Fast Versus Slow Progressors of Infarct Growth in Large Vessel Occlusion Stroke Clinical and Research Implications
Fast Versus Slow Progressors of Infarct Growth in Large Vessel Occlusion Stroke Clinical and Research Implications
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DOI：
10.1161/strokeaha.117.017673
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发表时间：
2017-09-01
期刊：
影响因子：
8.3
通讯作者：
Jovin, Tudor G.
中科院分区：
文献类型：
--
作者：
Rocha, Marcelo;Jovin, Tudor G.
2622 中风 2017 年 9 月 脑水肿和有症状的颅内出血，这定义了恶性特征。 27 由于此类患者的良好结果率最低，因此他们被认为对再灌注反应不佳。 27 然而，与单独的标准药物治疗相比，对于出现大面积梗死并在症状出现后早期接受治疗的 LVO 卒中超快进展者，机械取栓的益处尚未完全排除。 28 尽管如此，这一亚组患者仍然在很大程度上被排除在急性血管内治疗之外，因为以前认为再灌注在这种情况下是有害的，因为症状性颅内出血和恶性水肿的发生率增加。另一方面，大型转诊中心前循环 LVO 患者的慢进展发生率可能≤ 30%。 17 据报道，据报道，进展缓慢的患者在卒中发生 8 小时后仍可从血管内再灌注中获得实质性益处，且安全性合理，因此检验这一假设的 29 项随机临床试验已成为该领域的优先事项。 30 最近，已完成和正在进行的试验正在测试血管内治疗对急性 MCA/ICA 闭塞后 24 小时内可能出现的患者的益处（NCT01852201、NCT02142283 和 NCT02586415）。 DAWN（在接受 Trevo 神经干预的苏醒和迟发中风分类中进行临床不匹配的 DWI 或 CTP 评估）的初步结果显示，延迟再灌注对小核缺血患者具有临床益处。这强化了这样一个概念：不进行再灌注的缓慢进展者最终也会像快速进展者一样获得不良结果。这项研究的结果正在等待在同行评审期刊上发表。然而，由于急性 LVO 导致的梗塞快速和缓慢进展的潜在病理生理学尚不完全清楚。
2622 Stroke September 2017 cerebral edema and symptomatic intracranial hemorrhage, which defines a malignant profile. 27 Because such patients have lowest rates of favorable outcomes, they are thought to respond poorly to reperfusion. 27 However, when compared with standard medical therapy alone, the benefit of mechanical thrombectomy has not been entirely ruled out in ultrafast progressors of LVO stroke who present with large infarcts and are treated early after symptom onset. 28 Nonetheless, this subgroup of patients remains largely excluded from acute endovascular treatment because of the previously held belief that reperfusion is detrimental in this circumstance because of increased incidence of symptomatic intracranial hemorrhage and malignant edema. On the other end, the incidence of slow progressors may be≤ 30% of patients with anterior circulation LVO in large referral centers. 17 Because slow progressors have been reported to still derive substantial benefit from endovascular reperfusion well after 8 hours after stroke onset with a reasonable safety profile, 29 randomized clinical trials to test this hypothesis have become a priority for the field. 30 Recently, completed and ongoing trials are testing the benefit of endovascular therapy in patients who may present≤ 24 hours after acute MCA/ICA occlusion (NCT01852201, NCT02142283, and NCT02586415). Preliminary results of DAWN (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention with Trevo) have shown clinical benefit of delayed reperfusion in patients with small ischemic cores. This reinforces the concept that slow progressors who do not reperfuse will eventually also have poor outcomes as fast progressors. The findings of this study await publication in peer-reviewed journals. However, the underlying pathophysiology of fast and slow progressors of infarction because of acute LVO is not completely understood.