From the Department of Neurology, Stanford Stroke Center, Palo Alto, CA (N.K.M., G.W.A., S.C., S.H., M.S., J.T.P.L., S.K., M. Mlynash, R.B., M.G.L.); and Department of Radiology, Stanford University Medical Center, Palo Alto, CA (M. Marks, R.B.).
Stroke. 2014 May;45(5):1369-74. doi: 10.1161/STROKEAHA.114.004772. Epub 2014 Apr 3.
The Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 (DEFUSE 2) study has shown that clinical response to endovascular reperfusion differs between patients with and without perfusion-diffusion (perfusion-weighted imaging-diffusion-weighted imaging, PWI-DWI) mismatch: patients with mismatch have a favorable clinical response to reperfusion, whereas patients without mismatch do not. This study examined whether alternative mismatch criteria can also differentiate patients according to their response to reperfusion.
Patients from the DEFUSE 2 study were categorized according to vessel occlusion on magnetic resonance angiography (MRA) and DWI lesion volume criteria (MRA-DWI mismatch) and symptom severity and DWI criteria (clinical-DWI mismatch). Favorable clinical response was defined as an improvement of ≥8 points on the National Institutes of Health Stroke Scale (NIHSS) by day 30 or an NIHSS score of ≤1 at day 30. We assessed, for each set of criteria, whether the association between reperfusion and favorable clinical response differed according to mismatch status.
A differential response to reperfusion was observed between patients with and without MRA-DWI mismatch defined as an internal carotid artery or M1 occlusion and a DWI lesion<50 mL. Reperfusion was associated with good functional outcome in patients who met these MRA-DWI mismatch criteria (odds ratio [OR], 8.5; 95% confidence interval [CI], 2.3-31.3), whereas no association was observed in patients who did not meet these criteria (OR, 0.5; 95% CI, 0.08-3.1; P for difference between the odds, 0.01). No differential response to reperfusion was observed with other variations of the MRA-DWI or clinical-DWI mismatch criteria.
The MRA-DWI mismatch is a promising alternative to DEFUSE 2's PWI-DWI mismatch for patient selection in endovascular stroke trials.
扩散和灌注成像评估理解卒中演变 2 期（DEFUSE 2）研究表明，血管内再灌注治疗的临床反应在有灌注-弥散（灌注加权成像-弥散加权成像，PWI-DWI）不匹配和无灌注-弥散不匹配的患者之间存在差异：不匹配的患者对再灌注有良好的临床反应，而无不匹配的患者则没有。本研究旨在探讨替代不匹配标准是否也可以根据患者对再灌注的反应来区分患者。
根据磁共振血管造影（MRA）和弥散加权成像（DWI）病变体积标准（MRA-DWI 不匹配）以及症状严重程度和 DWI 标准（临床-DWI 不匹配），对 DEFUSE 2 研究中的患者进行分类。良好的临床反应定义为 30 天内 NIHSS 评分改善≥8 分或 30 天内 NIHSS 评分≤1 分。我们评估了对于每一组标准，再灌注与良好的临床反应之间的相关性是否因不匹配状态而异。
在符合颈内动脉或 M1 闭塞和 DWI 病变<50 mL 的 MRA-DWI 不匹配标准的患者中，观察到再灌注与良好的功能结局之间存在差异。对于符合这些 MRA-DWI 不匹配标准的患者，再灌注与良好的功能结局相关（比值比[OR]，8.5；95%置信区间[CI]，2.3-31.3），而不符合这些标准的患者则没有观察到相关性（OR，0.5；95%CI，0.08-3.1；OR 差异的 P 值为 0.01）。对于其他 MRA-DWI 或临床-DWI 不匹配标准的变化，没有观察到再灌注的差异反应。
与 DEFUSE 2 的 PWI-DWI 不匹配相比，MRA-DWI 不匹配是血管内卒中试验中患者选择的一种有前途的替代方法。
