Lee K H, Lee S J, Cho S J, Na D G, Byun H S, Kim Y B, Song H J, Jin I S, Chung C S
Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-ku, Seoul, 135-710, Korea.
Arch Neurol. 2000 Jul;57(7):1000-8. doi: 10.1001/archneur.57.7.1000.
Intravenous thrombolysis for acute ischemic stroke has been investigated in several clinical trials without enough information on collateral blood flow and perfusion deficit in the ischemic areas. The therapeutic time window varies from patient to patient depending on these factors. Triphasic perfusion computed tomography (TPCT) can provide this information as reliably as conventional angiography.
To assess the safety and efficacy of thrombolysis within 3 or 7 hours of stroke onset according to the extent of perfusion deficit on TPCT.
In 46 patients with acute middle cerebral artery (MCA) territory stroke, TPCT was performed with power injector-controlled, intravenous administration of contrast media after taking precontrast CT scans. Sequential scans of early, middle, and late phases were performed. The entire procedure took 5 minutes. Depending on collateral blood flow, the perfusion deficit on TPCT was graded as "severe perfusion deficit" or "moderate perfusion deficit." Twenty-nine patients were excluded based on clinical, laboratory, and TPCT findings. Seventeen patients were treated with an intravenous recombinant tissue-type plasminogen activator, 0.9 mg/kg. The 17 treated patients were divided into 2 groups: group 1 with small severe perfusion deficit (</=33% of the presumed MCA territory) and group 2 with medium-sized severe perfusion deficit (>33% but </=50% of the presumed MCA territory). The 13 patients in group 1 were treated within 7 hours of onset and the 4 patients in group 2 were treated within 3 hours.
Initial mean National Institutes of Health Stroke Scale score was 12.1 (range, 6.0-20.0) in group 1 and 19.0 (range, 18.0-21. 0) in group 2. The initial score correlated better with the total extent of moderate perfusion deficit and severe perfusion deficit than that of severe perfusion deficit alone. Mean time lapse to thrombolysis was 4.2 hours (range, 1.5-7.0 hours) in group 1 and 2.2 hours (range, 1.9-2.5 hours) in group 2. Eight patients (47%), 7 from group 1 and 1 from group 2, improved by 4 points or more from baseline Stroke Scale score within 24 hours of thrombolysis. Patients with moderate perfusion deficit of 50% or more of MCA territory (n = 4) had a better chance of early improvement than did those (n = 13) with moderate perfusion deficit of less than 50% (4 of 4 vs 4 of 13). No fatal hemorrhage occurred. Only 1 patient (6%) had symptomatic small basal ganglia hemorrhage after thrombolysis.
Thrombolysis can be safely performed within 3 or 7 hours of stroke onset according to the extent of severe perfusion deficit on TPCT. A larger extent of moderate perfusion deficit on TPCT may predict early improvement after thrombolysis.
多项临床试验对急性缺血性卒中的静脉溶栓疗法进行了研究，但关于缺血区域侧支血流和灌注缺损的信息不足。治疗时间窗因这些因素而异，因人而异。三相灌注计算机断层扫描（TPCT）能够像传统血管造影一样可靠地提供此类信息。
根据TPCT上灌注缺损的程度，评估卒中发作3小时或7小时内溶栓的安全性和有效性。
对46例急性大脑中动脉（MCA）区域卒中患者，在进行平扫CT扫描后，采用高压注射器控制静脉注射造影剂进行TPCT检查。进行早期、中期和晚期的连续扫描。整个过程耗时5分钟。根据侧支血流情况，将TPCT上的灌注缺损分为“严重灌注缺损”或“中度灌注缺损”。根据临床、实验室和TPCT检查结果，排除29例患者。17例患者接受了静脉注射重组组织型纤溶酶原激活剂，剂量为0.9 mg/kg。17例接受治疗的患者分为2组：1组为轻度严重灌注缺损（≤假定MCA区域的33%），2组为中度严重灌注缺损（>假定MCA区域的33%但≤50%）。1组的13例患者在发病7小时内接受治疗，2组的4例患者在发病3小时内接受治疗。
1组患者初始美国国立卫生研究院卒中量表平均评分为12.1（范围6.0 - 20.0），2组为19.0（范围18.0 - 21.0）。初始评分与中度灌注缺损和严重灌注缺损的总范围的相关性优于仅与严重灌注缺损的相关性。1组溶栓的平均时间间隔为4.2小时（范围1.5 - 7.0小时），2组为2.2小时（范围1.9 - 2.5小时）。8例患者（47%），1组7例，2组1例，在溶栓后24小时内卒中量表评分较基线提高4分或更多。MCA区域中度灌注缺损达50%或更多的患者（n = 4）比中度灌注缺损小于50%的患者（n = 13）有更好的早期改善机会（4/4比4/1十三）。未发生致命性出血。仅1例患者（6%）在溶栓后出现有症状的基底节小出血。
根据TPCT上严重灌注缺损的程度，可在卒中发作3小时或7小时内安全地进行溶栓治疗。TPCT上较大范围的中度灌注缺损可能预示溶栓后早期改善。
