JAMA:急性缺血性卒中，颅内血栓再通与临床、影像和血栓特征的关系
AbstractImportance: Recanalization of intracranial thrombus is associated with improved clinical outcome in patients with acute ischemic stroke. The association of intravenous alteplase treatment and thrombus characteristics with recanalization over time is important for stroke triage and future trial design.Objective: To examine recanalization over time across a range of intracranial thrombus occlusion sites and clinical and imaging characteristics in patients with ischemic stroke treated with intravenous alteplase or not treated with alteplase.
Design, Setting, and Participants: Multicenter prospective cohort study of 575 patients from 12 centers (in Canada, Spain, South Korea, the Czech Republic, and Turkey) with acute ischemic stroke and intracranial arterial occlusion demonstrated on computed tomographic angiography (CTA).
Exposures: Demographics, clinical characteristics, time from alteplase to recanalization, and intracranial thrombus characteristics (location and permeability) defined on CTA.
Main Outcomes and Measures: Recanalization on repeat CTA or on first angiographic acquisition of affected intracranial circulation obtained within 6 hours of baseline CTA, defined using the revised arterial occlusion scale (rAOL) (scores from 0 to 3 ).
Results: Among 575 patients (median age, 72 years ; 51.5% men; median time from patient last known well to baseline CTA of 114 minutes ), 275 patients (47.8%) received intravenous alteplase only, 195 (33.9%) received intravenous alteplase plus endovascular thrombectomy, 48 (8.3%) received endovascular thrombectomy alone, and 57 (9.9%) received conservative treatment. Median time from baseline CTA to recanalization assessment was 158 minutes (IQR, 79-268); median time from intravenous alteplase start to recanalization assessment was 132.5 minutes (IQR, 62-238). Successful recanalization occurred at an unadjusted rate of 27.3% (157/575) overall, including in 30.4% (143/470) of patients who received intravenous alteplase and 13.3% (14/105) who did not (difference, 17.1% ). Among patients receiving alteplase, the following factors were associated with recanalization: time from treatment start to recanalization assessment (OR, 1.28 for every 30-minute increase in time ), more distal thrombus location, eg, distal M1 middle cerebral artery (39/84 ) vs internal carotid artery (10/92 ) (OR, 5.61 ), and higher residual flow (thrombus permeability) grade, eg, hairline streak (30/45 ) vs none (91/377 ) (OR, 7.03 ).
Conclusions and Relevance: In patients with acute ischemic stroke, more distal thrombus location, greater thrombus permeability, and longer time to recanalization assessment were associated with recanalization of arterial occlusion after administration of intravenous alteplase; among patients who did not receive alteplase, rates of arterial recanalization were low. These findings may help inform treatment and triage decisions in patients with acute ischemic stroke.
急性缺血性脑卒中颅内血栓再通与提高临床预后是密切相关的。经静脉阿替普酶治疗与再通后血栓岁时间变化特点的相关性对于脑卒中分类治疗及远期分类管理是及其重要的。由Bijoy K. Menon等研究人员对上述两者的相关性进行研究，并得到了突破性发现，并将结果撰文发表于JAMA顶尖杂志。
Bijoy K. Menon分析并总结了服用阿替普酶治疗的急性缺血性脑卒中患者颅内血栓栓塞血管再通后随时间的变化特点及相应临床、影像学特点。
该研究在多个中心共收集了575例急性缺血性脑卒中并CT显示颅内动脉闭塞的患者，收集了患者人口学特征、临床病史、自服用阿替普酶至血管再通的时间及CTA中血肿的影像学特点等资料。主要结果评价标准为在行基线CTA6小时内对责任血管进行再次CTA或进行初次血管造影检查时血管再通，再通标准参照rAOL评分（评分为0-3，0为闭塞未见明显变化，3为闭塞完全再通）。
在纳入的575例患者中，共有275(47.8%)例患者仅接受了经静脉阿替普酶治疗，195 (33.9%)例患者接受了经静脉阿替普酶联合介入取栓术治疗，48 (8.3%)例患者仅接受了介入取栓术治疗，而有57(9.9%)患者接受了保守治疗。自基线CTA检查至血管再通评价的中位数时间为158分钟 (IQR， 79-268)；自接受阿替普酶治疗至血管再通评价的中位数时间为132.5 分钟(IQR， 62-238)。整体上，血管再通率为27.3% (157/575)，其中包括接受了经静脉阿替普酶治疗的患者占30.4% (143/470)，未接受经静脉阿替普酶治疗的患者占13.3% (14/105) (相差17.1% )。在接受经静脉阿替普酶治疗的患者中，与血管再通相关的指标有：接受阿替普酶治疗至血管再通评价的时间(每增加30分钟，OR增加1.28 )、血栓位置更远（如大脑中动脉远端(39/84 )与颈内动脉(10/92 )）及储备侧支循环能力越强（如线样侧枝循环(30/45 )与无侧枝循环(91/377 )(OR， 7.03 )）。
本研究表明，对于急性缺血性脑卒中的患者，血栓位置越远、血栓渗透性越高、治疗时间到血栓评价的时间越长是经静脉阿替普酶治疗后动脉闭塞后再通的相关指标；在未接受阿替普酶治疗的患者，动脉闭塞后再通几率很小。本研究发现有助于对急性缺血性脑卒中患者治疗和危险分级决策的制定。
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