From the Neurology Department, Hospital de Clínicas, U.N.A. San Lorenzo, Paraguay (A.F.); Stroke Unit (M. Rubiera, M. Ribó, J.P., D.R.-L., M.M., S.B., L.S., E.S., P.M., E.S., C.A.M.) and Neuroradiology Department (M.R., M.R., J.P., D.R.-L., M.M., S.B., L.S., E.S., P.M., E.S., A.T., M.L., P.C., C.A.M.), Vall D' Hebron Hospital, Barcelona, Spain; and Neurology Department, Clínica Alemana, Santiago, Chile (D.C.).
Stroke. 2015 Nov;46(11):3149-53. doi: 10.1161/STROKEAHA.115.010608. Epub 2015 Sep 29.
Collateral circulation (CC) has been associated with recanalization, infarct volume, and clinical outcome in patients undergoing acute reperfusion therapies. However, its relationship with the development to malignant middle cerebral artery infarction (mMCAi) has not been evaluated. Our aim was to determine the impact of CC using multiphase computed tomographic angiography (during the acute stroke phase in the prediction of mMCAi.
Patients with consecutive acute stroke with <4.5 hours who were evaluated for reperfusion therapies and presented with an M1-MCA or terminal internal carotid artery occlusion by CTA were included. CC was evaluated on 6 grades by multiphase CTA according to the University of Calgary CC Scale; CC status was defined as poor (grades, 0-3) or good (grades, 4-5). The mMCAi was defined according to clinical and radiological criteria. Recanalization was assessed with transcranial Doppler at 24 hours and final Thrombolysis in Brain Ischemia score≥2b in patients undergoing endovascular reperfusion treatment.
Eighty-two patients were included. Mean age was 65.1±13.83 years, median baseline National Institutes of Health Stroke Scale score was 18 (interquartile range, 13-20), and 67.9% M1 and 32.1% terminal internal carotid artery occlusions. Fifty-three patients received endovascular reperfusion treatment. Fifteen patients developed mMCAi. In the univariate analysis, patients with mMCAi had lower CC scores (2.29 versus 3.71; P=0.001). Endovascular reperfusion treatment was associated with lower rate of mMCAi development than only intravenous reperfusion treatment (9.4% versus 29.6%; P=0.028). Patients with poor CC had higher risk of developing mMCAi (13% versus 2%; P=0.001). On the multivariate analysis adjusted by age, vessel occlusion, baseline National Institutes of Health Stroke Scale, and recanalization, the presence of poor CC by multiphase CTA was the only independent predictor of mMCAi (P=0.048; odds ratio, 9.72; 95% confidence interval, 1.387-92.53).
CC assessment by multiphase CTA independently predicts malignant MCA infarction progression. In patients with persistent occlusion after reperfusion therapies, the presence of poor CC may improve the early mMCAi detection and management.
侧支循环（CC）与接受急性再灌注治疗的患者的再通、梗死体积和临床结局相关。然而，其与恶性大脑中动脉梗死（mMCAi）的发展之间的关系尚未得到评估。我们的目的是使用多相 CT 血管造影（在急性卒中阶段）评估 CC，以预测 mMCAi。
纳入发病时间＜4.5 小时且接受再灌注治疗评估并存在 M1-MCA 或颈内动脉终末段闭塞的连续急性卒中患者。根据卡尔加里大学 CC 量表，用多相 CTA 对 CC 进行 6 级评估；CC 状态定义为差（0-3 级）或好（4-5 级）。根据临床和影像学标准定义 mMCAi。对接受血管内再灌注治疗的患者，在 24 小时用经颅多普勒进行再通评估，并在最终的血栓溶解脑缺血评分≥2b 时。
共纳入 82 例患者。平均年龄为 65.1±13.83 岁，中位基线 NIHSS 评分为 18（四分位距 13-20），67.9%的患者为 M1 段闭塞，32.1%为颈内动脉终末段闭塞。53 例患者接受了血管内再灌注治疗。15 例患者发生 mMCAi。在单变量分析中，发生 mMCAi 的患者的 CC 评分较低（2.29 比 3.71；P=0.001）。与单纯静脉内再灌注治疗相比，血管内再灌注治疗与较低的 mMCAi 发生率相关（9.4%比 29.6%；P=0.028）。CC 较差的患者发生 mMCAi 的风险更高（13%比 2%；P=0.001）。多变量分析调整年龄、血管闭塞、基线 NIHSS 和再通后，多相 CTA 显示的 CC 不良是 mMCAi 的唯一独立预测因素（P=0.048；比值比，9.72；95%置信区间，1.387-92.53）。
多相 CTA 评估的 CC 独立预测恶性 MCA 梗死进展。在再灌注治疗后持续闭塞的患者中，存在 CC 不良可能会提高早期 mMCAi 的检出率和管理。
