中血管闭塞性卒中取栓术的证据、策略与路径：系统综述。
完整摘要 · 中文译文
背景：中等血管闭塞（MeVOs）占急性缺血性卒中的25-40%，构成了一个重要的治疗前沿领域。尽管血管内血栓切除术（EVT）的技术成功率很高，但近期随机试验结果却较为复杂，形成了一种悖论，并凸显了采用精准医疗方法的必要性。 方法：我们按照PRISMA指南进行了一项系统评价。筛选后，共纳入42项原始研究（4项随机对照试验和38项队列研究）。证据采用三级分层体系进行综合和评估，并应用了GRADE框架。证据的总体确定性范围为中等至极低。 结果：观察性研究通常纳入基线NIHSS评分较高且影像学筛选标准更严格的人群，一般报告了良好的功能独立率（接受EVT治疗的患者中mRS 0-2分占60-80%）。然而，这些比率可能部分反映了选择偏倚，而非纯粹的治疗相关效应。成功再通率经常达到（>85%），但症状性出血和血管穿孔等安全性问题需要仔细管理。成功取决于将先进影像学（例如，用于“目标不匹配”的CT灌注）与个性化技术装备相结合的精准策略，包括根据闭塞部位、血栓负荷和解剖结构选择的专用低剖面支架取栓器和抽吸导管。一个“八项关键”框架解读了中性试验结果，强调了患者选择异质性。未来的进展取决于精细化的影像学。 标准、专用设备开发和经过验证的选择工具。 结论：当前随机证据并未显示血管内血栓切除术（EVT）对未经选择的MeVO卒中患者具有总体功能获益，而手术相关出血风险似乎高于最佳药物治疗。对于经过仔细选择的具有致残性神经功能缺损、可挽救脑组织及良好血管解剖条件的患者，由经验丰富的团队使用适合远端血管的技术实施EVT可能是合理的。未来的工作应优先考虑经过验证的选择工具、标准化影像学定义、远端特异性设备以及富集最可能获益患者的试验设计。
完整摘要 · 英文原文
BACKGROUND: Medium vessel occlusions (MeVOs) account for 25-40% of acute ischemic strokes and present a significant therapeutic frontier. Despite high technical success rates of endovascular thrombectomy (EVT), recent randomized trial results have been nuanced, creating a paradox and underscoring the need for a precision-based approach. METHODS: We conducted a systematic review following PRISMA guidelines. After screening, 42 original studies were included (4 RCTs and 38 cohort studies). Evidence was synthesized and appraised using a three-tiered hierarchy. The GRADE framework was applied. Overall certainty of evidence ranged from moderate to very low. RESULTS: Observational studies, which often enrolled populations with higher baseline NIHSS scores and stricter imaging selection criteria, generally reported favorable functional independence rates (mRS 0-2 in 60-80% of EVT-treated patients). However, these rates may partly reflect selection bias rather than a purely treatment-related effect. Successful recanalization is frequently achieved (>85%), but safety concerns like symptomatic hemorrhage and vessel perforation require careful management. Success hinges on a precision strategy integrating advanced imaging (e.g., CT perfusion for "Target Mismatch") with a tailored technical arsenal. This includes dedicated low-profile stent retrievers and aspiration catheters, selected based on occlusion site, thrombus burden, and anatomy. A "Eight Keys" framework interprets neutral trial results, highlighting patient selection heterogeneity. Future progress depends on refined imaging criteria, dedicated device development, and validated selection tools. CONCLUSION: Current randomized evidence does not demonstrate an overall functional benefit of endovascular thrombectomy (EVT) for unselected MeVO stroke, while procedure-related hemorrhagic risk appears higher than with best medical therapy. EVT may be reasonable in carefully selected patients with disabling deficits, salvageable tissue, and favorable anatomy, when performed by experienced teams using distal-appropriate techniques. Future work should prioritize validated selection tools, standardized imaging definitions, distal-specific devices, and trial designs enriched for patients most likely to benefit.