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급성 허혈성 뇌종중에서 재개통 치료 후 저체온치료의 효과: 3개 기관 후향적 연구
- Alternative Title
- Young Eun Gil
- Author(s)
- 길영은
- Alternative Author(s)
- Young Eun Gil
- Advisor
- 홍지만
- Department
- 일반대학원 의학과
- Publisher
- The Graduate School, Ajou University
- Publication Year
- 2019--2
- Language
- eng
- Alternative Abstract
- 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.
- Fulltext
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- Graduate School of Ajou University > Department of Medicine > 3. Theses(Master)
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