A trial of imaging selection and endovascular treatment for ischemic stroke.
A trial of imaging selection and endovascular treatment for ischemic stroke.
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DOI：
10.1056/nejmoa1212793
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发表时间：
2013-03-07
期刊：
影响因子：
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通讯作者：
MR RESCUE Investigators
中科院分区：
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作者：
Kidwell CS;Jahan R;Gornbein J;Alger JR;Nenov V;Ajani Z;Feng L;Meyer BC;Olson S;Schwamm LH;Yoo AJ;Marshall RS;Meyers PM;Yavagal DR;Wintermark M;Guzy J;Starkman S;Saver JL;MR RESCUE Investigators
脑成像是否可以识别最有可能从急性缺血性卒中治疗中获益的患者，以及血管内血栓切除术是否可以改善此类患者的临床结局仍不清楚。在本研究中，我们将大血管前循环卒中发作后8小时内的患者随机分配接受机械取栓术（Merci取栓器或Penumbra系统）或接受标准治疗。所有患者均接受了治疗前的脑计算机断层扫描或磁共振成像。根据患者是否具有有利的半影模式（大量可挽救组织和小梗死核心）或非半影模式（大核心或小或无半影）对随机化进行分层。我们使用90天改良兰金量表评估结局，范围从0（无症状）到6（死亡）。在118例合格患者中，平均年龄为65.5岁，平均入组时间为5.5小时，58%的患者具有良好的半影模式。栓子切除术组67%的患者实现了血运重建。90天死亡率为21%，症状性颅内出血的发生率为4%;两组之间的发生率均无差异。在所有患者中，取栓术组和标准治疗组的改良兰金量表平均评分无差异（3.9 vs. 3.9，P = 0.99）。在具有良好半影模式（平均评分，3.9 vs. 3.4; P = 0.23）或非半影模式（平均评分，4.0 vs. 4.4; P = 0.32）的患者中，栓子切除术并不上级标准治疗。在90天改良兰金量表评分的主要分析中，治疗前成像模式和治疗分配之间无相互作用（P = 0.14）。神经影像学上有利的半影模式并不能识别出从急性缺血性卒中血管内治疗中获益的患者，也没有显示栓子切除术上级标准治疗。（由国家神经疾病和中风研究所资助; MR RESCUE ClinicalTrials.gov编号，NCT 00389467。
Whether brain imaging can identify patients who are most likely to benefit from therapies for acute ischemic stroke and whether endovascular thrombectomy improves clinical outcomes in such patients remains unclear. In this study, we randomly assigned patients within 8 hours after the onset of large-vessel, anterior-circulation strokes to undergo mechanical embolectomy (Merci Retriever or Penumbra System) or receive standard care. All patients underwent pretreatment computed tomography or magnetic resonance imaging of the brain. Randomization was stratified according to whether the patient had a favorable penumbral pattern (substantial salvageable tissue and small infarct core) or a non-penumbral pattern (large core or small or absent penumbra). We assessed outcomes using the 90-day modified Rankin scale, ranging from 0 (no symptoms) to 6 (dead). Among 118 eligible patients, the mean age was 65.5 years, the mean time to enrollment was 5.5 hours, and 58% had a favorable penumbral pattern. Revascularization in the embolectomy group was achieved in 67% of the patients. Ninety-day mortality was 21%, and the rate of symptomatic intracranial hemorrhage was 4%; neither rate differed across groups. Among all patients, mean scores on the modified Rankin scale did not differ between embolectomy and standard care (3.9 vs. 3.9, P = 0.99). Embolectomy was not superior to standard care in patients with either a favorable penumbral pattern (mean score, 3.9 vs. 3.4; P = 0.23) or a nonpenumbral pattern (mean score, 4.0 vs. 4.4; P = 0.32). In the primary analysis of scores on the 90-day modified Rankin scale, there was no interaction between the pretreatment imaging pattern and treatment assignment (P = 0.14). A favorable penumbral pattern on neuroimaging did not identify patients who would differentially benefit from endovascular therapy for acute ischemic stroke, nor was embolectomy shown to be superior to standard care. (Funded by the National Institute of Neurological Disorders and Stroke; MR RESCUE ClinicalTrials.gov number, NCT00389467.)