结合MRI与美国国立卫生研究院卒中量表（NIHSS）阈值预测急性缺血性卒中的预后：对患者选择的价值
Combining MRI with NIHSS thresholds to predict outcome in acute ischemic stroke: value for patient selection.
作者信息
Schaefer P W, Pulli B, Copen W A, Hirsch J A, Leslie-Mazwi T, Schwamm L H, Wu O, González R G, Yoo A J
机构信息
From the Departments of Radiology (P.W.S., B.P., W.A.C., J.A.H., T.L.-M., O.W., R.G.G., A.J.Y.)
From the Departments of Radiology (P.W.S., B.P., W.A.C., J.A.H., T.L.-M., O.W., R.G.G., A.J.Y.).
出版信息
AJNR Am J Neuroradiol. 2015 Feb;36(2):259-64. doi: 10.3174/ajnr.A4103. Epub 2014 Sep 25.
BACKGROUND AND PURPOSE
Selecting acute ischemic stroke patients for reperfusion therapy on the basis of a diffusion-perfusion mismatch has not been uniformly proved to predict a beneficial treatment response. In a prior study, we have shown that combining clinical with MR imaging thresholds can predict clinical outcome with high positive predictive value. In this study, we sought to validate this predictive model in a larger patient cohort and evaluate the effects of reperfusion therapy and stroke side.
MATERIALS AND METHODS
One hundred twenty-three consecutive patients with anterior circulation acute ischemic stroke underwent MR imaging within 6 hours of stroke onset. DWI and PWI volumes were measured. Lesion volume and NIHSS score thresholds were used in models predicting good 3-month clinical outcome (mRS 0-2). Patients were stratified by treatment and stroke side.
RESULTS
Receiver operating characteristic analysis demonstrated 95.6% and 100% specificity for DWI > 70 mL and NIHSS score > 20 to predict poor outcome, and 92.7% and 91.3% specificity for PWI (mean transit time) < 50 mL and NIHSS score < 8 to predict good outcome. Combining clinical and imaging thresholds led to an 88.8% (71/80) positive predictive value with a 65.0% (80/123) prognostic yield. One hundred percent specific thresholds for DWI (103 versus 31 mL) and NIHSS score (20 versus 17) to predict poor outcome were significantly higher in treated (intravenous and/or intra-arterial) versus untreated patients. Prognostic yield was lower in right- versus left-sided strokes for all thresholds (10.4%-20.7% versus 16.9%-40.0%). Patients with right-sided strokes had higher 100% specific DWI (103.1 versus 74.8 mL) thresholds for poor outcome, and the positive predictive value was lower.
CONCLUSIONS
Our predictive model is validated in a much larger patient cohort. Outcome may be predicted in up to two-thirds of patients, and thresholds are affected by stroke side and reperfusion therapy.
背景与目的
基于弥散灌注不匹配来选择急性缺血性脑卒中患者进行再灌注治疗，尚未被一致证明能预测有益的治疗反应。在之前的一项研究中，我们已经表明，将临床指标与磁共振成像阈值相结合可以以较高的阳性预测值预测临床结局。在本研究中，我们试图在更大的患者队列中验证这一预测模型，并评估再灌注治疗和卒中部位的影响。
材料与方法
123例连续的前循环急性缺血性脑卒中患者在卒中发作6小时内接受了磁共振成像检查。测量了弥散加权成像（DWI）和灌注加权成像（PWI）体积。在预测3个月良好临床结局（改良Rankin量表评分0 - 2分）的模型中使用了病变体积和美国国立卫生研究院卒中量表（NIHSS）评分阈值。患者按治疗方式和卒中部位进行分层。
结果
受试者工作特征分析显示，DWI>70 mL和NIHSS评分>20预测不良结局的特异性分别为95.6%和100%，PWI（平均通过时间）<50 mL和NIHSS评分<8预测良好结局的特异性分别为92.7%和91.3%。将临床和影像阈值相结合导致阳性预测值为88.8%（71/80），预后率为65.0%（80/123）。在预测不良结局时，治疗组（静脉和/或动脉内治疗）与未治疗组相比，DWI（103对31 mL）和NIHSS评分（20对17）的100%特异性阈值显著更高。对于所有阈值，右侧卒中与左侧卒中相比，预后率更低（10.4% - 20.7%对16.9% - 40.0%）。右侧卒中患者预测不良结局的100%特异性DWI阈值更高（103.1对74.8 mL），且阳性预测值更低。
结论
我们的预测模型在更大的患者队列中得到了验证。多达三分之二的患者结局可以被预测，且阈值受卒中部位和再灌注治疗的影响。
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