From the Stanford University School of Medicine, CA (S.C.D.C.).
Department of Medicine, Quantitative Sciences Unit (R.L.B., R.K.).
Stroke. 2018 Jul;49(7):1741-1746. doi: 10.1161/STROKEAHA.118.021402. Epub 2018 May 8.
Parenchymal hemorrhage (PH) after endovascular mechanical thrombectomy in acute ischemic stroke leads to worse outcomes. Better clinical and imaging biomarkers of symptomatic reperfusion PH are needed to identify patients at risk. We identified clinical and imaging predictors of reperfusion PH after endovascular mechanical thrombectomy with attention to early cerebral veins (ECVs) on postreperfusion digital subtraction angiography.
We performed a retrospective cohort study of consecutive acute ischemic stroke patients undergoing endovascular mechanical thrombectomy at our neurovascular referral center. Clinical and imaging characteristics were collected from patient health records, and random forest variable importance measures were used to identify predictors of symptomatic PH. Predictors of secondary outcomes, including 90-day mortality, functional dependence (modified Rankin Scale score, >2), and National Institutes of Health Stroke Scale shift, were also determined. Diagnostic test characteristics of ECV for symptomatic PH were determined using a receiver operating characteristic analysis. Differences between patients with and without symptomatic PH were assessed with Fisher exact test and the Wilcoxon rank sum (Mann-Whitney test) test at the 0.05 significance level.
Of 64 patients with anterior circulation large-vessel occlusion identified, 6 (9.4%) developed symptomatic PH. ECV was the strongest predictor of symptomatic PH with more than twice the importance of the next best predictor, male sex. Although ECV was also predictive of 90-day mortality and functional dependence, other characteristics were more important than ECV for these outcomes. The sensitivity and specificity of ECV alone for subsequent hemorrhage were both 0.83, with an area under the curve of 0.83 and 95% confidence interval of 0.66 to 1.00.
ECV on postendovascular mechanical thrombectomy digital subtraction angiography is highly diagnostic of subsequent symptomatic reperfusion hemorrhage in this data set. This finding has important implications for post-treatment management of blood pressure and anticoagulation.
急性缺血性脑卒中血管内机械取栓后发生实质血肿（PH）会导致更差的预后。需要更好的临床和影像学再灌注 PH 生物标志物来识别有风险的患者。我们通过对血管内机械取栓后数字减影血管造影（DSA）早期脑静脉（ECV）的关注，确定了与症状性再灌注 PH 相关的临床和影像学预测因素。
我们对在我们的神经血管转诊中心接受血管内机械取栓的连续急性缺血性脑卒中患者进行了回顾性队列研究。从患者的健康记录中收集临床和影像学特征，并使用随机森林变量重要性测量来确定症状性 PH 的预测因素。还确定了包括 90 天死亡率、功能依赖（改良 Rankin 量表评分，>2）和国立卫生研究院卒中量表（NIHSS）变化在内的次要结局的预测因素。使用接受者操作特征分析确定 ECV 对症状性 PH 的诊断测试特征。Fisher 确切检验和 Wilcoxon 秩和（Mann-Whitney U 检验）检验用于评估有症状 PH 患者与无症状 PH 患者之间的差异，显著性水平为 0.05。
在确定的 64 例前循环大血管闭塞患者中，有 6 例（9.4%）发生症状性 PH。ECV 是症状性 PH 的最强预测因素，其重要性是下一个最佳预测因素男性的两倍多。尽管 ECV 也可预测 90 天死亡率和功能依赖，但对于这些结局，其他特征比 ECV 更为重要。ECV 单独用于后续出血的敏感性和特异性均为 0.83，曲线下面积为 0.83，95%置信区间为 0.66 至 1.00。
在本数据集的血管内机械取栓后 DSA 中，ECV 对随后的症状性再灌注出血具有高度的诊断价值。这一发现对治疗后血压和抗凝治疗的管理具有重要意义。
