Kidwell Chelsea S, Saver Jeffrey L, Starkman Sidney, Duckwiler Gary, Jahan Reza, Vespa Paul, Villablanca J Pablo, Liebeskind David S, Gobin Y Pierre, Vinuela Fernando, Alger Jeffry R
Stroke Center, UCLA Medical Center, 710 Westwood Plaza, Los Angeles, CA 90095, USA.
Ann Neurol. 2002 Dec;52(6):698-703. doi: 10.1002/ana.10380.
Although animal models have demonstrated that late secondary cerebral injury after arterial occlusion and subsequent recanalization may limit the benefit of reperfusion therapy, this phenomenon has not been well characterized in humans. Diffusion-perfusion magnetic resonance imaging studies were performed before treatment, early after treatment, and at day 7 in patients undergoing vessel recanalization with intraarterial thrombolytics. Among 18 patients studied, mean age was 71 (range, 27-94), and median entry National Institutes of Health Stroke Scale score was 13 (range, 6-25). Early after recanalization, partial or complete normalization of diffusion imaging abnormalities occurred in 8 of 18 (44%) patients. Among the eight patients with early diffusion imaging reversal, late secondary injury by day 7 occurred in 5 (63%), and sustained normalization of all reversed tissue occurred in 3 (38%). Pretreatment apparent diffusion coefficient values were lowest in regions experiencing no reversal (mean apparent diffusion coefficient, 608 microm(2)/sec), intermediate in regions with reversal and secondary decline (617 microm(2)/sec), and highest in regions with sustained reversal (663 microm(2)/sec). There was a trend toward less improvement in neurological deficit in patients with secondary injury versus patients with sustained reversal. In the future, late secondary tissue injury may become an important therapeutic target for postreperfusion neuroprotective therapies, with treatment efficacy monitored by serial diffusion magnetic resonance imaging.
尽管动物模型已表明动脉闭塞及随后再通后的迟发性继发性脑损伤可能会限制再灌注治疗的益处，但这种现象在人类中尚未得到充分表征。对接受动脉内溶栓血管再通治疗的患者在治疗前、治疗后早期及第7天进行了弥散灌注磁共振成像研究。在研究的18例患者中，平均年龄为71岁（范围27 - 94岁），入院时美国国立卫生研究院卒中量表评分中位数为13分（范围6 - 25分）。再通后早期，18例患者中有8例（44%）的弥散成像异常出现部分或完全正常化。在8例早期弥散成像逆转的患者中，7天时发生迟发性继发性损伤的有5例（63%），所有逆转组织持续正常化的有3例（38%）。未发生逆转区域的治疗前表观扩散系数值最低（平均表观扩散系数，608μm²/秒），发生逆转并继发下降区域的该值处于中间水平（617μm²/秒），而持续逆转区域的该值最高（663μm²/秒）。与持续逆转的患者相比，继发性损伤患者的神经功能缺损改善趋势较小。未来，迟发性继发性组织损伤可能会成为再灌注后神经保护治疗的一个重要治疗靶点，可通过连续弥散磁共振成像监测治疗效果。
