Kerleroux Basile, Janot Kevin, Dargazanli Cyril, Daly-Eraya Dimitri, Ben-Hassen Wagih, Zhu François, Gory Benjamin, Hak Jean François, Perot Charline, Detraz Lili, Bourcier Romain, Rouchaud Aymeric, Forestier Géraud, Benzakoun Joseph, Marnat Gaultier, Gariel Florent, Mordasini Pasquale, Kaesmacher Johannes, Boulouis Grégoire
Diagnostic and Therapeutic Neuroradiology, CHRU de Tours, Tours, France.
Department of Interventional Neuroradiology, University Hospital Center of Montpellier, Gui de Chauliac Hospital, Montpellier, France.
J Stroke. 2020 May;22(2):225-233. doi: 10.5853/jos.2019.02908. Epub 2020 May 31.
Patients with acute ischemic stroke, proximal vessel occlusion and a large ischemic core at presentation are commonly not considered for mechanical thrombectomy (MT). We tested the hypothesis that in patients with baseline large infarct cores, identification of remaining penumbral tissue using perfusion imaging would translate to better outcomes after MT.
This was a multicenter, retrospective, core lab adjudicated, cohort study of adult patients with proximal vessel occlusion, a large ischemic core volume (diffusion weighted imaging volume ≥70 mL), with pre-treatment magnetic resonance imaging perfusion, treated with MT (2015 to 2018) or medical care alone (controls; before 2015). Primary outcome measure was 3-month favorable outcome (defined as a modified Rankin Scale of 0-3). Core perfusion mismatch ratio (CPMR) was defined as the volume of critically hypo-perfused tissue (Tmax >6 seconds) divided by the core volume. Multivariable logistic regression models were used to determine factors that were independently associated with clinical outcomes. Outputs are displayed as adjusted odds ratio (aOR) and 95% confidence interval (CI).
A total of 172 patients were included (MT n=130; Control n=42; mean age 69.0±15.4 years; 36% females). Mean core-volume and CPMR were 102.3±36.7 and 1.8±0.7 mL, respectively. As hypothesized, receiving MT was associated with increased probability of favorable outcome and functional independence, as CPMR increased, a difference becoming statistically significant above a mismatch-ratio of 1.72. Similarly, receiving MT was also associated with favorable outcome in the subgroup of 74 patients with CPMR >1.7 (aOR, 8.12; 95% CI, 1.24 to 53.11; P=0.028). Overall (prior to stratification by CPMR) 73 (42.4%) patients had a favorable outcome at 3 months, with no difference amongst groups.
s In patients currently deemed ineligible for MT due to large infarct ischemic cores at baseline, CPMR identifies a subgroup strongly benefiting from MT. Prospective studies are warranted.
急性缺血性卒中、近端血管闭塞且就诊时存在大面积缺血核心的患者通常不被考虑进行机械取栓（MT）治疗。我们检验了这样一个假设：在基线存在大面积梗死核心的患者中，使用灌注成像识别出剩余的半暗带组织，在MT治疗后会带来更好的预后。
这是一项多中心、回顾性、核心实验室判定的队列研究，研究对象为近端血管闭塞、梗死核心体积大（弥散加权成像体积≥70 mL）、治疗前接受过磁共振成像灌注检查的成年患者，这些患者于2015年至2018年接受了MT治疗或仅接受了药物治疗（对照组，2015年之前）。主要结局指标为3个月时良好预后（定义为改良Rankin量表评分为0 - 3分）。核心灌注不匹配率（CPMR）定义为严重灌注不足组织（Tmax>6秒）的体积除以梗死核心体积。采用多变量逻辑回归模型确定与临床结局独立相关的因素。结果以调整后的优势比（aOR）和95%置信区间（CI）表示。
共纳入172例患者（MT组n = 130；对照组n = 42；平均年龄69.0±15.4岁；36%为女性）。平均梗死核心体积和CPMR分别为102.3±36.7 mL和1.8±0.7 mL。正如所假设的，接受MT治疗与良好预后和功能独立的概率增加相关，随着CPMR增加，当不匹配率高于1.72时，差异具有统计学意义。同样，在CPMR>1.7的74例患者亚组中，接受MT治疗也与良好预后相关（aOR，8.12；95% CI，1.24至53.11；P = 0.028）。总体而言（在按CPMR分层之前），73例（42.4%）患者在3个月时预后良好，各亚组之间无差异。
在目前因基线梗死缺血核心大而被认为不符合MT治疗条件的患者中，CPMR可识别出从MT治疗中显著获益的亚组。有必要进行前瞻性研究。
