽管有症状的颅内出血和死亡率较高,但EVT组的预后良好的可能性更高。继续纳入正在进行的远端血管闭塞随机试验是必要的。
The optimal management of patients with isolated posterior cerebral artery occlusion is uncertain. We compared clinical outcomes for endovascular therapy (EVT) versus medical management (MM) in patients with isolated posterior cerebral artery occlusion.
This multinational case-control
study conducted at 27 sites in Europe and North America included consecutive patients with isolated posterior cerebral artery occlusion presenting within 24 hours of time last well from January 2015 to August 2022. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The coprimary outcomes were the 90-day modified Rankin Scale ordinal shift and ≥2-point decrease in the National Institutes of Health Stroke Scale.
Of 1023 patients, 589 (57.6%) were male with median (interquartile range) age of 74 (64-82) years. The median (interquartile range) National Institutes of Health Stroke Scale was 6 (3-10). The occlusion segments were P1 (41.2%), P2 (49.2%), and P3 (7.1%). Overall, intravenous thrombolysis was administered in 43% and EVT in 37%. There was no difference between the EVT and MM groups in the 90-day modified Rankin Scale shift (aOR, 1.13 [95% CI, 0.85-1.50]; P=0.41). There were higher odds of a decrease in the National Institutes of Health Stroke Scale by ≥2 points with EVT (aOR, 1.84 [95% CI, 1.35-2.52]; P=0.0001). Compared with MM, EVT was associated with a higher likelihood of excellent outcome (aOR, 1.50 [95% CI, 1.07-2.09]; P=0.018), complete vision recovery, and similar rates of functional independence (modified Rankin Scale score, 0-2), despite a higher rate of SICH and mortality (symptomatic intracranial hemorrhage, 6.2% versus 1.7%; P=0.0001; mortality, 10.1% versus 5.0%; P=0.002).
In patients with isolated posterior cerebral artery occlusion, EVT was associated with similar odds of disability by ordinal modified Rankin Scale, higher odds of early National Institutes of Health stroke scale improvement, and complete vision recovery compared with MM. There was a higher likelihood of excellent outcome in the EVT group despite a higher rate of symptomatic intracranial hemorrhage and mortality. Continued enrollment into ongoing distal vessel occlusion randomized trials is warranted.