Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02215, USA.
Cerebrovasc Dis. 2012;33(6):525-31. doi: 10.1159/000337335. Epub 2012 Apr 25.
To date limited information regarding outcome-modifying factors in patients with acute intracranial large artery occlusion (ILAO) in the anterior circulation is available. Leukoaraiosis (LA) is a common finding among patients with ischemic stroke and has been associated with poor post-stroke outcomes but its association with ILAO remains poorly characterized. This study sought to clarify the contribution of baseline LA and other common risk factors to 90-day outcome (modified Rankin Scale, mRS) after stroke due to acute anterior circulation ILAO.
We retrospectively analyzed 1,153 consecutive patients with imaging-confirmed ischemic stroke during a 4-year period (2007-2010) at a single academic institution. The final study cohort included 87 patients with acute ILAO subjected to multimodal CT imaging within 24 h of symptom onset. LA severity was assessed using the van Swieten scale on non-contrast CT. Leptomeningeal collaterals were graded using CT angiogram source images. Hemorrhagic transformation (HT) was determined on follow-up CT. Multivariate logistic regression controlling for HT, treatment modality, demographic, as well as baseline clinical and imaging characteristics was used to identify independent predictors of a poor outcome (90-day mRS >2).
The median National Institutes of Health Stroke Scale (NIHSS) at baseline was 15 (interquartile range 9-21). Twenty-four percent of the studied patients had severe LA. They were more likely to have hypertension (p = 0.028), coronary artery disease (p = 0.015), poor collaterals (p < 0.001), higher baseline NIHSS (p = 0.003), higher mRS at 90 days (p < 0.001), and were older (p = 0.002). Patients with severe LA had a uniformly poor outcome (p < 0.001) irrespective of treatment modality. Poor outcome was independently associated with higher baseline NIHSS (p < 0.001), worse LA (graded and dichotomized, p < 0.001), reduced leptomeningeal collaterals (graded and dichotomized, p < 0.001), presence of HT (p < 0.001), presence of parenchymal hemorrhages (p = 0.01), baseline mRS (p = 0.002), and older age (p = 0.043). The association between severe LA (p = 0.0056; OR 13.86; 95% CI 1.94-∞) and baseline NIHSS (p = 0.0001; OR 5.11; 95% CI 2.07-14.49 for each 10-point increase) with poor outcome maintained after adjustment for confounders in the final regression model. In this model, there was no significant association between presence of HT and poor outcome (p = 0.0572).
Coexisting LA may predict poor functional outcome in patients with acute anterior circulation ILAO independent of other known important outcome predictors such as comorbid state, admission functional deficit, collateral status, hemorrhagic conversion, and treatment modality.
目前，关于前循环急性颅内大动脉闭塞（ILAO）患者的预后影响因素的信息有限。脑白质疏松症（LA）是缺血性卒中患者的常见表现，与卒中后预后不良相关，但与 ILAO 的关系尚不清楚。本研究旨在阐明基线 LA 及其他常见危险因素对急性前循环 ILAO 后 90 天结局（改良 Rankin 量表，mRS）的影响。
我们回顾性分析了 4 年内（2007-2010 年）在一家学术机构确诊的 1153 例影像学证实的缺血性卒中患者。最终研究队列纳入了 87 例在症状发作后 24 小时内行多模态 CT 影像学检查的急性 ILAO 患者。使用非增强 CT 上的 van Swieten 量表评估 LA 严重程度。使用 CT 血管造影源图像评估软脑膜侧支循环。通过随访 CT 评估出血性转化（HT）。采用多变量逻辑回归，控制 HT、治疗方式、人口统计学以及基线临床和影像学特征，以确定预后不良（90 天 mRS >2）的独立预测因素。
基线 NIHSS 中位数为 15（四分位距 9-21）。24%的研究患者有严重的 LA。他们更可能患有高血压（p=0.028）、冠状动脉疾病（p=0.015）、侧支循环不良（p<0.001）、较高的基线 NIHSS（p=0.003）、较高的 90 天 mRS（p<0.001）和年龄较大（p=0.002）。无论治疗方式如何，严重 LA 的患者结局均较差（p<0.001）。预后不良与较高的基线 NIHSS（p<0.001）、较差的 LA（分级和二分法，p<0.001）、软脑膜侧支循环减少（分级和二分法，p<0.001）、HT 存在（p<0.001）、实质出血（p=0.01）、基线 mRS（p=0.002）和年龄较大（p=0.043）相关。严重 LA（p=0.0056；OR 13.86；95%CI 1.94-∞）与基线 NIHSS（p=0.0001；OR 5.11；95%CI 2.07-14.49，每增加 10 分）与不良预后的关联在最终回归模型中调整混杂因素后仍存在。在该模型中，HT 的存在与不良预后无显著相关性（p=0.0572）。
急性前循环 ILAO 患者伴发 LA 可能独立于其他已知的重要预后预测因素，如合并症状态、入院时的功能缺损、侧支循环状态、出血性转化和治疗方式，预测不良的功能结局。
