Association of Thrombectomy With Stroke Outcomes Among Patient Subgroups Secondary Analyses of the DEFUSE 3 Randomized Clinical Trial

被引：22

作者：

Lansberg, Maarten G. ^{[1
]}

Mlynash, Michael ^{[1
]}

Hamilton, Scott ^{[1
]}

Yeatts, Sharon D. ^{[2
]}

Christensen, Soren ^{[1
]}

Kemp, Stephanie ^{[1
]}

Lavori, Philip W. ^{[1
]}

Ortega-Gutierrez, Santiago ^{[3
,5
]}

Broderick, Joe ^{[4
]}

Heit, Jeremy ^{[1
]}

Marks, Michael P. ^{[1
]}

Albers, Gregory W. ^{[1
]}

Ortega-Gutierrez, Santiago ^{[3
,5
]}

Leira, Enrique ^{[5
]}

McTaggart, Ryan ^{[6
]}

Yaghi, Shadi ^{[6
]}

Torbey, Michel ^{[7
]}

Powers, Ciaran J. ^{[7
]}

Kim-Tenser, May ^{[8
]}

Tenser, Matthew ^{[8
]}

Lansberg, Maarten ^{[9
]}

Marks, Michael ^{[9
]}

Leslie-Mazwi, Thabele ^{[10
]}

Hurst, Robert ^{[11
]}

Kasner, Scott ^{[12
]}

Sarraj, Amrou ^{[13
]}

Spiegel, Gary ^{[13
]}

Ansari, Sameer A. ^{[14
]}

Prabhakaran, Shyam ^{[14
]}

Altschul, Dorothea ^{[15
]}

de Havenon, Adam ^{[16
]}

Park, Min ^{[16
]}

Fifi, Johanna ^{[17
]}

Tuhrim, Stanley ^{[17
]}

Hoesch, Robert ^{[18
]}

Blatter, Duane ^{[18
]}

Kayan, Yasha ^{[19
]}

Young, Mark ^{[19
]}

Stephens, Ray ^{[20
]}

Finch, Ira ^{[20
]}

Afshinnik, Arash ^{[21
]}

Ryan, Robert ^{[21
]}

Chaudhary, Neeraj ^{[22
]}

Brown, Devin ^{[22
]}

Feske, Steven ^{[23
]}

Aziz-Sultan, Ali ^{[23
]}

Smith, Wade ^{[24
]}

Cooke, Daniel ^{[24
]}

Warach, Steven ^{[25
]}

Miley, Jefferson ^{[25
]}

机构：

[1] Stanford Univ, Stanford, CA 94305 USA

[2] Med Univ South Carolina, Charleston, SC 29425 USA

[3] Univ Iowa, Iowa City, IA USA

[4] Univ Cincinnati, Cincinnati, OH USA

[5] Univ Iowa Hosp & Clin, Iowa City, IA 52242 USA

[6] Rhode Isl Hosp, Providence, RI 02903 USA

[7] Ohio State Univ, Wexner Med Center

[8] Univ Southern Calif, Keck Hosp, Los Angeles, CA USA

[9] Stanford Univ, Med Ctr, Stanford, CA 94305 USA

[10] Massachusetts Gen Hosp, Boston, MA 02114 USA

[11] Hosp Univ Penn, Philadelphia, PA 19104 USA

[12] Univ Penn, Philadelphia, PA 19104 USA

[13] Mem Hermann Texas Med Ctr, Houston, TX USA

[14] Northwestern Univ, Feinberg Sch Med, Evanston, IL 60208 USA

[15] Valley Hosp, Las Vegas, NV USA

[16] Univ Utah Healthcare, Salt Lake City, UT USA

[17] Mt Sinai Hosp, New York, NY 10029 USA

[18] Intermt Med Ctr, Murray, UT USA

[19] Abbott NW Hosp, Minneapolis, MN USA

[20] John Muir Med Ctr, Walnut Creek, CA USA

[21] Univ Calif San Francisco, Fresno, CA USA

[22] Univ Michigan, Med Ctr, Ann Arbor, MI 48109 USA

[23] Brigham & Womens Hosp, Boston, MA 02115 USA

[24] Univ Calif San Francisco, Med Ctr, San Francisco, CA 94143 USA

[25] Univ Med Ctr Brackenridge, Dell Med Sch, Austin, TX USA

[26] Univ Wisconsin, Madison, WI 53706 USA

[27] Oregon Hlth & Sci Univ, Portland, OR 97201 USA

[28] Univ Alabama Birmingham, Birmingham, AL USA

[29] Scripps Mem Hosp La Jolla, La Jolla, CA USA

[30] Univ Calif San Diego, Med Ctr, Hillcrest Hosp, La Jolla, CA 92093 USA

[31] Beth Israel Deaconess Med Ctr, Boston, MA 02215 USA

[32] Palmetto Hlth Univ South Carolina, Columbia, SC 29208 USA

[33] Hennepin Cty Med Ctr, Minneapolis, MN 55415 USA

[34] Cleveland Clin, Cleveland, OH 44106 USA

[35] MedStar Washington Hosp Ctr, Washington, DC USA

[36] Univ Minnesota, Med Ctr Fairview, Minneapolis, MN 55455 USA

[37] Univ Cincinnati, Med Ctr, Cincinnati, OH 45221 USA

[38] NewYorkPresbyterian Columbia Univ, Med Ctr, New York, NY USA

[39] Mercy Hlth St Vincent Hosp & Med Ctr, Toledo, OH USA

[40] Vanderbilt Univ Sch Med, Nashville, TN USA

[41] NewYork Presbyterian Weill Cornell Med Ctr, New York, NY USA

[42] Providence Hlth & Serv, Renton, WA, Australia

[43] Harboiview Med Ctr, Seattle, WA USA

来源：

JAMA NEUROLOGY | 2019年 / 76卷 / 04期

关键词：

ISCHEMIC-STROKE; ENDOVASCULAR REPERFUSION; TIME; PERFUSION;

D O I：

10.1001/jamaneurol.2018.4587

中图分类号：

R74 [神经病学与精神病学];

学科分类号：

摘要：

IMPORTANCE The DEFUSE 3 randomized clinical trial previously demonstrated benefit of endovascular thrombectomy for acute ischemic stroke in the 6- to 16-hour time window. For treatment recommendations, it is important to know if the treatment benefit was universal. OBJECTIVE To determine the outcomes among patients who may have a reduced effect of thrombectomy, including those who are older, have milder symptoms, or present late. DESIGN, SETTING. AND PARTICIPANTS DEFUSE 3 was a randomized, open-label, blinded end point trial conducted from May 2016 to May 2017. This multicenter study included 38 sites in the United States. Of 296 patients who were enrolled in DEFUSE 3, 182 patients met all inclusion criteria and were randomized and included in the intention-to-treat analysis, which was conducted in August 2017. These patients had acute ischemic strokes due to an occlusion of the internal carotid artery or middle cerebral artery and evidence of salvageable tissue on perfusion computed tomography or magnetic resonance imaging. The study was stopped early for efficacy. INTERVENTIONS Endovascular thrombectomy plus medical management vs medical management alone. MAIN OUTCOMES AND MEASURES Functional outcome at day 90, assessed on the modified Rankin Scale. Multivariate ordinal logistic regression was used to calculate the adjusted proportional association between endovascular treatment and clinical outcome (shift in the distribution of modified Rankin Scale scores expressed as a common odds ratio) among patients of different ages, baseline stroke seventies, onset-to-treatment times, locations of the arterial occlusion, and imaging modalities used to document the presence of salvageable tissue (computed tomography vs magnetic resonance imaging). RESULTS This study included 182 patients (median [interquartile range] age, 70 [59-80] years; median [interquartile range] National Institutes of Health Stroke Scale score, 16 [11-21], and 92 women [51%]). In the overall cohort, independent predictors of better functional outcome were younger age, lower baseline National Institutes of Health Stroke Scale score, and lower serum glucose level. The common odds ratio for improved functional outcome with endovascular therapy, adjusted for these variables, was 3.1(95% CI, 1.8-5.4). There was no significant interaction between this treatment effect and age (P = .93), National Institutes of Health Stroke Scale score (P = .87), time to randomization (P = .56), imaging modality (P = .49), or location of the arterial occlusion (P = .54). CONCLUSIONS AND RELEVANCE Endovascular thrombectomy, initiated up to 16 hours after last known well time in patients with salvageable tissue on perfusion imaging, benefits patients with a broad range of clinical features. Owing to the small sample size of this study, a pooled analysis of late time window endovascular stroke trials is needed to confirm these results.

引用

页码：447 / 453

页数：7

共 13 条

[1] Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging [J].

Albers, G. W. ;

Marks, M. P. ;

Kemp, S. ;

Christensen, S. ;

Tsai, J. P. ;

Ortega-Gutierrez, S. ;

McTaggart, R. A. ;

Torbey, M. T. ;

Kim-Tenser, M. ;

Leslie-Mazwi, T. ;

Sarraj, A. ;

Kasner, S. E. ;

Ansari, S. A. ;

Yeatts, S. D. ;

Hamilton, S. ;

Mlynash, M. ;

Heit, J. J. ;

Zaharchuk, G. ;

Kim, S. ;

Carrozzella, J. ;

Palesch, Y. Y. ;

Demchuk, A. M. ;

Bammer, R. ;

Lavori, P. W. ;

Broderick, J. P. ;

Lansberg, M. G. .

NEW ENGLAND JOURNAL OF MEDICINE, 2018, 378 (08) :708-718

[2] A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3) [J].

Albers, Gregory W. ;

Lansberg, Maarten G. ;

Kemp, Stephanie ;

Tsai, Jenny P. ;

Lavori, Phil ;

Christensen, Soren ;

Mlynash, Michael ;

Kim, Sun ;

Hamilton, Scott ;

Yeatts, Sharon D. ;

Palesch, Yuko ;

Bammer, Roland ;

Broderick, Joe ;

Marks, Michael P. .

INTERNATIONAL JOURNAL OF STROKE, 2017, 12 (08) :896-905

[3] Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials [J].

Goyal, Mayank ;

Menon, Bijoy K. ;

van Zwam, Wim H. ;

Dippel, Diederik W. J. ;

Mitchell, Peter J. ;

Demchuk, Andrew M. ;

Davalos, Antoni ;

Majoie, Charles B. L. M. ;

van der Lugt, Aad ;

de Miquel, Maria A. ;

Donnan, Geoff Rey A. ;

Roos, Yvo B. W. E. M. ;

Bonafe, Alain ;

Jahan, Reza ;

Diener, Hans-Christoph ;

van den Berg, Lucie A. ;

Levy, Elad I. ;

Berkhemer, Olvert A. ;

Pereira, Vitor M. ;

Rempel, Jeremy ;

Millan, Monica ;

Davis, Stephen M. ;

Roy, Daniel ;

Thornton, John ;

San Roman, Luis ;

Ribo, Marc ;

Beumer, Debbie ;

Stouch, Bruce ;

Brown, Scott ;

Campbell, Bruce C. V. ;

van Oostenbrugge, Robert J. ;

Saver, Jeff Rey L. ;

Hill, Michael D. ;

Jovin, Tudor G. .

LANCET, 2016, 387 (10029) :1723-1731

[4]

Hacke W, 2004, LANCET, V363, P768

[5] Computed Tomographic Perfusion to Predict Response to Recanalization in Ischemic Stroke [J].

Lansberg, Maarten G. ;

Christensen, Soren ;

Kemp, Stephanie ;

Mlynash, Michael ;

Mishra, Nishant ;

Federau, Christian ;

Tsai, Jenny P. ;

Kim, Sun ;

Nogueria, Raul G. ;

Jovin, Tudor ;

Devlin, Thomas G. ;

Akhtar, Naveed ;

Yavagal, Dileep R. ;

Haussen, Diogo ;

Dehkharghani, Seena ;

Bammer, Roland ;

Straka, Matus ;

Zaharchuk, Greg ;

Marks, Michael P. ;

Albers, Gregory W. .

ANNALS OF NEUROLOGY, 2017, 81 (06) :849-856

[6] Response to endovascular reperfusion is not time-dependent in patients with salvageable tissue [J].

Lansberg, Maarten G. ;

Cereda, Carlo W. ;

Mlynash, Michael ;

Mishra, Nishant K. ;

Inoue, Manabu ;

Kemp, Stephanie ;

Christensen, Soren ;

Straka, Matus ;

Zaharchuk, Greg ;

Marks, Michael P. ;

Bammer, Roland ;

Albers, Gregory W. .

NEUROLOGY, 2015, 85 (08) :708-714

[7] MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study [J].

Lansberg, Maarten G. ;

Straka, Matus ;

Kemp, Stephanie ;

Mlynash, Michael ;

Wechsler, Lawrence R. ;

Jovin, Tudor G. ;

Wilder, Michael J. ;

Lutsep, Helmi L. ;

Czartoski, Todd J. ;

Bernstein, Richard A. ;

Chang, Cherylee W. J. ;

Warach, Steven ;

Fazekas, Franz ;

Inoue, Manabu ;

Tipirneni, Aaryani ;

Hamilton, Scott A. ;

Zaharchuk, Greg ;

Marks, Michael P. ;

Bammer, Roland ;

Albers, Gregory W. .

LANCET NEUROLOGY, 2012, 11 (10) :860-867

[8] Evolution of cerebral infarct volume assessed by diffusion-weighted magnetic resonance imaging [J].

Lansberg, MG ;

O'Brien, MW ;

Tong, DC ;

Moseley, ME ;

Albers, GW .

ARCHIVES OF NEUROLOGY, 2001, 58 (04) :613-617

[9] Thrombolysis in very elderly people: controlled comparison of SITS International Stroke Thrombolysis Registry and Virtual International Stroke Trials Archive [J].

Mishra, Nishant K. ;

Ahmed, Niaz ;

Andersen, Grethe ;

Egido, Jose A. ;

Lindsberg, Perttu J. ;

Ringleb, Peter A. ;

Wahlgren, Nils G. ;

Lees, Kennedy R. .

BMJ-BRITISH MEDICAL JOURNAL, 2010, 341 :1144

[10] Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct [J].

Nogueira, R. G. ;

Jadhav, A. P. ;

Haussen, D. C. ;

Bonafe, A. ;

Budzik, R. F. ;

Bhuva, P. ;

Yavagal, D. R. ;

Ribo, M. ;

Cognard, C. ;

Hanel, R. A. ;

Sila, C. A. ;

Hassan, A. E. ;

Millan, M. ;

Levy, E. I. ;

Mitchell, P. ;

Chen, M. ;

English, J. D. ;

Shah, Q. A. ;

Silver, F. L. ;

Pereira, V. M. ;

Mehta, B. P. ;

Baxter, B. W. ;

Abraham, M. G. ;

Cardona, P. ;

Veznedaroglu, E. ;

Hellinger, F. R. ;

Feng, L. ;

Kirmani, J. F. ;

Lopes, D. K. ;

Jankowitz, B. T. ;

Frankel, M. R. ;

Costalat, V. ;

Vora, N. A. ;

Yoo, A. J. ;

Malik, A. M. ;

Furlan, A. J. ;

Rubiera, M. ;

Aghaebrahim, A. ;

Olivot, J. -M. ;

Tekle, W. G. ;

Shields, R. ;

Graves, T. ;

Lewis, R. J. ;

Smith, W. S. ;

Liebeskind, D. S. ;

Saver, J. L. ;

Jovin, T. G. .

NEW ENGLAND JOURNAL OF MEDICINE, 2018, 378 (01) :11-21

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