Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, Mannheim, Germany.
Cerebrovasc Dis. 2013;35(6):554-9. doi: 10.1159/000351146. Epub 2013 Jul 6.
Early recanalization and increase in collateral blood supply are powerful predictors of favourable outcome in acute ischaemic stroke. The factors contributing to the heterogeneous response to intravenous thrombolysis therapy in individual patients, however, are not fully understood. The on-going single-centre 'MR perfusion imaging during thrombolysis' study uses repetitive arterial spin labelling (ASL) measurements to characterize the haemodynamic processes in acute stroke during therapy. The first milestone was to develop an appropriate infrastructure for thrombolysis in the magnetic resonance imaging (MRI) scanner without time delay and ensuring optimal patient safety and care.
Between February and December 2011, 16 patients with acute neurological symptoms suggestive of hemispheric stroke within 4.5 h after symptom onset were included. In addition to clinical data, we documented the time from onset to arrival at the hospital, start and duration of MRI examination, start of thrombolytic therapy, and complications. The decision to thrombolyse was made after a routine stroke MRI protocol. During the 60-min systemic thrombolysis, repetitive ASL perfusion imaging was acquired, providing non-invasive information on cerebral perfusion. Continuous ECG monitoring, pulse oximetry, blood pressure measurements every 5 min, and short neurological assessments every 15 min were performed in every patient.
The median initial NIHSS score of the patients presenting with a mean of 84 min after onset was 4 (range 2-18). MRI examination was initiated within a mean of 45 min after arrival at the hospital. Five patients identified as stroke mimics were not treated with recombinant tissue plasminogen activator (rt-PA), and in 1 case with basilar artery occlusion bridging therapy was performed outside the scanner. In the remaining 10 patients, rt-PA therapy was started in the scanner directly after decision making on the basis of clinical information and baseline MRI. The mean door-to-needle time was 60 min (range 44-115) including approximately 10 min needed for acquiring informed consent. While 4 patients required antihypertensive treatment, no relevant complications were encountered.
Fast and safe medical care in patients during systemic thrombolysis in the MRI scanner is feasible. Despite the process of obtaining informed consent, with a dedicated and experienced stroke team the door-to-needle time can be kept in a range recommended by current guidelines. Continuous real-time information about the dynamics of cerebral perfusion from ASL perfusion in acute stroke patients undergoing thrombolysis may provide additional information for the understanding of the events following acute arterial obstruction and its course.
急性缺血性脑卒中患者早期再通和增加侧支血流供应是预后良好的有力预测因素。然而，导致个体患者对静脉溶栓治疗反应存在异质性的因素尚不完全清楚。正在进行的单中心“溶栓期间磁共振灌注成像”研究使用重复动脉自旋标记（ASL）测量来描述治疗期间急性脑卒中的血液动力学过程。第一个里程碑是在磁共振成像（MRI）扫描仪中建立一种无时间延迟的、确保最佳患者安全和护理的溶栓基础结构。
2011 年 2 月至 12 月期间，纳入了 16 名症状发作后 4.5 小时内出现急性神经系统症状、疑似半球性脑卒中的患者。除了临床数据外，我们还记录了从发病到到达医院的时间、MRI 检查的开始和持续时间、溶栓治疗的开始和持续时间以及并发症。在进行常规脑卒中 MRI 检查后，决定进行溶栓治疗。在 60 分钟的系统性溶栓过程中，采集重复的 ASL 灌注成像，提供脑灌注的无创信息。每位患者均进行连续心电图监测、脉搏血氧饱和度监测、每 5 分钟测量血压和每 15 分钟进行简短的神经学评估。
平均发病 84 分钟后入院的患者的初始 NIHSS 评分中位数为 4 分（范围 2-18）。MRI 检查在到达医院后平均 45 分钟内开始。5 名被认为是脑卒中模拟患者的患者未接受重组组织型纤溶酶原激活剂（rt-PA）治疗，1 例基底动脉闭塞患者在扫描仪外进行了桥接治疗。在其余 10 名患者中，根据临床信息和基线 MRI 直接在决定后在扫描仪中开始 rt-PA 治疗。平均门到针时间为 60 分钟（范围 44-115 分钟），包括大约 10 分钟用于获取知情同意书。虽然 4 名患者需要降压治疗，但未出现相关并发症。
在 MRI 扫描仪中进行系统性溶栓时，为患者提供快速、安全的医疗护理是可行的。尽管获得知情同意书的过程很复杂，但通过专门且经验丰富的脑卒中团队，可将门到针时间保持在当前指南推荐的范围内。对接受溶栓治疗的急性动脉阻塞患者进行 ASL 灌注的实时动态脑灌注信息可能为理解急性动脉阻塞及其病程中的事件提供额外信息。
