Περίληψη:
Objective
To evaluate the comparative safety and efficacy of direct endovascular
thrombectomy (dEVT) compared to bridging therapy (BT; IV tissue
plasminogen activator + EVT) and to assess whether BT potential benefit
relates to stroke severity, size, and initial presentation to EVT vs
non-EVT center.
Methods
In a prospective multicenter cohort study of imaging selection for
endovascular thrombectomy (Optimizing Patient Selection for Endovascular
Treatment in Acute Ischemic Stroke [SELECT]), patients with anterior
circulation large vessel occlusion (LVO) presenting to EVT-capable
centers within 4.5 hours from last known well were stratified into BT vs
dEVT. The primary outcome was 90-day functional independence (modified
Rankin Scale [mRS] score 0-2). Secondary outcomes included a shift
across 90-day mRS grades, mortality, and symptomatic intracranial
hemorrhage. We also performed subgroup analyses according to initial
presentation to EVT-capable center (direct vs transfer), stroke
severity, and baseline infarct core volume.
Results
We identified 226 LVOs (54% men, mean age 65.6 +/- 14.6 years, median
NIH Stroke Scale [NIHSS] score 17, 28% received dEVT). Median time
from arrival to groin puncture did not differ in patients with BT when
presenting directly (dEVT 1.43 [interquartile range (IQR) 1.13-1.90]
hours vs BT 1.58 [IQR 1.27-2.02] hours, p = 0.40) or transferred to
EVT-capable centers (dEVT 1.17 [IQR 0.90-1.48] hours vs BT 1.27 [IQR
0.97-1.87] hours, p = 0.24). BT was associated with higher odds of
90-day functional independence (57% vs 44%, adjusted odds ratio
[aOR] 2.02, 95% confidence interval [CI] 1.01-4.03, p = 0.046) and
functional improvement (adjusted common OR 2.06, 95% CI 1.18-3.60, p =
0.011) and lower likelihood of 90-day mortality (11% vs 23%, aOR 0.20,
95% CI 0.07-0.58, p = 0.003). No differences in any other outcomes were
detected. In subgroup analyses, patients with BT with baseline NIHSS
scores <15 had higher functional independence likelihood compared to
those with dEVT (aOR 4.87, 95% CI 1.56-15.18, p = 0.006); this
association was not evident for patients with NIHSS scores >= 15 (aOR
1.05, 95% CI 0.40-2.74, p = 0.92). Similarly, functional outcomes
improvements with BT were detected in patients with core volume strata
(ischemic core <50 cm(3): aOR 2.10, 95% CI 1.02-4.33, p = 0.044 vs
ischemic core >= 50 cm(3): aOR 0.41, 95% CI 0.01-16.02, p = 0.64) and
transfer status (transferred: aOR 2.21, 95% CI 0.93-9.65, p = 0.29 vs
direct to EVT center: aOR 1.84, 95% CI 0.80-4.23, p = 0.15).
Conclusions
BT appears to be associated with better clinical outcomes, especially
with milder NIHSS scores, smaller presentation core volumes, and those
who were “dripped and shipped.” We did not observe any potential
benefit of BT in patients with more severe strokes.
Συγγραφείς:
Sarraj, Amrou
Grotta, James
Albers, Gregory W.
Hassan, Ameer
E.
Blackburn, Spiros
Day, Arthur
Sitton, Clark
Abraham,
Michael
Cai, Chunyan
Dannenbaum, Mark
Pujara, Deep and
Hicks, William
Budzik, Ronald
Vora, Nirav
Arora, Ashish and
Alenzi, Bader
Tekle, Wondwossen G.
Kamal, Haris
Mir, Osman
and Barreto, Andrew D.
Lansberg, Maarten
Gupta, Rishi and
Martin-Schild, Sheryl
Savitz, Sean
Tsivgoulis, Georgios and
SELECT Investigators
