급성 허혈성 뇌종중에서 재개통 치료 후 저체온치료의 효과: 3개 기관 후향적 연구
Therapeutic hypothermia after recanalization in acute ischemic stroke patients: Analyses of multicenter, consecutively-enrolled, observational, retrospective endovascular treatment registry (ASIAN-KR)
- 주제(키워드) ischemic stroke , therapeutic hypothermia , endovascular therapy , reperfusion injury , malignant MCA infarction
- 발행기관 아주대학교
- 지도교수 홍지만
- 발행년도 2019
- 학위수여년월 2019. 2
- 학위명 석사
- 학과 및 전공 일반대학원 의학과
- 실제URI http://www.dcollection.net/handler/ajou/000000028368
- 본문언어 영어
- 저작권 아주대학교 논문은 저작권에 의해 보호받습니다.
초록/요약
The results of large randomized studies showed that endovascular therapy (EVT) is effective in patients with acute ischemic stroke patients with large vessel occlusion, and recanalization therapy have become an indispensable treatment for the acute ischemic stroke. However, it is unclear whether EVT would be beneficial for stroke involving the whole territory of the middle cerebral artery (MCA), called ‘malignant MCA infarction’. Malignant middle cerebral artery (MCA) infarction is associated with a dismal prognosis regardless of maximum intensive care and timely carrying decompressive hemicranietomy. Due to evolution of treatment modality about EVT, the treatment direction to reduce reperfusion injury has come to a new horizon. After recanalization, reperfusion injury, which is expressed by edema and hemorrhagic transformation occurs, and several medical therapies that minimize such neuronal damage have been studied. One of them is a therapeutic hypothermia, and there are not many studies that have been verified as a multi-center trial. Therefore, we aimed to evaluate the efficacy of therapeutic hypothermia in acute ischemic stroke patients after endovascular recanalization therapy. We also investigated the therapeutic hypothermia effect in subgroups that included only malignant MCA infarct patients. The ASIAN KR, a multi-center, retrospective, neurointervention registry in South Korea was analyzed from January 2011 to May 2016. We investigated baseline demographics, risk factors, endovascular treatment parameters, and outcome. Clinical and radiological outcomes were compared between therapeutic hypothermia (TH) and no therapeutic hypothermia (NH) group. Patients with anterior circulation were selected from all patients, malignant MCA infarction is determined as (1) baseline Alberta Stroke program early CT (ASPECT) below 6 and (2) diffusion-weighted imaging (DWI) lesion volume measurement (>82 ml) or National Institutes of Health Stroke Scale (NIHSS) score >20 with item Ia >0. Among 721 consecutive patients, 548 patients with anterior circulation infarction were selected, 91 patients had therapeutic hypothermia, and 457 patients had not. TH group (vs. NH group) significantly had a low value of baseline ASPECT score (p<0.001) and a higher DWI volume (p<0.001). In order to overcome the differences in the groups, we used a propensity score matching. Even after adjusting baseline demographics as a conventional propensity method of 1:2 matching, the bias of baseline DWI volume (55.22±47.60 [n=91] vs. 37.82±64.73 [n=182], p<0.001) and EVT method (stent retriever: n=62, 68.1% vs. n=75, 41.2%; aspiration: n=19, 20.9% vs. n=74, 40,7%; others: n=10, 11.0% vs. n=33, 18.1%; p<0.001) did not balance between TH and NH groups. TH group (vs. NH group) had a lower prevalence of good outcome at 3 month (modified Rankin Scale [mRS] 0-1; n=22, 24.2% vs. n=70, 38.5%, p=0.019, mRS 0-2; n=35, 38.5% vs. n=101, 55.5%, p=0.008). In subgroup analysis, 80 patients were diagnosed as malignant MCA infarction. Twenty-eight patients had received therapeutic hypothermia. Age, diabetes, baseline NIHSS score, stroke etiology were unbalanced between TH and NH groups. TH group (vs. NH group) had a better clinical outcome (32.1% vs. 7.7% p=0.009) and a lower frequency of hemorrhagic transformation (none vs. any hemorrhage, p=0.007). After adjusting potential confounders to predict good outcome, therapeutic hypothermia (OR 4.63; CI 1.20-17.89; p=0.026) and hypertension (OR 0.18; CI 0.04-0.74; p=0.018) were independent determinants. Due to the difficulty in statistical interpretation from not balanced baseline characteristic between the TH and NH group, our current data was not to be conclusive on clinical benefit of therapeutic hypothermia in acute ischemic stroke. However, our data demonstrated that therapeutic hypothermia reduced impending hemorrhagic transformation and leaded to an improvement of short-term clinical outcome in patients with malignant MCA infarction who received EVT.
more목차
Introduction 1
Patients and methods 4
A.Patients and protocols 4
B. Endovascular treatment 6
C. Hypothermia treatment protocol 6
D. Clinical and radiological evaluation 6
E. Propensity score matching 7
F. Statistical analysis 8
Results 9
A. Comparison between the hypothermia and no hypothermia groups 9
B. Non-malignant MCA group and hypothermia 14
C. Malignant MCA group and hypothermia 19
Discussion 26
A. Unmet need for additional treatment of acute ischemic stroke 26
B. Neuroprotective mechanism and effect of therapeutic hypothermia on various conditions 26
C. Therapeutic hypothermia in non-malignant MCA infarction 27
D. Therapeutic hypothermia in malignant MCA infarction 28
E. Limitations 29
Conclusion 30
References 31
국문요약 39
