平扫CT与脑血容量 ASPECTS错配患者进行血管内治疗的安全性与有效性研究
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摘要
目的探讨存在平扫CT(noncontrast computed tomographic,NCCT)-脑血容量(cerebral blood volume,CBV)Alberta卒中项目早期CT评分(ASPECTS)<0(N-C<0)的患者(即平扫CT低密度范围大于CBV下降区域,两者存在错配)进行血管内治疗(endovascular treatment,ET)的安全性与有效性,并观察相关预测指标对ET预后的作用。方法收集本院2015年1月至2018年8月连续就诊的前循环颅内大血管闭塞的血管内治疗290例患者进行回顾性研究。根据N-C评分分为N-C<0组和N-C≥0组;安全性指标为90 d死亡、严重颅内出血、症状性颅内出血(symptomatic intracranial hemorrhage,sICH);有效性指标为住院7 d、出院NIHSS评分及90 d良好预后(mRS≤2)。比较两组间差异,并通过多因素Logistic回归分析影响良好预后的相关因素。结果符合入组条件共有144例患者,其中N-C<0组25例,N-C≥0组119例。与N-C≥0组比较,N-C<0组患者具有更低的NCCT ASPECTS[(6.96±1.77)vs(8.73±1.25),P<0.001],同时两组间责任血管分型(P=0.036)、穿刺到再通时间差异均有统计学意义(P=0.017)。两组的安全性与有效性差异均无统计学意义(P>0.05)。多因素回归模型当中,CBV ASPECTS(P=0.010,OR=1.460,95%CI=1.095～1.945)是预测良好预后的独立指标。结论 N-C<0组的患者可以从ET中获益,并且未增加颅内出血风险,NCCT低密度不应作为排除或判断ET预后不佳的标准,需根据CBV图像进一步详细评估。
Objective In acute ischemic stroke(AIS), the low density range of non-contrast computed tomography(NCCT) is larger than that of cerebral blood volume(CBV) from time to time, and there is a mismatch between them. The study aimed to study the safety and efficacy of endovascular treatment(ET) in the patients with NCCT-CBV Alberta stroke program early CT score(ASPECTS)<0(N-C<0) and explore the role of related predictors in the prognosis. Methods Clinical data of 290 consecutive patients with anterior circulation intracranial vascular occlusion undergoing ET in our hospital from January 2015 to August 2018 were collected to conduct a retrospective study. According to N-C score, they were divided into N-C<0 and N-C>0 groups. The safety outcome were assessed by 90 days of death, severe intracranial hemorrhage, symptomatic intracranial hemorrhage(sICH), and the efficacy outcome included National Institutes of Health Stroke Scale(NIHSS) score at day 7 or discharge, and good functional outcome(mRS≤2) at day 90. The differences between the N-C<0 and ≥0 groups were compared, and the related predictors for good prognosis were explored by multivariate logistic regression analysis. Results A total of 144 patients were eligible for our inclusion criteria, of 25 in the N-C<0 group and 119 in the N-C≥0 group. The N-C<0 group had lower NCCT ASPECTS than the other group(6.96±1.77 vs 8.73±1.25, P<0.001). Meanwhile, significant differences were seen in the classification of vessels(P=0.036) and the time from puncture to recanalization(P=0.017) between the 2 groups. There were no significant differences in safety and efficacy between the 2 groups. Multivariate regression model showed that CBV ASPECTS(P=0.010, OR=1.460, 95%CI=1.095～1.945) was an independent predictor for good prognosis. Conclusion The patients with N-C<0 are benefited from ET without increasing risk of intracranial hemorrhage. The low-density lesions of NCCT should not be used as a criterion for excluding or judging the poor functional outcome of ET, but should be further evaluated according to CBV images.
Objective In acute ischemic stroke(AIS), the low density range of non-contrast computed tomography(NCCT) is larger than that of cerebral blood volume(CBV) from time to time, and there is a mismatch between them. The study aimed to study the safety and efficacy of endovascular treatment(ET) in the patients with NCCT-CBV Alberta stroke program early CT score(ASPECTS)<0(N-C<0) and explore the role of related predictors in the prognosis. Methods Clinical data of 290 consecutive patients with anterior circulation intracranial vascular occlusion undergoing ET in our hospital from January 2015 to August 2018 were collected to conduct a retrospective study. According to N-C score, they were divided into N-C<0 and N-C>0 groups. The safety outcome were assessed by 90 days of death, severe intracranial hemorrhage, symptomatic intracranial hemorrhage(sICH), and the efficacy outcome included National Institutes of Health Stroke Scale(NIHSS) score at day 7 or discharge, and good functional outcome(mRS≤2) at day 90. The differences between the N-C<0 and ≥0 groups were compared, and the related predictors for good prognosis were explored by multivariate logistic regression analysis. Results A total of 144 patients were eligible for our inclusion criteria, of 25 in the N-C<0 group and 119 in the N-C≥0 group. The N-C<0 group had lower NCCT ASPECTS than the other group(6.96±1.77 vs 8.73±1.25, P<0.001). Meanwhile, significant differences were seen in the classification of vessels(P=0.036) and the time from puncture to recanalization(P=0.017) between the 2 groups. There were no significant differences in safety and efficacy between the 2 groups. Multivariate regression model showed that CBV ASPECTS(P=0.010, OR=1.460, 95%CI=1.095～1.945) was an independent predictor for good prognosis. Conclusion The patients with N-C<0 are benefited from ET without increasing risk of intracranial hemorrhage. The low-density lesions of NCCT should not be used as a criterion for excluding or judging the poor functional outcome of ET, but should be further evaluated according to CBV images.
引文
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[13] BARBER P A,DEMCHUK A M,ZHANG J,et al.Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy.ASPECTS study group.Alberta stroke programme early CT score[J].Lancet,2000,355(9216):1670-1674.
[14] PADRONI M,BERNARDONI A,TAMBORINO C,et al.Cerebral blood volume ASPECTS is the best predictor of clinical outcome in acute ischemic stroke:A retrospective,combined semi-quantitative and quantitative assessment[J].PLoS ONE,2016,11(1):e0147910.DOI:10.1371/journal.pone.0147910.
[15] BONED S,PADRONI M,RUBIERA M,et al.Admission CT perfusion may overestimate initial infarct core:the ghost infarct core concept[J].J Neurointerv Surg,2017,9(1):66-69.DOI:10.1136/neurintsurg-2016-012494.
[16] HIGASHIDA R T,FURLAN A J,ROBERTS H,et al.Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke[J].Stroke,2003,34(8):e109-e137.DOI:10.1161/01.STR.0000082721.62796.09.
[17] TAN I Y,DEMCHUK A M,HOPYAN J,et al.CT angiography clot burden score and collateral score:correlation with clinical and radiologic outcomes in acute middle cerebral artery infarct[J].AJNR Am J Neuroradiol,2009,30(3):525-531.DOI:10.3174/ajnr.A1408.
[18] FORD G,FREEMANTLE N.ECASS-Ⅱ:intravenous alteplase in acute ischaemic stroke.European co-operative acute stroke study-II[J].Lancet,1999,353(9146):65.DOI:10.1016/S0140-6736(98)00005-1.
[19] YOO A J,BERKHEMER O A,FRANSEN P S S,et al.Effect of baseline alberta stroke program early CT score on safety and efficacy of intra-arterial treatment:A subgroup analysis of a randomised phase 3 trial (MR CLEAN)[J].Lancet Neurol,2016,15(7):685-694.DOI:10.1016/S1474-4422(16)00124-1.
[20] DEMAERSCHALK B M,SILVER B,WONG E,et al.ASPECT scoring to estimate >1/3 middle cerebral artery territory infarction[J].Can J Neurol Sci,2006,33(2):200-204.DOI:10.1017/S0317167100004972.
[21] DEMEESTERE J,GARCIA-ESPERON C,GARCIA-BERMEJO P,et al.Evaluation of hyperacute infarct volume using ASPECTS and brain CT perfusion core volume[J].Neurology,2017,88(24):2248-2253.DOI:10.1212/WNL.0000000000004028.
[22] PADRONI M,BONED S,RIBó M,et al.CBVASPECTS improvement over CTASPECTS on determining irreversible ischemic lesion decreases over time[J].Interv Neurol,2016,5(3/4):140-147.DOI:10.1159/000446969.
[23] BAL S,BHATIA R,MENON B K,et al.Time dependence of reliability of noncontrast computed tomography in comparison to computed tomography angiography source image in acute ischemic stroke[J].Int J Stroke,2015,10(1):55-60.DOI:10.1111/j.1747-4949.2012.00859.x.
[24] PUETZ V,DZIALOWSKI I,HILL M D,et al.Intracranial thrombus extent predicts clinical outcome,final infarct size and hemorrhagic transformation in ischemic stroke:the clot burden score[J].Int J Stroke,2008,3(4):230-236.DOI:10.1111/j.1747-4949.2008.00221.x.
[25] GROTTA J C,CHIU D,LU M,et al.Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy[J].Stroke,1999,30(8):1528-1533.DOI:10.1161/01.STR.30.8.1528.
[26] KALAFUT M A,SCHRIGER D L,SAVER J L,et al.Detection of early CT signs of >1/3 middle cerebral artery infarctions:interrater reliability and sensitivity of CT interpretation by physicians involved in acute stroke care[J].Stroke,2000,31(7):1667-1671.DOI:10.1161/01.STR.31.7.1667.
[2] NOGUEIRA R G,JADHAV A P,HAUSSEN D C,et al.Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct[J].N Engl J Med,2018,378(1):11-21.DOI:10.1056/NEJMoa1706442.
[3] ALBERS G W,MARKS M P,KEMP S,et al.Thrombectomy for Stroke at 6 to 16 hours with selection by perfusion imaging[J].N Engl J Med,2018,378(8):708-718.DOI:10.1056/NEJMoa1713973.
[4] BERKHEMER O A,FRANSEN P S,BEUMER D,et al.A randomized trial of intraarterial treatment for acute ischemic stroke[J].N Engl J Med,2015,372(1):11-20.DOI:10.1056/NEJMoa1411587.
[5] GOYAL M,DEMCHUK A M,MENON B K,et al.Randomized assessment of rapid endovascular treatment of ischemic stroke[J].N Engl J Med,2015,372(11):1019-1030.DOI:10.1056/NEJMoa1414905.
[6] SAVER J L,GOYAL M,BONAFE A,et al.Stent-retriever thrombectomy after intravenous t-PA vs.t-PA alone in stroke[J].N Engl J Med,2015,372(24):2285-2295.DOI:10.1056/NEJMoa1415061.
[7] CAMPBELL B C,MITCHELL P J,KLEINIG T J,et al.Endovascular therapy for ischemic stroke with perfusion-imaging selection[J].N Engl J Med,2015,372(11):1009-1018.DOI:10.1056/NEJMoa1414792.
[8] JOVIN T G,CHAMORRO A,COBO E,et al.Thrombectomy within 8 hours after symptom onset in ischemic stroke[J].N Engl J Med,2015,372(24):2296-2306.DOI:10.1056/nejmoa1503780.
[9] GOYAL M,MENON B K,VAN ZWAM W H,et al.Endovascular thrombectomy after large-vessel ischaemic stroke:A meta-analysis of individual patient data from five randomised trials[J].Lancet,2016,387(10029):1723-1731.DOI:10.1016/S0140-6736(16)00163-X.
[10] MAN S M,AOKI J,HUSSAIN M S,et al.Predictors of infarct growth after endovascular therapy for acute ischemic stroke[J].J Stroke Cerebrovasc Dis,2015,24(2):401-407.DOI:10.1016/j.jstrokecerebrovasdis.2014.09.004.
[11] BAI J L,LYDEN P D.Revisiting cerebral postischemic reperfusion injury:new insights in understanding reperfusion failure,hemorrhage,and edema[J].Int J Stroke,2015,10(2):143-152.DOI:10.1111/ijs.12434.
[12] JOVIN T G,YONAS H,GEBEL J M,et al.The cortical ischemic core and not the consistently present penumbra is a determinant of clinical outcome in acute middle cerebral artery occlusion[J].Stroke,2003,34(10):2426-2433.DOI:10.1161/01.STR.0000091232.81947.C9.
[13] BARBER P A,DEMCHUK A M,ZHANG J,et al.Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy.ASPECTS study group.Alberta stroke programme early CT score[J].Lancet,2000,355(9216):1670-1674.
[14] PADRONI M,BERNARDONI A,TAMBORINO C,et al.Cerebral blood volume ASPECTS is the best predictor of clinical outcome in acute ischemic stroke:A retrospective,combined semi-quantitative and quantitative assessment[J].PLoS ONE,2016,11(1):e0147910.DOI:10.1371/journal.pone.0147910.
[15] BONED S,PADRONI M,RUBIERA M,et al.Admission CT perfusion may overestimate initial infarct core:the ghost infarct core concept[J].J Neurointerv Surg,2017,9(1):66-69.DOI:10.1136/neurintsurg-2016-012494.
[16] HIGASHIDA R T,FURLAN A J,ROBERTS H,et al.Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke[J].Stroke,2003,34(8):e109-e137.DOI:10.1161/01.STR.0000082721.62796.09.
[17] TAN I Y,DEMCHUK A M,HOPYAN J,et al.CT angiography clot burden score and collateral score:correlation with clinical and radiologic outcomes in acute middle cerebral artery infarct[J].AJNR Am J Neuroradiol,2009,30(3):525-531.DOI:10.3174/ajnr.A1408.
[18] FORD G,FREEMANTLE N.ECASS-Ⅱ:intravenous alteplase in acute ischaemic stroke.European co-operative acute stroke study-II[J].Lancet,1999,353(9146):65.DOI:10.1016/S0140-6736(98)00005-1.
[19] YOO A J,BERKHEMER O A,FRANSEN P S S,et al.Effect of baseline alberta stroke program early CT score on safety and efficacy of intra-arterial treatment:A subgroup analysis of a randomised phase 3 trial (MR CLEAN)[J].Lancet Neurol,2016,15(7):685-694.DOI:10.1016/S1474-4422(16)00124-1.
[20] DEMAERSCHALK B M,SILVER B,WONG E,et al.ASPECT scoring to estimate >1/3 middle cerebral artery territory infarction[J].Can J Neurol Sci,2006,33(2):200-204.DOI:10.1017/S0317167100004972.
[21] DEMEESTERE J,GARCIA-ESPERON C,GARCIA-BERMEJO P,et al.Evaluation of hyperacute infarct volume using ASPECTS and brain CT perfusion core volume[J].Neurology,2017,88(24):2248-2253.DOI:10.1212/WNL.0000000000004028.
[22] PADRONI M,BONED S,RIBó M,et al.CBVASPECTS improvement over CTASPECTS on determining irreversible ischemic lesion decreases over time[J].Interv Neurol,2016,5(3/4):140-147.DOI:10.1159/000446969.
[23] BAL S,BHATIA R,MENON B K,et al.Time dependence of reliability of noncontrast computed tomography in comparison to computed tomography angiography source image in acute ischemic stroke[J].Int J Stroke,2015,10(1):55-60.DOI:10.1111/j.1747-4949.2012.00859.x.
[24] PUETZ V,DZIALOWSKI I,HILL M D,et al.Intracranial thrombus extent predicts clinical outcome,final infarct size and hemorrhagic transformation in ischemic stroke:the clot burden score[J].Int J Stroke,2008,3(4):230-236.DOI:10.1111/j.1747-4949.2008.00221.x.
[25] GROTTA J C,CHIU D,LU M,et al.Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy[J].Stroke,1999,30(8):1528-1533.DOI:10.1161/01.STR.30.8.1528.
[26] KALAFUT M A,SCHRIGER D L,SAVER J L,et al.Detection of early CT signs of >1/3 middle cerebral artery infarctions:interrater reliability and sensitivity of CT interpretation by physicians involved in acute stroke care[J].Stroke,2000,31(7):1667-1671.DOI:10.1161/01.STR.31.7.1667.