Neurological Surgery 脳神経外科51巻2号

2023年03月発行

特集 新時代を迎えた脳血管内治療—文献レビューで学ぶ進歩とトレンド Ⅲ 虚血性病変

脳塞栓〈適応と成績編〉

著者： 早川幹人¹

所属機関： ¹筑波大学医学医療系脳卒中予防・治療学講座

ページ範囲：P.314 - P.327

Point
・経動脈的血栓溶解療法や主にMerciリトリーバー^®（Concentric Medical）を用いた血管内再開通療法は，内科治療に優る転帰改善効果を示すことができなかった．
・主にステントリトリーバーを用いたMR CLEAN以降の試験結果より，NIHSS ≧ 6の内頚動脈/中大脳動脈M1部閉塞で，ASPECTS ≧ 6の症例に対する発症6時間以内の血栓回収療法は標準治療となった．
・DAWN，DEFUSE 3の結果から，発症6時間以降の神経症状と虚血コアにミスマッチのある前方循環主幹動脈閉塞例に対する血栓回収療法の有効性も確立した．
・ASPECTS 3〜5の広範梗塞例や，PC-ASPECTS ≧ 6の脳底動脈閉塞例に対する血栓回収療法の有意な転帰改善効果が報告されている．

参考文献

1）National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group：Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 333：1581-1587, 1995

2）del Zoppo GJ, et al：Local intra-arterial fibrinolytic therapy in acute carotid territory stroke. A pilot study. Stroke 19：307-313, 1988

3）Furlan A, et al：Intra-artertial prourokinase for acute ischemic stroke. The PROACT Ⅱ study：a randomized controlled trial. Prolyse in acute cerebral thromboembolism. JAMA 282：2003-2011, 1999

4）Ogawa A, et al；MELT Japan Study Group：Randomized trial of intraarterial infusion of urokinase within 6 hours of middle cerebral artery stroke：the middle cerebral artery embolism local fibrinolytic intervention trial（MELT）Japan. Stroke 38：2633-2639, 2007

5）Nakano S, et al：Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion：an alternative option to intra-arterial thrombolysis. Stroke 33：2872-2876, 2002

6）Hayakawa M, et al；JR-NET Study Group：Endovascular treatment of acute stroke with major vessel occlusion before approval of mechanical thrombectomy devices in Japan：Japanese Registry of Neuroendovascular Therapy（JR-NET）and JR-NET 2. Neurol Med Chir（Tokyo）54：23-31, 2014

7）Chopko BW, et al：Transcatheter snare removal of acute middle cerebral artery thromboembolism：technical case report. Neurosurgery 46：1529-1531, 2000

8）Smith WS, et al：Mechanical thrombectomy for acute ischemic stroke：final results of the Multi MERCI trial. Stroke 39：1205-1212, 2008

9）Penumbra Pivotal Stroke Trial Investigators：The penumbra pivotal stroke trial：safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke 40：2761-2768, 2009

10）Broderick JP, et al；Interventional Management of Stroke（IMS）III Investigators：Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. N Engl J Med 368：893-903, 2013

11）Ciccone A, et al；SYNTHESIS Expansion Investigators：Endovascular treatment for acute ischemic stroke. N Engl J Med 368：904-913, 2013

12）Kidwell CS, et al；MR RESCUE Investigators：A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med 368：914-923, 2013

13）Castaño C, et al：Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation：a pilot study. Stroke 41：1836-1840, 2010

14）Saver JL, et al；SWIFT Trialists：Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke（SWIFT）：a randomised, parallel-group, non-inferiority trial. Lancet 380：1241-1249, 2012

15）Nogueira RG, et al；TREVO 2 Trialists：Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke（TREVO 2）：a randomised trial. Lancet 380：1231-1240, 2012

16）Turk AS, et al：ADAPT FAST study：a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg 6：260-264, 2014

17）Hayakawa M, et al；JR-NET investigators：Trends in endovascular reperfusion therapy for acute stroke after introduction of mechanical thrombectomy devices：Japanese Registry of NeuroEndovascular Therapy（JR-NET）3. Neurol Med Chir（Tokyo）60：191-201, 2020

18）Berkhemer OA, et al；MR CLEAN Investigators：A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372：11-20, 2015

19）Goyal M, et al；ESCAPE Trial Investigators：Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372：1019-1030, 2015

20）Campbell BC, et al；EXTEND-IA Investigators：Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372：1009-1018, 2015

21）Saver JL, et al；SWIFT PRIME Investigators：Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372：2285-2295, 2015

22）Jovin TG, et al；REVASCAT Trial Investigators：Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372：2296-2306, 2015

23）Goyal M, et al；HERMES collaborators：Endovascular thrombectomy after large-vessel ischaemic stroke：a meta-analysis of individual patient data from five randomised trials. Lancet 387：1723-1731, 2016

24）Nogueira RG, et al；DAWN Trial Investigators：Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 378：11-21, 2018

25）Albers GW, et al；DEFUSE 3 Investigators：Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 378：708-718, 2018

26）Jovin TG, et al：Thrombectomy for anterior circulation stroke beyond 6 h from time last known well（AURORA）：a systematic review and individual patient data meta-analysis. Lancet 399：249-258, 2022

27）Bracard S, et al；THRACE investigators：Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke（THRACE）：a randomised controlled trial. Lancet Neurol 15：1138-1147, 2016

28）Muir KW, et al；PISTE Investigators：Endovascular therapy for acute ischaemic stroke：the Pragmatic Ischaemic Stroke Thrombectomy Evaluation（PISTE）randomised, controlled trial. J Neurol Neurosurg Psychiatry 88：38-44, 2017

29）Román LS, et al；HERMES collaborators：Imaging features and safety and efficacy of endovascular stroke treatment：a meta-analysis of individual patient-level data. Lancet Neurol 17：895-904, 2018

30）Yoshimura S, et al：Endovascular therapy for acute stroke with a large ischemic region. N Engl J Med 386：1303-1313, 2022

31）Liu X, et al；BEST Trial Investigators：Endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion（BEST）：an open-label, randomised controlled trial. Lancet Neurol 19：115-122, 2020

32）Langezaal LCM, et al；BASICS Study Group：Endovascular therapy for stroke due to basilar-artery occlusion. N Engl J Med 384：1910-1920, 2021

33）Tao C, et al；ATTENTION Investigators：Trial of endovascular treatment of acute basilar-artery occlusion. N Engl J Med 387：1361-1372, 2022

34）Jovin TG, et al；BAOCHE Investigators：Trial of thrombectomy 6 to 24 hours after stroke due to basilar-artery occlusion. N Engl J Med 387：1373-1384, 2022

35）Puetz V, et al：Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke 39：2485-2490, 2008

36）Smith WS, et al；MERCI Trial Investigators：Safety and efficacy of mechanical embolectomy in acute ischemic stroke：results of the MERCI trial. Stroke 36：1432-1438, 2005

37）DeGraba TJ, et al：Progression in acute stroke：value of the initial NIH stroke scale score on patient stratification in future trials. Stroke 30：1208-1212, 1999

38）Wardlaw JM, Mielke O：Early signs of brain infarction at CT：observer reliability and outcome after thrombolytic treatment：systematic review. Radiology 235：444-453, 2005

39）Demaerschalk BM, et al：ASPECT scoring to estimate ＞ 1/3 middle cerebral artery territory infarction. Can J Neurol Sci 33：200-204, 2006

40）Albers GW, et al；AURORA Investigators：Assessment of optimal patient selection for endovascular thrombectomy beyond 6 hours after symptom onset：a pooled analysis of the AURORA database. JAMA Neurol 78：1064-1071, 2021

41）Terasawa Y, et al：Could clinical diffusion-mismatch determined using DWI ASPECTS predict neurological improvement after thrombolysis before 3 h after acute stroke? J Neurol Neurosurg Psychiatry 81：864-868, 2010

42）日本脳卒中学会，日本脳神経外科学会，日本脳神経血管内治療学会：経皮経管的脳血栓回収用機器 適正使用指針 第4版2020年3月．脳卒中 42：281-313, 2020

43）Uchida K, et al；RESCUE-Japan LIMIT Investigators：Association between Alberta Stroke Program Early Computed Tomography Score and efficacy and safety outcomes with endovascular therapy in patients with stroke from large-vessel occlusion：a secondary analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism-Japan Large Ischemic Core Trial（RESCUE-Japan LIMIT）. JAMA Neurol 79：1260-1266, 2022

44）Schonewille WJ, et al；BASICS study group：Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study（BASICS）：a prospective registry study. Lancet Neurol 8：724-730, 2009

45）Powers WJ, et al：Guidelines for the early management of patients with acute ischemic stroke：2019 update to the 2018 guidelines for the early management of acute ischemic stroke：a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 50：e344-e418, 2019　doi：10.1161/STR.0000000000000211

46）Nguyen TN, et al：Noncontrast computed tomography vs computed tomography perfusion or magnetic resonance imaging selection in late presentation of stroke with large-vessel occlusion. JAMA Neurol 79：22-31, 2022

47）Nguyen TN, et al；SVIN GAPS Committee：Mechanical thrombectomy in the late presentation of anterior circulation large vessel occlusion stroke：a guideline from the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Committee. Stroke Vasc Interv Neurol 3：e00512, 2023　doi：10.1161/SVIN.122.000512

48）早川幹人：血管内再開通療法．新井　一，他（監）：最新主要文献でみる脳神経外科学レビュー．総合医学社，東京，2019，pp. 97-101

49）早川幹人，松丸祐司：3．超急性期治療（2）血管内再開通療法．日臨 80（増刊号2）：31-37, 2022

50）早川幹人：血管内再開通療法．新井　一，他（監）：最新主要文献でみる脳神経外科学レビュー 2023-'24．総合医学社，東京，2022，pp. 107-112