基于 CT 灌注的皮质脑血流不足评分可预测颅内破裂动脉瘤患者的结局：一项队列研究。
Cortical Blood Flow Insufficiency Scores with Computed Tomography Perfusion can Predict Outcomes in Aneurysmal Subarachnoid Hemorrhage Patients: A Cohort Study.
机构信息
Department of Comprehensive Strokology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, Japan.
Department of Neurosurgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, Japan.
出版信息
Neurocrit Care. 2021 Jun;34(3):946-955. doi: 10.1007/s12028-020-01108-w. Epub 2020 Oct 9.
BACKGROUND
The World Federation of Neurosurgical Societies (WFNS) scale is widely accepted for predicting outcomes for subarachnoid hemorrhage (SAH) patients. However, it is difficult to definitely predict outcomes for the most poor grade, WFNS grade 5. The present study aimed to investigate the prognostic ability of a novel classification using computed tomography perfusion (CTP) findings, called the cortical blood flow insufficiency (CBFI) scores.
METHODS
CTP was performed on admission for aneurysmal SAH followed by radical treatments within 72 hours of onset. Twenty-four cerebral cortex regions of interest (ROIs) were defined. CBFI was defined as Tmax > 4 s in each ROI, and CBFI scores were calculated based on the total number of ROIs with CBFI. Using the optimal cutoff value based on receiver operating characteristics (ROC) analysis to predict patient functional outcomes, CBFI scores were divided into "high" or "low" CBFI scores. Patient functional outcomes at 90 days were categorized based on modified Rankin Scale scores (0-3, favorable group; 4-6 unfavorable group) (0-4, non-catastrophic group; 5-6, catastrophic group).
RESULTS
Fifty-seven patients were included in this study, of whom 21 (36.8%) and 13 (22.8%) were in the unfavorable and the catastrophic groups, respectively. A factor predicting unfavorable and catastrophic outcomes was CBFI score cutoff value of 7 points (area under the curve, 0.73 and 0.81, respectively). In multivariable logistic regression analysis for unfavorable outcome, high CBFI scores (odds ratio (OR), 8.6; 95% confidence interval (CI), 1.1-65.4; P = 0.04) and WFNS grade 5 (OR, 30.0; 95% CI, 4.5-201.0; P < 0.001) remained as independent predictors, while for catastrophic outcome, high CBFI scores (OR, 25.3; 95% CI, 3.3-194.0; P = 0.002) and age (OR, 1.1; 95% CI, 1.0-1.2; P = 0.02) remained as independent predictors. Conversely, WFNS grade 5 was not an independent predictor of catastrophic outcomes (OR, 3.8; 95% CI, 0.6-24.0; P = 0.15). In high CBFI scores, the OR of the delayed cerebral ischemia (DCI) occurrence was 9.6 (95% CI, 1.5-61.4; P = 0.02) after adjusting for age.
CONCLUSION
High CBFI scores could predict unfavorable and catastrophic outcomes for aneurysmal SAH patients and DCI occurrence.
背景
世界神经外科学会联合会（WFNS）分级量表广泛用于预测蛛网膜下腔出血（SAH）患者的预后。然而，对于 WFNS 分级 5 级的最差预后患者，很难明确预测。本研究旨在探讨一种基于 CT 灌注（CTP）发现的新分类方法——皮质血流不足（CBFI）评分对预后的预测能力。
方法
对接受治疗的颅内破裂动脉瘤性 SAH 患者在发病后 72 小时内行 CTP 检查，并进行根治性治疗。共定义了 24 个大脑皮质感兴趣区（ROI）。Tmax＞4s 定义为皮质血流不足（CBFI），根据 CBFI 的 ROI 总数计算 CBFI 评分。基于受试者工作特征（ROC）分析确定最佳截断值以预测患者的功能结局，将 CBFI 评分分为“高”或“低”CBFI 评分。根据改良 Rankin 量表评分（0-3 分为预后良好组；4-6 分为预后不良组）（0-4 分为非灾难性组；5-6 分为灾难性组）将患者 90 天的功能结局进行分类。
结果
本研究共纳入 57 例患者，其中 21 例（36.8%）和 13 例（22.8%）分别属于预后不良组和灾难性组。预测预后不良和灾难性结局的因素是 CBFI 评分截断值为 7 分（曲线下面积分别为 0.73 和 0.81）。多变量逻辑回归分析显示，高 CBFI 评分（优势比（OR）8.6；95%置信区间（CI）1.1-65.4；P=0.04）和 WFNS 分级 5 级（OR 30.0；95%CI 4.5-201.0；P＜0.001）是预后不良的独立预测因素，而对于灾难性结局，高 CBFI 评分（OR 25.3；95%CI 3.3-194.0；P=0.002）和年龄（OR 1.1；95%CI 1.0-1.2；P=0.02）是独立预测因素。相反，WFNS 分级 5 级不是灾难性结局的独立预测因素（OR 3.8；95%CI 0.6-24.0；P=0.15）。在高 CBFI 评分患者中，调整年龄因素后，迟发性脑缺血（DCI）的发生 OR 为 9.6（95%CI 1.5-61.4；P=0.02）。
结论
高 CBFI 评分可预测颅内破裂动脉瘤性 SAH 患者的预后不良和灾难性结局以及 DCI 的发生。
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