Flossmann Enrico, Redgrave Jessica N, Briley Dennis, Rothwell Peter M
FRCP, Stroke Prevention Research Unit, University Department of Clinical Neurology, Level 6, West Wing, The John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK.
Stroke. 2008 Sep;39(9):2457-60. doi: 10.1161/STROKEAHA.107.511428. Epub 2008 Jul 17.
Knowledge of the vascular territory of a recent transient ischemic attack or minor stroke determines appropriate investigations and the need for territory-specific interventions such as endarterectomy and stenting. However, there are few published data on the accuracy of clinical assessment of the vascular territory.
We studied agreement of clinical diagnosis of vascular territory in consecutive patients with transient ischemic attack or minor stroke with diffusion-weighted MRI who had an acute ischemic lesion(s) in a single vascular territory (determined by a neuroradiologist). Three independent neurologists (one had seen the patients, the others had a clinical summary) diagnosed the most likely vascular territory (carotid or vertebrobasilar) for each patient blind to brain imaging.
One hundred thirty-three (28.0%) of 476 patients had a high signal lesion on diffusion-weighted imaging of whom 115 (86.5%) had a minor stroke and 18 (13.5%) a transient ischemic attack. Interobserver agreement (kappa statistic) on the territory ranged from 0.46 to 0.60. The agreement with diffusion-weighted imaging was only moderate (observer 1: kappa=0.54, 95% CI=0.36 to 0.72; observer 2: 0.48, 0.31 to 0.64; observer 3: 0.48, 0.28 to 0.67). Only the presence of visual symptoms improved the accuracy of the vascular territory diagnosis (range of kappa: 0.63 to 0.77) but not the presence of motor, speech, or sensory symptoms. Sensitivity and specificity for the diagnosis of vertebrobasilar territory ranged between 54.2% and 70.8% and 84.4% to 91.7%, respectively.
The reliability of clinical diagnosis of the vascular territory is only moderate, highlighting the importance of sensitive brain imaging after transient ischemic attack or minor stroke. Further imaging-based research is required to determine the optimal clinical diagnostic criteria for classification of the vascular territory.
了解近期短暂性脑缺血发作或轻度卒中的血管供血区对于确定合适的检查以及是否需要进行特定供血区干预（如动脉内膜切除术和支架置入术）至关重要。然而，关于血管供血区临床评估准确性的已发表数据较少。
我们研究了连续的短暂性脑缺血发作或轻度卒中患者，这些患者经弥散加权磁共振成像（MRI）检查发现急性缺血性病变位于单一血管供血区（由神经放射科医生确定），比较临床诊断的血管供血区与MRI结果的一致性。三位独立的神经科医生（一位看过患者，另外两位只有临床总结）在不知脑部影像结果的情况下，对每位患者最可能的血管供血区（颈动脉或椎基底动脉供血区）进行诊断。
476例患者中，133例（28.0%）在弥散加权成像上有高信号病变，其中115例（86.5%）为轻度卒中，18例（13.5%）为短暂性脑缺血发作。观察者间对供血区的一致性（kappa统计量）在0.46至0.60之间。与弥散加权成像的一致性仅为中等程度（观察者1：kappa = 0.54，95%可信区间 = 0.36至0.72；观察者2：0.48，0.31至0.64；观察者3：0.48，0.28至0.67）。只有视觉症状的存在提高了血管供血区诊断的准确性（kappa范围：0.63至至0.77），而运动、言语或感觉症状的存在并未提高准确性。诊断椎基底动脉供血区的敏感性和特异性分别在54.2%至70.8%和84.4%至91.7%之间。
血管供血区临床诊断的可靠性仅为中等程度，这凸显了短暂性脑缺血发作或轻度卒中后进行敏感脑成像检查的重要性。需要进一步基于成像的研究来确定血管供血区分型的最佳临床诊断标准。
