Shinoyama Mizuya, Nakagawara Jyoji, Yoneda Hiroshi, Suzuki Michiyasu, Ono Hidetoshi, Kunitsugu Ichiro, Kamiyama Kenji, Osato Toshiaki, Nakamura Hirohiko
Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan ; Department of Neurosurgery, Yamaguchi University School of Medicine, Yamaguchi, Japan.
Cerebrovasc Dis Extra. 2013 Feb 13;3(1):14-25. doi: 10.1159/000346113. Print 2013 Jan.
Hemorrhagic transformation (HT) following acute ischemic stroke is a major problem, especially for the indication of reperfusion therapy including intravenous administration of recombinant tissue plasminogen activator (IV rt-PA). The specific predictive factors of HT have not yet been established. The present study evaluated the findings of computed tomography perfusion (CTP) images as predictors of subsequent HT to identify patients with low HT risk for reperfusion therapy such as IV rt-PA.
We retrospectively reviewed 68 consecutive stroke patients (41 males; mean age 72.9 years) with steno-occlusive lesions in the major trunk, including 10 patients who underwent IV rt-PA. Each HT was detected on a follow-up T2*-weighted magnetic resonance image until 2 weeks after stroke onset and categorized into four groups [hemorrhagic infarction (HI) type 1 and 2, and parenchymal hematoma (PH) type 1 and 2] according to the European Cooperative Acute Stroke Study (ECASS) classification. We assessed clinical features and radiological findings between the HT and non-HT groups or the PH2 and non-PH2 groups. The efficacy of initial time to peak (TTP) mapping of CTP for predicting HT or PH2 was evaluated.
Thirty-four patients (50%) developed subsequent HT: 18 (52.9%) had HI and 16 (47.1%) had PH, including 9 PH2 patients (13.2%). IV rt-PA was not significantly associated with HT or PH2 occurrence. Forty of the 68 patients (59%) revealed defect areas on the initial TTP mapping (TTP map-defect), and 34 of these 40 patients (85%) developed secondary HT and 9 patients (22.5%) developed PH2. Initial 'TTP map-defect' was significantly associated with the occurrence of HT (p < 0.0001) and PH2 (p = 0.0070). Thirty of the 34 patients (88.2%) in the HT group experienced delayed recanalization of the occluded vessels, in contrast to only 8 of the 34 patients (23.6%) in the non-HT group. All patients of the PH2 group showed recanalization (p = 0.0042). In 40 'TTP map-defect'-positive patients, delayed recanalization was associated with the occurrence of HT (p < 0.0001) and PH2 (p = 0.0491). All 28 patients without 'TTP map-defect' did not develop HT, including 8 patients (28.6%) with delayed recanalization.
Initial 'TTP map-defect' of CTP could accurately predict HT risk including PH2 risk and identify low-risk patients even in the delayed period.
急性缺血性卒中后的出血性转化（HT）是一个主要问题，尤其是对于包括静脉注射重组组织型纤溶酶原激活剂（IV rt-PA）在内的再灌注治疗指征而言。HT的具体预测因素尚未确定。本研究评估了计算机断层扫描灌注（CTP）图像的结果作为后续HT的预测指标，以识别适合IV rt-PA等再灌注治疗且HT风险较低的患者。
我们回顾性分析了68例连续的主要血管主干存在狭窄闭塞性病变的卒中患者（41例男性；平均年龄72.9岁），其中10例接受了IV rt-PA治疗。在卒中发作后2周内，通过随访T2*加权磁共振图像检测每次HT，并根据欧洲急性卒中协作研究（ECASS）分类将其分为四组[1型和2型出血性梗死（HI），以及1型和2型脑实质血肿（PH）]。我们评估了HT组与非HT组或PH2组与非PH2组之间的临床特征和影像学表现。评估了CTP的初始达峰时间（TTP）图预测HT或PH2的效能。
34例患者（50%）出现了后续HT：18例（52.9%）为HI，16例（47.1%）为PH，其中9例为PH2患者（13.2%）。IV rt-PA与HT或PH2的发生无显著相关性。68例患者中有40例（59%）在初始TTP图上显示有缺损区域（TTP图缺损），这40例患者中有34例（85%）发生了继发性HT，9例（22.5%）发生了PH2。初始“TTP图缺损”与HT（p < 0.0001）和PH2（p = 0.0070）的发生显著相关。HT组的34例患者中有30例（88.2%）出现了闭塞血管的延迟再通，相比之下，非HT组的34例患者中只有8例（23.6%）出现延迟再通。PH2组的所有患者均显示再通（p = 0.0042）。在40例“TTP图缺损”阳性患者中，延迟再通与HT（p < 0.0001）和PH2（p = 0.0491）的发生相关。所有28例无“TTP图缺损”的患者均未发生HT，包括8例（28.6%）出现延迟再通的患者。
CTP的初始“TTP图缺损”能够准确预测包括PH2风险在内的HT风险，并能识别即使在延迟期内的低风险患者。
