Atchaneeyasakul Kunakorn, Shang Ty, Haussen Diogo, Ortiz Gustavo, Yavagal Dileep
Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA.
Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
Interv Neurol. 2020 Jan;8(2-6):135-143. doi: 10.1159/000490580. Epub 2019 Mar 15.
The recently published multicenter randomized DAWN trial confirmed greater outcome benefit of endovascular therapy (ET) for anterior circulation large vessel occlusion ischemic stroke from 6 to 24 h from symptom onset compared to medical management in patients selected by advanced imaging with MRI or perfusion CT to identify mismatch between clinical deficit and infarct volume, which represents salvageable penumbra. The debate of CT over MRI is usually the potentially increase time consumption and the difficulty in establishing an adequate standardized workflow utilizing MRI during the hyperacute phase.
While CT-based selection of patients is the current standard of care, we sought to determine the time impact of the alternative approach of MRI selection in the 0-12 h window.
In the MRI in Acute Management of Ischemic Stroke (MIAMIS) registry, we retrospectively analyzed 89 consecutive patients from January 2008 to January 2010 who presented with acute stroke symptoms with a National Institutes of Health Stroke Scale score ≥5 or aphasia within 0-12 h from symptom onset. The presence of penumbra was determined by MR perfusion-diffusion mismatch or clinical diffusion mismatch. Patients were stratified based on the presence of mismatch and clinical outcomes in patients who received ET. Imaging times were recorded.
The MRI turnaround time was 95.5 ± 48.5 min. The total MRI time was 27.7 ± 12.8 min. Seventeen (19.1%) patients were found to have nonvascular etiology. Mismatch was found in 35 (48.6%) patients with acute ischemic stroke (AIS). Patients with nonvascular etiology were younger (55.7 vs. 65.6 years, < 0.02), without any vessel occlusion or mismatch noticed in this group. We dichotomized the 39 AIS patients with vessel occlusion into two subgroups: these with mismatch and these without. Patients without mismatch were older (76.7 vs. 64.4 years, < 0.05), more likely to have congestive heart failure (71.4 vs. 22%, < 0.03), a higher total serum cholesterol level (196 vs. 156 mg/dL, < 0.04), and medium to large lesions on diffusion-weighted imaging (DWI) (85.7 vs. 37.5%, < 0.04).
Multimodality MRI screening for AIS symptoms for ET is feasible. Optimizing each center's protocol and the utilization of MRI with DWI only may be a time-saving alternative.
最近发表的多中心随机DAWN试验证实，对于症状发作6至24小时的前循环大血管闭塞性缺血性卒中，与药物治疗相比，在通过MRI或灌注CT等先进成像技术筛选出临床缺损与梗死体积不匹配（代表可挽救的半暗带）的患者中，血管内治疗（ET）能带来更大的预后益处。CT与MRI的争论通常在于，CT可能会增加时间消耗，且在超急性期难以建立充分的标准化MRI工作流程。
虽然基于CT选择患者是当前的标准治疗方法，但我们试图确定在0至12小时时间窗内采用MRI选择患者的替代方法对时间的影响。
在急性缺血性卒中的MRI管理（MIAMIS）登记研究中，我们回顾性分析了2008年1月至2010年1月期间连续纳入的89例急性卒中症状患者，这些患者在症状发作后0至12小时内美国国立卫生研究院卒中量表评分≥5或有失语症状。通过磁共振灌注 - 扩散不匹配或临床扩散不匹配来确定半暗带的存在。根据不匹配的存在情况和接受ET治疗患者的临床结局进行分层。记录成像时间。
MRI周转时间为95.5±48.5分钟。MRI总时间为27.7±12.8分钟。17例（19.1%）患者被发现有非血管性病因。在35例（48.6%）急性缺血性卒中（AIS）患者中发现不匹配。非血管性病因的患者更年轻（55.7岁对65.6岁，P<0.02），该组未发现任何血管闭塞或不匹配情况。我们将39例有血管闭塞的AIS患者分为两个亚组：有不匹配的和没有不匹配的。没有不匹配的患者年龄更大（76.7岁对64.4岁，P<0.05），更可能有充血性心力衰竭（71.4%对22%，P<0.03），总血清胆固醇水平更高（196mg/dL对156mg/dL，P<0.04），在扩散加权成像（DWI）上有中到大的病灶（85.7%对37.5%，P<0.04）。
对AIS症状进行多模态MRI筛查以进行ET治疗是可行的。优化每个中心的方案并仅使用DWI进行MRI检查可能是一种节省时间的替代方法。
