Maas Matthew B, Furie Karen L, Lev Michael H, Ay Hakan, Singhal Aneesh B, Greer David M, Harris Gordon J, Halpern Elkan, Koroshetz Walter J, Smith Wade S
Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass, USA.
Stroke. 2009 Sep;40(9):2988-93. doi: 10.1161/STROKEAHA.109.555664. Epub 2009 Jul 16.
Multimodal imaging is gaining an important role in acute stroke. The benefit of obtaining additional clinically relevant information must be weighed against the detriment of increased cost, delaying time to treatment, and adverse events such as contrast-induced nephropathy. Use of National Institutes of Health Stroke Scale (NIHSS) score to predict a proximal arterial occlusion (PO) is suggested by several case series as a viable method of selecting cases appropriate for multimodal imaging.
Six hundred ninety-nine patients enrolled in a prospective cohort study involving CT angiographic imaging in acute stroke were dichotomized according to the presence of a PO, including a subgroup of 177 subjects with middle cerebral artery M1 occlusion.
The median NIHSS score of patients found to have a PO was higher than the overall median (9 versus 5, P<0.0001). The median NIHSS score of patients with middle cerebral artery M1 occlusion was 14. NIHSS score > or =10 had 81% positive predictive value for PO but only 48% sensitivity with the majority of subjects with PO presenting with lower NIHSS scores. All patients with NIHSS score > or =2 would need to undergo angiographic imaging to detect 90% of PO.
High NIHSS score correlates with the presence of a proximal arterial occlusion in patients presenting with acute cerebral ischemia. No NIHSS score threshold can be applied to select a subgroup of patients for angiographic imaging without failing to capture the majority of cases with clinically important occlusive lesions. The finding of minimal clinical deficits should not deter urgent angiographic imaging in otherwise appropriate patients suspected of acute stroke.
多模态成像在急性卒中中发挥着重要作用。获取额外临床相关信息的益处必须与成本增加、治疗延迟以及诸如造影剂肾病等不良事件的损害相权衡。几个病例系列研究表明，使用美国国立卫生研究院卒中量表（NIHSS）评分来预测近端动脉闭塞（PO）是选择适合多模态成像病例的一种可行方法。
在一项涉及急性卒中CT血管造影成像的前瞻性队列研究中，699名患者根据是否存在PO进行二分法分类，其中包括177名大脑中动脉M1段闭塞的亚组患者。
被发现存在PO的患者的NIHSS评分中位数高于总体中位数（9对5，P<0.0001）。大脑中动脉M1段闭塞患者的NIHSS评分中位数为14。NIHSS评分≥10对PO的阳性预测值为81%，但敏感性仅为48%，大多数PO患者的NIHSS评分较低。所有NIHSS评分≥2的患者都需要接受血管造影成像以检测90%的PO。
在急性脑缺血患者中，高NIHSS评分与近端动脉闭塞的存在相关。没有NIHSS评分阈值可用于选择血管造影成像的患者亚组而不遗漏大多数具有临床重要闭塞性病变的病例。对于疑似急性卒中的其他合适患者，即使临床缺陷最小，也不应阻止进行紧急血管造影成像。
