From the Department of Neurology (Y.Z., R.Z., S.Y., Meixia Zhang, Z.C., H.H., M.L.), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China.
Department of Radiology (Minming Zhang), the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China.
Stroke. 2018 Nov;49(11):2683-2691. doi: 10.1161/STROKEAHA.118.021426.
Background and Purpose- Whether patients with small perfusion lesions benefit from thrombolysis remains an uncertainty. We assessed acute ischemic stroke patients with a total perfusion lesion of <15 mL and tested the hypothesis the pattern of corticospinal tract (CST) involvement might predict outcome in thrombolysis-eligible patients. Methods- We used a prospectively collected cohort of acute ischemic stroke patients being assessed for thrombolysis at 7 centers. Three neurologists categorized the presence of hypoperfusion and infarction within CST. Excellent outcome was defined as 90-day modified Rankin Scale score 0 to 1. Results- Of 2654 patients, 407 had a perfusion lesion <15 mL and were clinically eligible for thrombolysis (243 being treated). Median National Institutes of Health Stroke Scale was 5.0, and 312 (76.7%) patients achieved excellent outcome. Alteplase treatment was an independent unfavorable factor for excellent outcome (alteplase-treated 72.0% versus untreated 83.5%; odds ratio, 0.541; P=0.025). For patients with CST hypoperfusion without CST infarction, alteplase treatment was an independent favorable factor for excellent outcome (alteplase-treated 75.6% versus untreated 47.1%; odds ratio, 4.096; P=0.045). Among patients with CST infarction, alteplase treatment was an independent unfavorable factor for excellent outcome (alteplase-treated 30.6% versus untreated 88.9%; odds ratio, 0.002; P=0.003). Among patients without either CST hypoperfusion or CST infarction, alteplase treatment was not an independent influencing factor for excellent outcome (alteplase-treated 80.1% versus untreated 87.7%; P=0.258). Conclusions- Only patients with CST hypoperfusion without CST infarction among eligible acute ischemic stroke patients with small perfusion lesions could benefit from thrombolysis, which needs to be confirmed in future prospective studies. Patient selection, including an assessment of lesion location rather than purely lesion volume, may be ideal.
对于存在小范围灌注损伤的患者，溶栓治疗是否获益仍然存在不确定性。本研究评估了总灌注损伤<15ml 的急性缺血性脑卒中患者，并检验了皮质脊髓束（CST）受累模式可能预测溶栓治疗患者结局的假说。
我们使用前瞻性收集的 7 家中心急性缺血性脑卒中患者溶栓评估队列。3 位神经科医生对 CST 内低灌注和梗死的存在进行分类。良好结局定义为 90 天改良 Rankin 量表评分为 0-1 分。
2654 例患者中，407 例存在<15ml 的灌注损伤且临床适合溶栓治疗（243 例接受治疗）。美国国立卫生研究院卒中量表中位数为 5.0 分，312 例（76.7%）患者获得了良好结局。阿替普酶治疗是良好结局的独立不利因素（阿替普酶治疗组 72.0%，未治疗组 83.5%；比值比 0.541；P=0.025）。对于存在 CST 低灌注而无 CST 梗死的患者，阿替普酶治疗是良好结局的独立有利因素（阿替普酶治疗组 75.6%，未治疗组 47.1%；比值比 4.096；P=0.045）。对于存在 CST 梗死的患者，阿替普酶治疗是良好结局的独立不利因素（阿替普酶治疗组 30.6%，未治疗组 88.9%；比值比 0.002；P=0.003）。对于既不存在 CST 低灌注也不存在 CST 梗死的患者，阿替普酶治疗不是良好结局的独立影响因素（阿替普酶治疗组 80.1%，未治疗组 87.7%；P=0.258）。
在存在小范围灌注损伤的适合溶栓治疗的急性缺血性脑卒中患者中，仅有 CST 低灌注而无 CST 梗死的患者可能从溶栓治疗中获益，这需要在未来的前瞻性研究中进一步证实。患者选择，包括对病灶位置的评估，而不仅仅是病灶体积，可能是理想的。
