Kawano Hiroyuki, Bivard Andrew, Lin Longting, Ma Henry, Cheng Xin, Aviv Richard, O'Brien Billy, Butcher Kenneth, Lou Min, Zhang Jingfen, Jannes Jim, Dong Qiang, Levi Christopher R, Parsons Mark W
Departments of Neurology, John Hunter Hospital, University of Newcastle, Lookout Road, New Lambton Heights, NSW 2305, Australia.
Department of Neurology, Monash Medical Centre, Monash University, 246 Clayton Road Clayton, VIC, 3168, Australia.
Brain. 2017 Mar 1;140(3):684-691. doi: 10.1093/brain/aww338.
See Saver (doi:10.1093/awx020) for a scientific commentary on this article.Stroke shortens an individual's disability-free life. We aimed to assess the relative prognostic influence of pre- and post-treatment perfusion computed tomography imaging variables (e.g. ischaemic core and penumbral volumes) compared to standard clinical predictors (such as onset-to-treatment time) on long-term stroke disability in patients undergoing thrombolysis. We used data from a prospectively collected international, multicentre, observational registry of acute ischaemic stroke patients who had perfusion computed tomography and computed tomography angiography before treatment with intravenous alteplase. Baseline perfusion computed tomography and follow-up magnetic resonance imaging were analysed to derive the baseline penumbra volume, baseline ischaemic core volume, and penumbra salvaged from infarction. The primary outcome measure was the effect of imaging and clinical variables on Disability-Adjusted Life Year. Clinical variables were age, sex, National Institutes of Health Stroke Scale score, and onset-to-treatment time. Age, sex, country, and 3-month modified Rankin Scale were extracted from the registry to calculate disability-adjusted life-year due to stroke, such that 1 year of disability-adjusted life-year equates to 1 year of healthy life lost due to stroke. There were 772 patients receiving alteplase therapy. The number of disability-adjusted life-year days lost per 1 ml of baseline ischaemic core volume was 17.5 (95% confidence interval, 13.2-21.9 days, P < 0.001). For every millilitre of penumbra salvaged, 7.2 days of disability-adjusted life-year days were saved (β = -7.2, 95% confidence interval, -10.4 to -4.1 days, P < 0.001). Each minute of earlier onset-to-treatment time resulted in a saving of 4.4 disability-free days after stroke (1.3-7.5 days, P = 0.006). However, after adjustment for imaging variables, onset-to-treatment time was not significantly associated with savings in disability-adjusted life-year days. Pretreatment perfusion computed tomography can (independently of clinical variables) predict significant gains, or loss, of disability-free life in patients undergoing reperfusion therapy for stroke. The effect of earlier treatment on disability-free life appears explained by salvage of penumbra, particularly when the ischaemic core is not too large.
有关本文的科学评论，请参阅Saver（doi:10.1093/awx020）。中风会缩短个体无残疾的寿命。我们旨在评估与标准临床预测指标（如发病至治疗时间）相比，治疗前和治疗后灌注计算机断层扫描成像变量（如缺血核心区和半暗带体积）对接受溶栓治疗的患者长期中风残疾的相对预后影响。我们使用了来自一个前瞻性收集的国际多中心急性缺血性中风患者观察性登记处的数据，这些患者在接受静脉注射阿替普酶治疗前进行了灌注计算机断层扫描和计算机断层血管造影。对基线灌注计算机断层扫描和随访磁共振成像进行分析，以得出基线半暗带体积、基线缺血核心区体积以及从梗死中挽救的半暗带。主要结局指标是成像和临床变量对伤残调整生命年的影响。临床变量包括年龄、性别、美国国立卫生研究院卒中量表评分以及发病至治疗时间。从登记处提取年龄、性别、国家和3个月改良Rankin量表，以计算中风导致的伤残调整生命年，即1年的伤残调整生命年相当于因中风而失去的1年健康生命。有772名患者接受了阿替普酶治疗。每1毫升基线缺血核心区体积导致的伤残调整生命年天数损失为17.5天（95%置信区间，13.2 - 21.9天，P < 0.001）。每挽救1毫升半暗带，可节省7.2天的伤残调整生命年天数（β = -7.2，95%置信区间，-10.4至 -4.1天，P < 0.001）。发病至治疗时间每提前1分钟，中风后可节省4.4天无残疾天数（1.3 - 7.5天，P = 0.006）。然而，在对成像变量进行调整后，发病至治疗时间与伤残调整生命年天数的节省无显著相关性。治疗前灌注计算机断层扫描能够（独立于临床变量）预测接受中风再灌注治疗患者无残疾生命的显著增加或减少。早期治疗对无残疾生命的影响似乎可以通过半暗带的挽救来解释，尤其是当缺血核心区不太大时。
