背景

在近端闭塞症中，再灌注治疗的效果在进展缓慢或快速的患者中可能有所不同。我们研究了静脉溶栓(用阿替普酶)加机械取栓(MT)与单独取栓在慢速与快速脑卒中进展患者中的效果。

方法

对SWIFT-DIRECT试验数据进行分析:408例患者随机分为IVT+MT组和MT组。梗死生长速度由初始阿尔伯塔脑卒中计划早期CT评分(ASPECTS)中衰减点的数量除以发病至成像时间来定义。

主要终点为3个月的功能独立性(修正Rankin评分0-2)。在初步分析中，研究人群根据中位梗死生长速度分为慢进展者和快进展者。二次分析也使用ASPECTS衰减的四分位数进行。

结果

我们纳入376例患者:191例IVT+MT，单独185 MT;中位年龄73岁(IQR 65-81);中位初始国立卫生研究院卒中量表(NIHSS) 17岁(IQR 13-20)。

中位梗死生长速度为1.2分/小时。

总的来说，我们没有观察到梗死生长速度和分配到任意一个随机组之间在有利结果的几率上有显著的相互作用(P=0.68)。

在IVT+MT组中，进展缓慢的患者颅内出血(ICH)的几率显著降低(22.8% vs 36.4%;OR 0.52, 95% CI 0.27至0.98)，在快速进展患者中更高(49.4% vs26.8%;OR 2.62,95% CI 1.42至4.82)(相互作用的P值<0.001)。在二次分析中观察到类似的结果。

结论

在这项SWIFT-DIRECT亚分析中，我们没有发现梗死生长速度与单独MT或联合IVT+MT治疗的有利结果的几率有显著相互作用的证据。

然而，在进展缓慢的患者中，先前的IVT与任何脑出血的发生显著减少相关，而在进展快的患者中则增加。

也就说，跨越桥接可能增加进展快速卒中患者的脑出血发生。

Abstract
Background: In proximal occlusions, the effect of reperfusion therapies may differ between slow or fast progressors. We investigated the effect of intravenous thrombolysis (IVT) (with alteplase)plus mechanical thrombectomy (MT) versus thrombectomy alone among slow versus fast stroke progressors.
Methods: The SWIFT-DIRECT trial data were analyzed: 408 patients randomized to IVT+MT or MT alone. Infarct growth speed was defined by the number of points of decay in the initial Alberta Stroke Program Early CT Score (ASPECTS)divided by the onset-to-imaging time. The primary endpoint was 3-month functional independence (modified Rankin scale 0-2). In the primary analysis, the study population was dichotomized into slow and fast progressors using median infarct growth velocity. Secondary analysis was also conducted using quartiles of ASPECTS decay.
Results: We included 376 patients: 191 IVT+MT,185 MT alone; median age 73 years (IQR 65-81);median initial National Institutes of Health Stroke Scale (NIHSS) 17 (IQR 13-20). The median infarct growth velocity was 1.2 points/hour. Overall, we did not observe a significant interaction between the infarct growth speed and the allocation to either randomization group on the odds of favourable outcome (P=0.68). In the IVT+MT group, odds of any intracranial hemorrhage (ICH)were significantly lower in slow progressors(22.8% vs 36.4%; OR 0.52, 95% CI 0.27 to 0.98)and higher among fast progressors (49.4% vs26.8%;OR 2.62,95% CI 1.42 to 4.82)(P value for interaction <0.001). Similar results were observed in secondary analyses.
Conclusion: In this SWIFT-DIRECT subanalysis, we did not find evidence for a significant interaction of the velocity of infarct growth on the odds of favourable outcome according to treatment by MT alone or combined IVT+MT. However, prior IVT was associated with significantly reduced occurrence of any ICH among slow progressors whereas this was increased in fast progressors.