Association of Reperfusion With Brain Edema in Patients With Acute Ischemic Stroke A Secondary Analysis of the MR CLEAN Trial
Association of Reperfusion With Brain Edema in Patients With Acute Ischemic Stroke A Secondary Analysis of the MR CLEAN Trial
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DOI：
10.1001/jamaneurol.2017.5162
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发表时间：
2018-04-01
期刊：
影响因子：
29
通讯作者：
Majoie, Charles B. L. M.
中科院分区：
文献类型：
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作者：
Kimberly, W. Taylor;Dutra, Bruna Garbugio;Majoie, Charles B. L. M.
血管内治疗性再灌注是否产生更多或更少的脑水肿尚不确定。目的阐明再灌注与脑水肿之间的关系。次要目的是评估脑水肿是否可能部分导致再灌注延迟或阿尔伯塔卒中项目早期计算机断层扫描评分较低的患者的不良结局。设计、设置和参与者这是对荷兰急性缺血性卒中血管内治疗的多中心随机临床试验的事后分析（MR CLEAN），这是一项比较急性前循环缺血性卒中患者血管内治疗与传统护理的前瞻性、随机、多中心临床试验。在2010年12月至2014年6月入组的502例患者中，2例患者拒绝参加。此外，排除标准是没有随访成像或存在脑实质血肿，导致462例患者纳入本研究。从2016年12月10日至2017年7月24日，通过测量所有可用随访扫描的中线移位（MLS），对脑水肿进行回顾性评估。观察者对临床数据不知情。主要结果和指标中线偏移被评估为存在或不存在，并作为一个连续变量。血管内治疗组采用改良脑梗死溶栓评分评估再灌注状态，两组均采用改良动脉闭塞病变评分评估再通状态。在90天的改良兰金量表评分用于功能outcome.Results的462例患者，平均（SD）年龄为65（11）岁，41.8%（n = 193）是女性。成功的再灌注和再通与MLS发生的可能性降低相关（分别为校正后的普通比值比0.25; 95%CI 0.12-0.53; P <0.001和校正后的普通比值比0.34; 95%CI 0.21-0.55; P <0.001）。中线移位是没有再灌注或再通的患者改良兰金量表评分变差的部分原因（MLS分别改变了30.3%和12.6%的logistic回归系数）。在延迟再灌注或较低的阿尔伯塔中风项目早期计算机断层扫描评分的患者中，MLS介导的部分更差的改良兰金量表评分，对应于回归系数的变化分别为33.3%和64.2%，respectively.CONCLUSIONS AND RELEVANCE成功再灌注与MLS减少相关。这项研究确定了再灌注与水肿有关的额外益处，以及挽救有梗死风险的缺血性脑组织。
IMPORTANCE It is uncertain whether therapeutic reperfusion with endovascular treatment yields more or less brain edema.OBJECTIVE To elucidate the association between reperfusion and brain edema. The secondary objectives were to evaluate whether brain edema could partially be responsible for worse outcomes in patients with later reperfusion or lower Alberta Stroke Program Early Computed Tomography Score.DESIGN, SETTING, AND PARTICIPANTS This was a post hoc analysis of the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN), which was a prospective, randomized, multicenter clinical trial of endovascular treatment compared with conventional care of patients with acute anterior circulation ischemic stroke. Of 502 patients enrolled from December 2010 to June 2014, 2 patients declined to participate. Additionally, exclusion criteria were absence of follow-up imaging or presence of parenchymal hematoma, resulting in 462 patients included in this study. Brain edema was assessed retrospectively, from December 10, 2016, to July 24, 2017, by measuring midline shift (MLS) in all available follow-up scans. Observers were blinded to clinical data.MAIN OUTCOMES AND MEASURES Midline shift was assessed as present or absent and as a continuous variable. Reperfusion status was assessed by the modified thrombolysis in cerebral infarction score in the endovascular treatment arm. The modified arterial occlusive lesion score was used to evaluate the recanalization status in both arms. The modified Rankin scale score at 90 days was used for functional outcome.RESULTS Of 462 patients, the mean (SD) age was 65 (11) years, and 41.8%(n = 193) were women. Successful reperfusion and recanalization were associated with a reduced likelihood of having MLS (adjusted common odds ratio, 0.25; 95% CI, 0.12-0.53; P < .001 and adjusted common odds ratio, 0.34; 95% CI, 0.21-0.55; P < .001, respectively). Midline shift was partially responsible for worse modified Rankin scale scores in patients without reperfusion or recanalization (MLS changed the logistic regression coefficients by 30.3% and 12.6%, respectively). In patients with delayed reperfusion or lower Alberta Stroke Program Early Computed Tomography Score, MLS mediated part of the worse modified Rankin scale scores, corresponding to a change in the regression coefficient of 33.3% and 64.2%, respectively.CONCLUSIONS AND RELEVANCE Successful reperfusion was associated with reduced MLS. This study identifies an additional benefit of reperfusion in relation to edema, as well as rescuing ischemic brain tissue at risk for infarction.