International Journal of Surgery 16 (2015) 36e41
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Analysis of prognostic factors of endovascular therapy in 59 patients with acute anterior circulation stroke: A retrospective cohort study e Observational Yang Yang, Chunyang Liang*, Qiang Zhang, Chunsen Shen, Shang Ma, Jinlong Mao, Ruxiang Xu Department of Neurosurgery, Affiliated Bayi Brain Hospital, General Hospital of Beijing Military Region, Beijing, China
h i g h l i g h t s The first choice of treatment for acute ischemic stroke is IV medicine. IAT has the most advantages. Endovascular therapy be used beyond the IVT time window.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 January 2015 Received in revised form 2 February 2015 Accepted 16 February 2015 Available online 2 March 2015
Introduction: Endovascular therapy (ET) is increasingly used for stroke patients out of the time window, based on the multimodal treatment (MMT) it can be used alone or in combination. The purpose of this study was to assess the outcome of intra-arterial thrombolysis (IAT) and MMT for acute anterior circulation ischemic stroke (ACIS), and reveal prognostic factors of ET in the authors' stroke center. Methods: A retrospective analysis of the data of 59 patients with ACIS who received ET from 2010 to 2014 in the stroke center was performed. A univariate analysis was conducted to reveal the differences between IAT and MMT, and the distinctions between favorable and unfavorable outcomes, logistic regression analysis was performed to determine the predictors of outcomes. Results: Thirty-four patients who accepted MMT had a higher baseline National Institutes of Health Stroke Scale score on admission (18.3 ± 4.2) compared with 25 patients who were treated with IAT (12.6 ± 4.3). The MMT group had a higher patent flow (23/34) (thrombolysis in myocardial infarction grade 2e3) compared with the IAT group (10/25). Moreover, the MMT group had a longer time for emergency department (ED) (5.8 ± 1.4) than the IAT group (5.2 ± 0.8). In multivariate analysis, age, time to ED, and NIHSS score at discharge are predictors for poor outcome, whereas perfect recanalization was associated with favorable outcome. Conclusion: MMT might be suitable for patients with a severe admission NIHSS and a higher patency rate than IAT. Vessel recanalization was the only predictor for favorable outcome. © 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Anterior circulation occlusion Endovascular therapy Intra arterial thrombolysis Multimode therapy Stroke
1. Introduction Ischemic stroke caused by the anterior circulation occlusion is a devastating cause of suffering to the patient, especially during the acute attack, due to the high rates of mortality and poor functional outcome. Intravenous (IV) use of recombinant tissue plasminogen
* Corresponding author. E-mail address: [email protected] (C. Liang). http://dx.doi.org/10.1016/j.ijsu.2015.02.013 1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
activator (rt-PA) is the gold standard of therapy for patients with acute ischemic stroke. However, this treatment approach is limited by not only the short time window of 3e4.5 h [1e3] but also the high reocclusion rate (34%) after thrombolysis, which has been shown by transcranial Doppler imaging and might result in neurological worsening in many patients [4e6]. Various cases reported that local intra-arterial thrombolysis (IAT) can be beneficial since the randomized trials [7e9]. There were other reports about combined intravenous thrombolysis (IVT)eIAT or the combination of endovascular therapy using drugs, mostly the rt-PA, and
Y. Yang et al. / International Journal of Surgery 16 (2015) 36e41
mechanical methods for relatively large lesions to enhance the chances of vessel reperfusion [10e16]. Recently, the Interventional Management of Stroke (IMS) study, which is a prospective, multicenter, randomized controlled trial, showed that the combination of endovascular therapy and IV rt-PA gain a similar safety outcome and has no significant differences in functional independence when compared with systemic rt-PA [17]. The existing data show that higher rates of recanalization were achieved with endovascular methods, particularly mechanical therapies, and consequently were associated with better outcomes [18]. However, there is no data suggesting that the multimode perfusion rate can be more beneficial than the intra-arterial (IA) drugs and lead to better outcomes. The aim of this study was to reveal the prognosis of anterior circulation stroke in patients who underwent IVTeIAT rt-PA and MMT, which might have the potential to show the predictors of endovascular therapy outcome. 2. Patients and methods 2.1. Patients and treatment A total of 304 patients were admitted due to acute stroke symptoms between May 2011 and June 30, 2014 in the authors' stroke center. A total of 153 patients received IAT or MMT, 65 patients of whom had an occlusion in the anterior circulation identified by magnetic resonance angiography (MRA), computed tomography angiography (CTA), or digital subtraction angiography (DSA). A total of 6 patients, including the 3 patients in the follow-up stage, were excluded due to missing data in this study. This retrospective analysis of all the data was approved by the institutional review board, and the study is compliant with the STROBE criteria [19]. A patient transported to the emergency department (ED) went through an urgent initial evaluation, following which the medical history was obtained from the patient or bystanders, which focused on the time of stroke onset; the stroke severity was recorded by using the National Institutes of Health Stroke Scale (NIHSS). IV access was established, blood pressure (BP) and glucose levels were checked, and blood samples were collected. Then the patient underwent the following procedures: cranial computed tomography (CT) perfusion to exclude hemorrhage; diffusion weighted imaging to evaluate whether the lesion is new; magnetic resonance imaging (MRI) perfusion and diffusion imaging for measuring the infarct core and penumbra; CTA, MRA, or DSA to show the localization of the occlusion sites. The results of all these procedures were revealed no more than 45 min after the arrival of the patient in the ED by a physician with expertise in reading CT and MRI studies of the brain parenchyma. The inclusion criteria for IVTeIAT were the following: BP controlled no more than 185/110 mmHg, a baseline NIHSS score of 4, diagnosis of vessel stenosis or occlusion due to the embolus, the time from symptom onset to treatment no longer than 6 h, hemorrhage being excluded in the CT scan. It has to be ensured that the informed consent is noticed by the patient or the immediate family members. The exclusion criteria were as follows: deep coma (Glasgow Coma Scale 1.5 s, platelet count of
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Analysis of prognostic factors of endovascular therapy in 59 patients with acute anterior circulation stroke: A retrospective cohort study e Observational Yang Yang, Chunyang Liang*, Qiang Zhang, Chunsen Shen, Shang Ma, Jinlong Mao, Ruxiang Xu Department of Neurosurgery, Affiliated Bayi Brain Hospital, General Hospital of Beijing Military Region, Beijing, China
h i g h l i g h t s The first choice of treatment for acute ischemic stroke is IV medicine. IAT has the most advantages. Endovascular therapy be used beyond the IVT time window.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 January 2015 Received in revised form 2 February 2015 Accepted 16 February 2015 Available online 2 March 2015
Introduction: Endovascular therapy (ET) is increasingly used for stroke patients out of the time window, based on the multimodal treatment (MMT) it can be used alone or in combination. The purpose of this study was to assess the outcome of intra-arterial thrombolysis (IAT) and MMT for acute anterior circulation ischemic stroke (ACIS), and reveal prognostic factors of ET in the authors' stroke center. Methods: A retrospective analysis of the data of 59 patients with ACIS who received ET from 2010 to 2014 in the stroke center was performed. A univariate analysis was conducted to reveal the differences between IAT and MMT, and the distinctions between favorable and unfavorable outcomes, logistic regression analysis was performed to determine the predictors of outcomes. Results: Thirty-four patients who accepted MMT had a higher baseline National Institutes of Health Stroke Scale score on admission (18.3 ± 4.2) compared with 25 patients who were treated with IAT (12.6 ± 4.3). The MMT group had a higher patent flow (23/34) (thrombolysis in myocardial infarction grade 2e3) compared with the IAT group (10/25). Moreover, the MMT group had a longer time for emergency department (ED) (5.8 ± 1.4) than the IAT group (5.2 ± 0.8). In multivariate analysis, age, time to ED, and NIHSS score at discharge are predictors for poor outcome, whereas perfect recanalization was associated with favorable outcome. Conclusion: MMT might be suitable for patients with a severe admission NIHSS and a higher patency rate than IAT. Vessel recanalization was the only predictor for favorable outcome. © 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Anterior circulation occlusion Endovascular therapy Intra arterial thrombolysis Multimode therapy Stroke
1. Introduction Ischemic stroke caused by the anterior circulation occlusion is a devastating cause of suffering to the patient, especially during the acute attack, due to the high rates of mortality and poor functional outcome. Intravenous (IV) use of recombinant tissue plasminogen
* Corresponding author. E-mail address: [email protected] (C. Liang). http://dx.doi.org/10.1016/j.ijsu.2015.02.013 1743-9191/© 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
activator (rt-PA) is the gold standard of therapy for patients with acute ischemic stroke. However, this treatment approach is limited by not only the short time window of 3e4.5 h [1e3] but also the high reocclusion rate (34%) after thrombolysis, which has been shown by transcranial Doppler imaging and might result in neurological worsening in many patients [4e6]. Various cases reported that local intra-arterial thrombolysis (IAT) can be beneficial since the randomized trials [7e9]. There were other reports about combined intravenous thrombolysis (IVT)eIAT or the combination of endovascular therapy using drugs, mostly the rt-PA, and
Y. Yang et al. / International Journal of Surgery 16 (2015) 36e41
mechanical methods for relatively large lesions to enhance the chances of vessel reperfusion [10e16]. Recently, the Interventional Management of Stroke (IMS) study, which is a prospective, multicenter, randomized controlled trial, showed that the combination of endovascular therapy and IV rt-PA gain a similar safety outcome and has no significant differences in functional independence when compared with systemic rt-PA [17]. The existing data show that higher rates of recanalization were achieved with endovascular methods, particularly mechanical therapies, and consequently were associated with better outcomes [18]. However, there is no data suggesting that the multimode perfusion rate can be more beneficial than the intra-arterial (IA) drugs and lead to better outcomes. The aim of this study was to reveal the prognosis of anterior circulation stroke in patients who underwent IVTeIAT rt-PA and MMT, which might have the potential to show the predictors of endovascular therapy outcome. 2. Patients and methods 2.1. Patients and treatment A total of 304 patients were admitted due to acute stroke symptoms between May 2011 and June 30, 2014 in the authors' stroke center. A total of 153 patients received IAT or MMT, 65 patients of whom had an occlusion in the anterior circulation identified by magnetic resonance angiography (MRA), computed tomography angiography (CTA), or digital subtraction angiography (DSA). A total of 6 patients, including the 3 patients in the follow-up stage, were excluded due to missing data in this study. This retrospective analysis of all the data was approved by the institutional review board, and the study is compliant with the STROBE criteria [19]. A patient transported to the emergency department (ED) went through an urgent initial evaluation, following which the medical history was obtained from the patient or bystanders, which focused on the time of stroke onset; the stroke severity was recorded by using the National Institutes of Health Stroke Scale (NIHSS). IV access was established, blood pressure (BP) and glucose levels were checked, and blood samples were collected. Then the patient underwent the following procedures: cranial computed tomography (CT) perfusion to exclude hemorrhage; diffusion weighted imaging to evaluate whether the lesion is new; magnetic resonance imaging (MRI) perfusion and diffusion imaging for measuring the infarct core and penumbra; CTA, MRA, or DSA to show the localization of the occlusion sites. The results of all these procedures were revealed no more than 45 min after the arrival of the patient in the ED by a physician with expertise in reading CT and MRI studies of the brain parenchyma. The inclusion criteria for IVTeIAT were the following: BP controlled no more than 185/110 mmHg, a baseline NIHSS score of 4, diagnosis of vessel stenosis or occlusion due to the embolus, the time from symptom onset to treatment no longer than 6 h, hemorrhage being excluded in the CT scan. It has to be ensured that the informed consent is noticed by the patient or the immediate family members. The exclusion criteria were as follows: deep coma (Glasgow Coma Scale 1.5 s, platelet count of
