Santos Emilie M M, Marquering Henk A, den Blanken Mark D, Berkhemer Olvert A, Boers Anna M M, Yoo Albert J, Beenen Ludo F, Treurniet Kilian M, Wismans Carrie, van Noort Kim, Lingsma Hester F, Dippel Diederik W J, van der Lugt Aad, van Zwam Wim H, Roos Yvo B W E M, van Oostenbrugge Robert J, Niessen Wiro J, Majoie Charles B
From the Departments of Radiology (E.M.M.S., H.A.M., O.A.B., A.M.M.B., L.F.B., K.M.T., C.W., K.N., C.B.M.), Biomedical Engineering and Physics (E.M.M.S., H.A.M., M.D.B., A.M.M.B.), and Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, The Netherlands; Departments of Radiology (E.M.M.S., A.L., W.J.N.), Medical Informatics (E.M.M.S., W.J.N.), Neurology (O.A.B., D.W.J.D.), and Public Health (H.F.L.), Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Robotics and Mechatronics, University of Twente, Twente, The Netherlands (A.M.M.B.); Division of Interventional Neuroradiology, Department of Radiology, Texas Stroke Institute, Plano (A.J.Y.); Departments of Radiology (W.H.Z.) and Neurology (R.J.O.), and Cardiovascular Research Institute Maastricht (W.H.Z., R.J.O.), Maastricht University MC, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands (W.H.Z.); and Faculty of Applied Sciences, Delft University of Technology, Delft, The Netherlands (W.J.N.).
Stroke. 2016 Mar;47(3):732-41. doi: 10.1161/STROKEAHA.115.011187. Epub 2016 Feb 4.
Preclinical studies showed that thrombi can be permeable and may, therefore, allow for residual blood flow in occluded arteries of patients having acute ischemic stroke. This perviousness may increase tissue oxygenation, improve thrombus dissolution, and augment intra-arterial treatment success. We hypothesize that the combination of computed tomographic angiography and noncontrast computed tomography imaging allows measurement of contrast agent penetrating a permeable thrombus, and it is associated with improved outcome.
Thrombus and contralateral artery attenuations in noncontrast computed tomography and computed tomographic angiography images were measured in 184 Multicenter Randomized Clinical trial of Endovascular treatment of acute ischemic stroke in the Netherlands (MR CLEAN) patients with thin-slice images. Two quantitative estimators of the thrombus permeability were introduced: computed tomographic angiography attenuation increase (Δ) and thrombus void fraction (ε). Patients were dichotomized as having a pervious or impervious thrombus and associated with outcome, recanalization, and final infarct volume.
Patients with Δ≥10.9 HU (n=81 [44%]) and ε≥6.5% (n=77 [42%]) were classified as having a pervious thrombus. These patients were 3.2 (95% confidence interval, 1.7-6.4) times more likely to have a favorable outcome, and 2.5 (95% confidence interval, 1.3-4.8) times more likely to recanalyze, for Δ based classification, and similarly for ε. These odds ratios were independent from intravenous or intra-arterial treatment. Final infarct volume was negatively correlated with both perviousness estimates (correlation coefficient, -0.39 for Δ and -0.40 for ε).
This study shows that simultaneous measurement of thrombus attenuation in noncontrast computed tomography and computed tomographic angiography allows for quantification of thrombus perviousness. Thrombus perviousness is strongly associated with improved functional outcome, smaller final infarct volume, and higher recanalization rate.
临床前研究表明，血栓可能具有渗透性，因此，在急性缺血性脑卒中患者的闭塞动脉中可能存在残余血流。这种渗透性可能会增加组织氧合、促进血栓溶解并提高动脉内治疗的成功率。我们假设，计算机断层血管造影（CTA）与非增强计算机断层扫描（CT）成像相结合能够测量造影剂穿透渗透性血栓的情况，并且这与改善的预后相关。
在荷兰急性缺血性脑卒中血管内治疗多中心随机临床试验（MR CLEAN）的184例患者中，利用薄层图像测量非增强CT和CTA图像中的血栓及对侧动脉衰减值。引入了两种血栓渗透性的定量评估指标：CTA衰减增加值（Δ）和血栓孔隙率（ε）。将患者分为血栓具有渗透性或不具有渗透性两组，并与预后、再通情况和最终梗死体积相关联。
Δ≥10.9 HU（n = 81 [44%]）且ε≥6.5%（n = 77 [42%]）的患者被归类为血栓具有渗透性。基于Δ分类，这些患者获得良好预后的可能性是其他患者的3.2倍（95%置信区间，1.7 - 6.4），再通的可能性是其他患者的2.5倍（95%置信区间，1.3 - 4.8），基于ε分类的情况类似。这些优势比与静脉或动脉内治疗无关。最终梗死体积与两种渗透性评估指标均呈负相关（相关系数，Δ为 -0.39，ε为 -0.40）。
本研究表明，同时测量非增强CT和CTA中的血栓衰减值能够对血栓渗透性进行量化。血栓渗透性与改善的功能预后、更小的最终梗死体积和更高的再通率密切相关。
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