Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data
Penumbral imaging and functional outcome in patients with anterior circulation ischaemic stroke treated with endovascular thrombectomy versus medical therapy: a meta-analysis of individual patient-level data
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DOI：
10.1016/s1474-4422(18)30314-4
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发表时间：
2019-01-01
期刊：
影响因子：
48
通讯作者：
Mitchell, Peter J.
中科院分区：
文献类型：
--
作者：
Campbell, Bruce C. V.;Majoie, Charles B. L. M.;Mitchell, Peter J.
背景CT灌注(CTP)和弥散或灌注MRI可帮助患者选择血管内取栓术。我们的目标是确定对不可逆损伤的缺血核心和潜在可挽救的半影区体积的成像评估是否与功能结果相关，以及它们是否与血管内血栓切除术对功能结果的治疗效果相互作用。方法在这项系统回顾和荟萃分析中，Hermes协作汇集了所有随机对照试验的患者水平数据，这些试验比较了血管内血栓切除术(主要使用支架取回器)和标准药物治疗前循环缺血性中风患者，这些试验发表在2010年1月1日至2017年5月31日的《公共医学》杂志上。主要终点是功能结果，在卒中后90天用改良的Rankin量表(MRS)进行评估。在行血管内取栓术或常规内科治疗前，以CTP表示相对脑血流量<正常脑血流量的30%或MRI表示表观弥散系数<620mum(2)/S作为缺血核心，以临界低灌注组织体积估计为CTP达到最大时间大于6 S的组织体积，错配体积(即估计的半暗带体积)计算为临界低灌注组织体积减去缺血核心体积。用多变量Logistic回归(功能独立性，定义为MRS评分0-2)和有序Logistic回归(功能改善至少一个MRS类别)分析所有患者和血管内再灌注率超过50%的患者的子集的缺血核心和半暗带体积与90天MRS评分的相关性，并对基线预后变量进行调整。这项荟萃分析是由Hermes执行委员会前瞻性设计的，但没有注册。结果我们确定了7项研究，涉及1764名患者，所有研究都包括在荟萃分析中。591名(34%)患者可以使用和评估CTP，309名(18%)患者可以使用弥散磁共振成像。在调整了缺血核心体积(优势比[OR]0.47[95%CI0.30-0.72]，p=0.0007)后，接受CTP的患者的功能独立性比接受弥散成像的患者更差，因此不能合并成像方式。脑缺血核心体积的增加与功能独立的可能性降低相关(CTP OR 0.77[0.69~0.86]/10mL，p(交互作用)=0.29；弥散磁共振OR 0.87[0.81~0.94]/10mL，p(交互作用)=0.94)。由于接受磁共振灌注成像的患者数量较少，仅在CTP组中检查了不匹配的体积，这与功能独立性或功能改善无关。在血管内再灌注率超过50%的CTP患者(n=186)中，年龄、缺血核心体积和成像到再灌注时间与功能改善独立相关。研究之间的偏差风险一般较低。解释估计的缺血核心体积与功能独立性和功能改善独立相关，但并不改变血管内血栓摘除术相对于标准药物治疗改善功能结果的治疗益处。结合缺血核心体积、年龄和预期的显影至再灌注时间将改善预后评估，并可能为血管内血栓切除术治疗决策提供信息。版权所有(C)2018爱思唯尔有限公司。保留所有权利。
Background CT perfusion (CTP) and diffusion or perfusion MRI might assist patient selection for endovascular thrombectomy. We aimed to establish whether imaging assessments of irreversibly injured ischaemic core and potentially salvageable penumbra volumes were associated with functional outcome and whether they interacted with the treatment effect of endovascular thrombectomy on functional outcome.Methods In this systematic review and meta-analysis, the HERMES collaboration pooled patient-level data from all randomised controlled trials that compared endovascular thrombectomy (predominantly using stent retrievers) with standard medical therapy in patients with anterior circulation ischaemic stroke, published in PubMed from Jan 1,2010, to May 31, 2017. The primary endpoint was functional outcome, assessed by the modified Rankin Scale (mRS) at 90 days after stroke. Ischaemic core was estimated, before treatment with either endovascular thrombectomy or standard medical therapy, by CTP as relative cerebral blood flow less than 30% of normal brain blood flow or by MRI as an apparent diffusion coefficient less than 620 mu m(2)/s. Critically hypoperfused tissue was estimated as the volume of tissue with a CTP time to maximum longer than 6 s. Mismatch volume (ie, the estimated penumbral volume) was calculated as critically hypoperfused tissue volume minus ischaemic core volume. The association of ischaemic core and penumbral volumes with 90-day mRS score was analysed with multivariable logistic regression (functional independence, defined as mRS score 0-2) and ordinal logistic regression (functional improvement by at least one mRS category) in all patients and in a subset of those with more than 50% endovascular reperfusion, adjusted for baseline prognostic variables. The meta-analysis was prospectively designed by the HERMES executive committee, but not registered.Findings We identified seven studies with 1764 patients, all of which were included in the meta-analysis. CTP was available and assessable for 591 (34%) patients and diffusion MRI for 309 (18%) patients. Functional independence was worse in patients who had CTP versus those who had diffusion MRI, after adjustment for ischaemic core volume (odds ratio [OR] 0.47 [95% CI 0.30-0.72], p=0.0007), so the imaging modalities were not pooled. Increasing ischaemic core volume was associated with reduced likelihood of functional independence (CTP OR 0.77 [0.69-0.86] per 10 mL, p(interaction)=0.29; diffusion MRI OR 0.87 [0.81-0.94] per 10 mL, p(interaction)=0.94). Mismatch volume, examined only in the CTP group because of the small numbers of patients who had perfusion MRI, was not associated with either functional independence or functional improvement. In patients with CTP with more than 50% endovascular reperfusion (n=186), age, ischaemic core volume, and imaging-to-reperfusion time were independently associated with functional improvement. Risk of bias between studies was generally low.Interpretation Estimated ischaemic core volume was independently associated with functional independence and functional improvement but did not modify the treatment benefit of endovascular thrombectomy over standard medical therapy for improved functional outcome. Combining ischaemic core volume with age and expected imagingto-reperfusion time will improve assessment of prognosis and might inform endovascular thrombectomy treatment decisions. Copyright (C) 2018 Elsevier Ltd. All rights reserved.