前循环大血管闭塞取栓前静脉溶栓的疗效是否因卒中病因不同而异
该研究对6项随机对照试验的个体参与者数据进行荟萃分析，纳入2313例前循环大血管闭塞且直接就诊于可取栓中心的患者，比较静脉溶栓联合血管内治疗与单纯血管内治疗。结果显示卒中病因（心源性栓塞、大动脉粥样硬化、其他/不明）未显著改变静脉溶栓对90天功能结局的疗效（交互作用P=0.60），仅在其他/不明病因亚组观察到静脉溶栓联合治疗与更好预后相关（校正共同优势比1.34，95%CI 1.05-1.69）。
要点
- 卒中病因不影响取栓前静脉溶栓对90天功能结局的总体疗效（交互作用P=0.60）。
- 其他/不明病因亚组中，静脉溶栓联合取栓与更好90天功能预后相关（校正共同优势比1.34，95%CI 1.05-1.69）。
- 安全性结局未因卒中病因或房颤状态出现治疗效应异质性。
核心结论
- 对于直接就诊于可取栓中心的前循环大血管闭塞患者，卒中病因不改变取栓前静脉溶栓的总体疗效或安全性。
- 其他/不明病因亚组中观察到的孤立获益需进一步确认。
研究设计与样本
- 研究设计为个体参与者数据荟萃分析，纳入6项比较静脉溶栓联合血管内治疗与单纯血管内治疗的随机对照试验。
- 共纳入2313例 eligible 患者，静脉溶栓联合组1160例，单纯取栓组1153例；中位年龄71岁（IQR 62-78），女性占44.3%。
主要发现
- 卒中病因分类：心源性栓塞977/2313例（42%），大动脉粥样硬化430例（19%），其他或不明/未确定906例（39%）。
- 未观察到卒中病因对静脉溶栓与90天功能结局关联的治疗效应修饰（交互作用P=0.60）。
- 其他/不明病因患者中，静脉溶栓联合取栓与更好90天功能预后相关（校正共同优势比1.34，95%CI 1.05-1.69）。
- 安全性结局未发现卒中病因的治疗效应修饰，所有结局均未发现房颤状态的治疗效应异质性。
临床怎么用
- 对于直接就诊于可取栓中心的前循环大血管闭塞患者，不应仅根据卒中病因决定是否在取栓前给予静脉溶栓。
- 其他/不明病因患者可能从取栓前静脉溶栓中获益，但该发现需进一步验证。
局限性
- 其他/不明病因亚组的获益为孤立发现，需确认。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
OBJECTIVE: The benefit of intravenous thrombolysis (IVT) before endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion (LVO) who present directly to EVT-capable centers remains uncertain, and the effect may differ according to underlying stroke etiology. We assessed whether the benefit of IVT plus EVT versus EVT alone varied by stroke etiologies (large-artery atherosclerosis, cardioembolism, or other/undetermined). METHODS: We performed an individual participant data meta-analysis of 6 randomized controlled trials (RCTs) that compared IVT plus EVT to EVT alone in patients with LVO within 4.5 hours of stroke onset or time last known well. The heterogeneity of treatment effect was assessed using ordinal logistic regression models with interaction terms for stroke etiology and treatment in the intention-to-treat population, followed by subsequent mixed-effects meta-analysis. An additional analysis was performed to assess whether the treatment effect of IVT plus EVT differed by atrial fibrillation status. RESULTS: Among 2,313 eligible patients from 6 RCTs, 1,160 were randomized to the IVT plus EVT group and 1,153 to the EVT alone group. Median age was 71 years (interquartile range [IQR] = 62-78 years), and 44.3% of patients were women. Stroke etiology was classified as cardioembolism in 977 of 2,313 patients (42%), large artery atherosclerosis in 430 (19%), and other or unknown/undetermined in 906 (39%). No evidence of treatment effect modification by stroke etiologies on the association between IVT and 90-day functional outcome was observed (P for interaction = 0.60). For patients with other/undetermined stroke etiology, IVT plus EVT was associated with better 90-day functional prognosis (adjusted common odds ratio for a lower level of disability = 1.34, 95% confidence interval [CI] = 1.05-1.69). No treatment effect modification by stroke etiology was found for safety outcomes. No treatment effect heterogeneity by atrial fibrillation was found for all outcomes. INTERPRETATION: Among patients with LVO presenting directly to EVT-capable centers, stroke etiologies do not modify the overall efficacy or safety of IVT before EVT. The isolated benefit observed in the other/undetermined subgroup requires confirmation. ANN NEUROL 2026;100:180-190.
引用
- Guo C, Cavalcante F, Yang S, et al. Stroke Etiologies With Intravenous Thrombolysis before Thrombectomy and Functional Outcomes in Anterior Circulation Large Vessel Occlusion. Ann Neurol. 2026. PMID: 42026777. doi:10.1002/ana.78225
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。