Association of Multiple Passes during Mechanical Thrombectomy with Incomplete Reperfusion and Lesion Growth.
Association of Multiple Passes during Mechanical Thrombectomy with Incomplete Reperfusion and Lesion Growth.
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机械血栓切除术期间多次通过与不完全再灌注和病变生长的关联。
DOI：
10.1159/000519796
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发表时间：
2022
影响因子：
2.9
通讯作者：
Lynch, John K.
中科院分区：
文献类型：
--
作者：
Luby, Marie;Merino, Jose G.;Davis, Rachel;Ansari, Saeed;Fisher, Marc;Hsia, Amie W.;Kim, Yongwoo;Latour, Lawrence L.;McCreedy, Evan S.;Sukhdeo Singh, Rena;Wright, Clinton B.;Lynch, John K.
尽管通过机械血栓切除术实现了完全再通，但血管内治疗 (EVT) 后获得的 MRI 仍可检测到灌注异常。 EVT 后残留灌注异常的存在可能与血脑屏障 (BBB) 破坏有关，血脑屏障 (BBB) 因多次血栓切除术对内皮的机械破坏而破裂。我们假设，与单次血栓切除术相比，多次血栓切除术与较高的残余灌注不足率和 24 小时内病灶生长增加相关。在这项分析中，我们纳入了 2015 年 1 月至 2018 年 2 月期间在两个卒中中心之一就诊的患者，如果他们在 MRA 或 CTA 上记录了前循环大血管闭塞 (LVO)，则症状出现后 12 小时内发生急性缺血性卒中，且 EVT 前基线 MRI 具有灌注不足的影像学证据，接受 EVT 治疗，并进行 EVT 后 MRI 检查，并在 24 小时进行定性可解释的 PWI 数据。使用> 6秒的时间延迟阈值的MRI Tmax图用于量化低灌注量。 24小时残余灌注不足仅定义为Tmax体积>10mL且延迟>6秒。完全再通定义为 EVT 完成时血管造影显示的脑梗塞 (mTICI 3) 的改良治疗。在 24 小时时对 EVT 后造影前液体衰减反转恢复 (FLAIR) 进行高信号急性再灌注损伤标志物 (HARM) 评估。主要早期神经功能改善（mENI）定义为入院 NIHSS 降低 ≥8 分或 24 小时评分为 0-1。良好的功能结果定义为 0-2（最新可用的第 30 天或 90 mRS）。纳入的 55 名患者中位年龄为 67 岁，其中 58% 为女性，45% 为黑人/非裔美国人，36% 为白人/白种人，入院中位 NIHSS 19，LVO 位置：71% M1、14.5% iICA、14.5% M2，69% 接受 IV rtPA 治疗。其中，58% 的患者接受了多次血栓切除术，39% 的患者在 24 小时内出现残余灌注异常，64% 的患者在 24 小时内出现严重的 HARM。调整完全再通后，只有多次血栓切除术（比值比，4.3±95% CI，1.07-17.2；p=0.04）是24小时残余灌注不足的独立预测因子。残留灌注不足的患者在 DWI 上病灶生长较大（59mL vs 8mL，p<0.001），24 小时 mENI 发生率较低（24% vs 70%，p=0.002），并且根据 30 或 90 天 mRS 的长期结果较差，5 vs 2（p<0.001）。我们的研究结果表明，即使在一些 EVT 时成功再通的患者中，EVT 后 MRI 上也存在不完全再灌注，并且与多次血栓切除术、病变生长和较差的结果相关。未来的研究需要调查残余灌注不足的患者是否可以从立即辅助治疗中受益，以限制病变生长并改善临床结果。
Despite complete recanalization by mechanical thrombectomy, abnormal perfusion can be detected on MRI obtained post-endovascular therapy (EVT). The presence of residual perfusion abnormalities post-EVT may be associated with blood-brain barrier (BBB) breakdown in response to mechanical disruption of the endothelium from multiple-pass thrombectomy. We hypothesize that multiple-pass vs single-pass thrombectomy is associated with a higher rate of residual hypoperfusion and increased lesion growth at 24 hours. For this analysis, we included patients presenting to one of two stroke centers between January 2015 and February 2018 with an acute ischemic stroke within 12 hours from symptom onset if they had a large vessel occlusion (LVO) of the anterior circulation documented on MRA or CTA, baseline MRI pre-EVT with imaging evidence of hypoperfusion, underwent EVT, and had a post-EVT MRI with qualitatively interpretable PWI data at 24 hours. MRI Tmax maps using a time delay threshold of >6 seconds were used to quantify hypoperfusion volumes. Residual hypoperfusion at 24 hours was solely defined as Tmax volume>10mL with >6 seconds delay. Complete recanalization was defined as modified treatment in cerebral infarction (mTICI 3) visualized on angiography at EVT completion. Hyperintense acute reperfusion injury marker (HARM) was assessed on post-EVT pre-contrast fluid attenuated inversion recovery (FLAIR) at 24 hours. Major early neurological improvement (mENI) was defined as a reduction of the admission NIHSS by ≥8 points or a score of 0-1 at 24 hours. Good functional outcome was defined a 0-2 on the latest available of day 30 or 90 mRS. Fifty-five patients were included with median age 67 years, 58% female, 45% Black/African-American, 36% White/Caucasian, median admission NIHSS 19, LVO locations: 71% M1, 14.5% iICA, 14.5% M2, 69% treated with IV rtPA. Of these, 58% had multiple-pass thrombectomy, 39% had residual perfusion abnormalities at 24 hours, and 64% had severe HARM at 24 hours. After adjusting for complete recanalization, only multiple-pass thrombectomy (odds ratio, 4.3 95% CI, 1.07-17.2; p=0.04) was an independent predictor of residual hypoperfusion at 24 hours. Patients with residual hypoperfusion had larger lesion growth on DWI (59mL vs 8mL, p<0.001), lower rate of mENI (24% vs 70%, p=0.002) at 24 hours, and worse long-term outcome based on mRS at 30 or 90 days, 5 vs 2 (p<0.001). Our findings suggest that incomplete reperfusion on post-EVT MRI is present even in some patients with successful recanalization at the time of EVT and is associated with multiple-pass thrombectomy, lesion growth, and worse outcome. Future studies are needed to investigate whether patients with residual hypoperfusion may benefit from immediate adjunctive therapy to limit lesion growth and improve clinical outcome.
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