Neuroendovascular Program, Massachusetts General Hospital, Boston.
Stroke Service, Massachusetts General Hospital, Boston.
JAMA Neurol. 2016 Jan;73(1):43-9. doi: 10.1001/jamaneurol.2015.3000.
Which imaging modality is optimal to select patients for endovascular stroke treatment remains unclear.
To evaluate the effectiveness of specific magnetic resonance imaging (MRI) and clinical criteria in the selection of patients with acute ischemic stroke for thrombectomy.
DESIGN, SETTING, AND PARTICIPANTS: In this observational, single-center, prospective cohort study, we studied 72 patients with middle cerebral artery or terminal internal carotid artery occlusion using computed tomographic angiography, followed by core infarct volume determination by diffusion weighted MRI, who underwent thrombectomy after meeting institutional criteria from January 1, 2012, through December 31, 2014. In this period, 31 patients with similar ischemic strokes underwent endovascular treatment without MRI and are categorized as computed tomography only and considered in a secondary analysis.
Patients were prospectively classified as likely to benefit (LTB) or uncertain to benefit (UTB) using diffusion-weighted imaging lesion volume and clinical criteria (age, National Institutes of Health Stroke Scale score, time from onset, baseline modified Rankin Scale [mRS] score, life expectancy).
The 90-day mRS score, with favorable defined as a 90-day mRS score of 2 or less.
Forty patients were prospectively classified as LTB and 32 as UTB. Reperfusion (71 of 103 patients) and prospective categorization as LTB (40 of 103 patients) were associated with favorable outcomes (P < .001 and P < .005, respectively). Successful reperfusion positively affected the distribution of mRS scores of the LTB cohort (P < .001). Reperfusion was achieved in 27 LTB patients (67.5%) and 24 UTB patients (75.0%) (P = .86). Favorable outcomes were obtained in 21 (52.5%) and 8 (25.0%) of LTB and UTB patients who were treated, respectively (P = .02). Favorable outcomes were observed in 20 of the 27 LTB patients (74.1%) who had successful reperfusion compared with 8 of the 24 UTB patients (33.3%) who had successful reperfusion (P = .004). The ratio of treated to screened patients was 1:3.
Prospective classification as LTB by MRI and clinical criteria is associated with likelihood of favorable outcome after thrombectomy, particularly if reperfusion is successful. Selection of patients using MRI compares favorably with selection using computed tomographic techniques with the distinction that a higher proportion of screened patients were treated.
选择适合血管内治疗的患者的最佳影像学方法仍不清楚。
评估特定磁共振成像（MRI）和临床标准在选择急性缺血性卒中患者进行血栓切除术的有效性。
设计、地点和参与者：在这项观察性、单中心、前瞻性队列研究中，我们使用计算机断层血管造影研究了 72 例大脑中动脉或终末颈内动脉闭塞患者，然后通过弥散加权 MRI 确定核心梗死体积，在符合机构标准后于 2012 年 1 月 1 日至 2014 年 12 月 31 日进行血栓切除术。在此期间，31 例类似的缺血性卒中患者接受了血管内治疗而未行 MRI 检查，并归类为仅行 CT 检查，并在二次分析中进行了考虑。
前瞻性使用弥散加权成像病变体积和临床标准（年龄、美国国立卫生研究院卒中量表评分、发病时间、基线改良 Rankin 量表评分、预期寿命）将患者分类为可能受益（LTB）或不确定受益（UTB）。
90 天 mRS 评分，预后良好定义为 90 天 mRS 评分为 2 或更低。
40 例患者前瞻性分类为 LTB，32 例为 UTB。再灌注（103 例患者中的 71 例）和前瞻性分类为 LTB（103 例患者中的 40 例）与良好结局相关（P<0.001 和 P<0.005）。成功再灌注对 LTB 队列的 mRS 评分分布有积极影响（P<0.001）。27 例 LTB 患者（67.5%）和 24 例 UTB 患者（75.0%）实现了再灌注（P=0.86）。接受治疗的 21 例 LTB 患者（52.5%）和 8 例 UTB 患者（25.0%）获得了良好结局（P=0.02）。27 例 LTB 患者中，20 例（74.1%）再灌注成功，24 例 UTB 患者中，8 例（33.3%）再灌注成功（P=0.004）。接受治疗的患者与接受筛选的患者之比为 1:3。
通过 MRI 和临床标准前瞻性分类为 LTB 与血栓切除术后获得良好结局相关，尤其是在再灌注成功的情况下。使用 MRI 选择患者的效果优于使用 CT 技术选择患者，区别在于筛选出的患者中有更高比例接受了治疗。
