From Brain and Mind Centre (S.A.), Camperdown, Sydney, Australia; Stroke Research Group (E.W.), Clinical Neurosciences, University of Cambridge, UK; and Department of Neurology (S.A., A.B., M.P., C.L.), John Hunter Hospital, University of Newcastle, Australia.
Neurology. 2018 Jan 23;90(4):e316-e322. doi: 10.1212/WNL.0000000000004858. Epub 2017 Dec 27.
While clinical benefit from thrombolysis decreases with increase in time from stroke onset, the relationship of acute physiologic tissue compartments and collateral response to stroke onset time remains unclear.
We studied consecutive patients with proximal arterial occlusions (n = 355) with whole-brain perfusion CT with CT angiography within 6 hours of stroke onset. Penumbra and core were defined using voxel-based thresholds. Tissue mismatch was defined as the ratio of penumbra to core. Collateral scores were assessed using a previously validated visual score.
Mean (SD) age was 72.1 (12.4) years, median (interquartile range) NIH Stroke Scale score 16 (4), mean (SD) time to imaging 152.5 (69.7) minutes. Penumbra volume (Spearman ρ = 0.119, = 0.026) and mismatch increased (Spearman ρ = 0.115, = 0.030) with time from onset. Core volume decreased (Spearman ρ = -0.112, = 0.035) while collateral scores increased with time (Spearman ρ = 0.117, = 0.028). On multivariable regression, good collateral scores predicted longer time since onset (β = 0.101, = 0.039) while mismatch was not a predictor (β = 0.001, = 0.351). Good collateral score was the strongest independent predictor of final infarct volume and improvement in clinical deficit.
In our large patient cohort study of proximal arterial occlusions, we found an incremental collateral response and preserved penumbral volume with time. Thus, tissue viability can be maintained in this time window (0-6 hours) after stroke if leptomeningeal collaterals are able to sustain the penumbra. Our findings suggest that a longer therapeutic window may exist for intra-arterial intervention and that multimodal imaging may have a role in strokes of unknown onset time.
虽然溶栓治疗的临床获益随着卒中发病后时间的延长而降低，但急性生理组织区室和侧支反应与卒中发病时间的关系仍不清楚。
我们研究了连续 355 例近端动脉闭塞患者，这些患者在卒中发病后 6 小时内行全脑灌注 CT 加 CT 血管造影。使用基于体素的阈值定义半暗带和核心区。组织不匹配定义为半暗带与核心区的比值。使用先前验证的视觉评分评估侧支评分。
平均（标准差）年龄为 72.1（12.4）岁，中位数（四分位间距）NIH 卒中量表评分为 16（4），平均（标准差）成像时间为 152.5（69.7）分钟。半暗带体积（Spearman ρ=0.119， =0.026）和不匹配程度（Spearman ρ=0.115， =0.030）随发病时间的延长而增加。核心区体积随时间减少（Spearman ρ=-0.112， =0.035），而侧支评分随时间增加（Spearman ρ=0.117， =0.028）。多变量回归分析显示，良好的侧支评分预测发病时间较长（β=0.101， =0.039），而不匹配程度不是预测因素（β=0.001， =0.351）。良好的侧支评分是最终梗死体积和临床缺损改善的最强独立预测因素。
在我们对近端动脉闭塞的大型患者队列研究中，我们发现随着时间的推移，侧支循环反应增加，半暗带区的组织保持活力。因此，如果软脑膜侧支能够维持半暗带，那么在卒中发病后 0-6 小时的时间窗口内，组织仍具有活力。我们的研究结果表明，动脉内介入治疗的治疗窗口可能更长，多模态成像可能在发病时间未知的卒中患者中发挥作用。
