目的:大脑后动脉(PCA)卒中的血管内血栓切除术(EVT)缺乏高水平证据。
方法:MEDLINE,Embase,和WebofScience数据库被查询为进行良好的队列研究,比较EVT和医疗管理(MM)的PCA中风。感兴趣的结果包括90天的功能结果,症状性颅内出血(sICH),和死亡。根据牛津循证医学中心标准确定证据水平。我们还对2016-2020年全国住院患者样本(NIS)进行了倾向评分匹配(PSM)分析,以通过实际数据为我们的发现提供支持。
结果:共有2,095名患者(685例EVT和1,410例MM)在5项进行良好的队列研究中被确认。EVT与90天时无残疾的几率显着相关(比值比[OR]1.25,95%CI1.04-1.50,p=0.015),但与功能独立性无关(OR0.87,95%CI0.72-1.07,p=0.18)。EVT也与较高的sICH几率相关(OR2.48,95%CI1.55-3.97,p<0.001)和数字上较高的死亡几率(OR1.32,95%CI0.73-2.38;p=0.35)。在NIS的95,585例PCA卒中患者的PSM分析显示,EVT(n=1,540)与较低的良好出院结局率相关(24.4%vs30.7%,p=0.037),住院死亡率较高(8.8%vs4.9%,p=0.021),ICH发生率较高(18.2%和11.7%,p=0.008),蛛网膜下腔出血的发生率较高(3.9%vs0.6%,p<0.001)。在中度至重度卒中患者中(NIH卒中量表5或以上),EVT与良好结局的比率显着升高(21.7%vs13.8%,p=0.023),死亡率相似(7.6%vs6.6%,p=0.67)和ICH(17.8%vs,13.1%,p=0.18)。
结论:我们的荟萃分析显示,虽然EVT可有效缓解PCA卒中所致的致残缺陷,它与不同的功能独立性几率不相关,可能与sICH的几率较高相关.我们对美国现实世界数据的大倾向评分匹配分析证实了这些发现。因此,对于每位患者,进行PCA血栓切除术的决定应谨慎个体化.未来的随机试验需要进一步探讨EVT治疗PCA卒中的有效性和安全性。
方法:这项研究提供了III类证据,表明在急性PCA缺血性卒中患者中,与单纯MM相比,EVT治疗90天时无致残缺陷的几率较高,sICH的几率较高.
OBJECTIVE: There is a paucity of high-level evidence for endovascular thrombectomy (EVT) in posterior cerebral artery (PCA) strokes.
METHODS: The MEDLINE, Embase, and Web of Science databases were queried for well-conducted cohort studies comparing EVT vs medical management (MM) for PCA strokes. Outcomes of interest included 90-day functional outcomes, symptomatic intracranial hemorrhage (sICH), and death. The level of evidence was determined per the Oxford Centre for Evidence-Based Medicine criteria. We also conducted a propensity score matched (PSM) analysis of the 2016-2020 National Inpatient Sample (NIS) to provide support for our findings with real-world data.
RESULTS: A total of 2,095 patients (685 EVT and 1,410 MM) were identified across 5 well-conducted cohort studies. EVT was significantly associated with higher odds of no disability at 90 days (odds ratio [OR] 1.25, 95% CI 1.04-1.50, p = 0.015) but not functional independence (OR 0.87, 95% CI 0.72-1.07, p = 0.18). EVT was also associated with higher odds of sICH (OR 2.48, 95% CI 1.55-3.97, p < 0.001) and numerically higher odds of death (OR 1.32, 95% CI 0.73-2.38; p = 0.35). PSM analysis of 95,585 PCA stroke patients in the NIS showed that EVT (n = 1,540) was associated with lower rates of good discharge outcomes (24.4% vs 30.7%, p = 0.037), higher rates of in-hospital mortality (8.8% vs 4.9%, p = 0.021), higher rates of ICH (18.2% and 11.7%, p = 0.008), and higher rates of subarachnoid hemorrhage (3.9% vs 0.6%, p < 0.001). Among patients with moderate to severe strokes (NIH Stroke Scale 5 or greater), EVT was associated with significantly higher rates of good outcomes (21.7% vs 13.8%, p = 0.023) with similar rates of mortality (7.6% vs 6.6%, p = 0.67) and ICH (17.8% vs, 13.1%, p = 0.18).
CONCLUSIONS: Our meta-analysis revealed that while EVT may be effective in alleviating disabling deficits due to PCA strokes, it is not associated with different odds of functional independence and may be associated with higher odds of sICH. These findings were corroborated by our large propensity score matched analysis of real-world data in the United States. Thus, the decision to pursue PCA thrombectomies should be carefully individualized for each patient. Future randomized trials are needed to further explore the efficacy and safety of EVT for the treatment of PCA strokes.
METHODS: This study provides Class III evidence that in patients with acute PCA ischemic stroke, treatment with EVT compared with MM alone was associated with higher odds of no disabling deficit at 90 days and higher odds of sICH.