Kim Kitae, Kim Beom Joon, Huh Jaewon, Yang Seong Kyu, Yang Mi Hwa, Han Moon-Ku, Jung Cheolkyu, Choi Byung Se, Kim Jae Hyoung, Bae Hee-Joon
Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea.
Lyda Hill Department of Bioinformatics, UT Southwestern Medical Center, Dallas, TX, USA.
J Stroke. 2021 Jan;23(1):69-81. doi: 10.5853/jos.2020.02110. Epub 2021 Jan 31.
Lesions on diffusion-weighted imaging (DWI) occasionally appear on follow-up magnetic resonance imaging (MRI) among initially DWI-negative but clinically suspicious stroke patients. We established the prevalence of positive conversion in DWI-negative stroke and determined the clinical factors associated with it.
This retrospective, observational, single-center study included 5,271 patients hospitalized due to stroke/transient ischemic attack (TIA) in a single university hospital during 2010 to 2017. Patients without initial DWI lesions underwent follow-up DWI imaging as a routine practice. Adjusted hazard ratios (aHRs) for recurrent stroke risk according to positive conversion were determined using Cox proportional hazard regression. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for positive conversion among initially DWI-negative patients were estimated.
In total, 694 (13.2%) patients (mean±standard deviation age, 62.9±13.7 years; male, 404 [58.2%]) were initially DWI-negative. Among them, 22.5% had positive-conversion on follow-up DWI. Positive conversion was associated with a higher risk of recurrent stroke (aHR, 3.12; 95% CI, 1.56 to 6.26). Early neurologic deterioration (aOR, 15.1; 95% CI, 5.71 to 47.66), atrial fibrillation (aOR, 6.17; 95% CI, 3.23 to 12.01), smoking (aOR, 3.76; 95% CI, 2.19 to 6.63), pre-stroke dependency (aOR, 1.62; 95% CI, 1.15 to 2.27), objective hemiparesis (aOR, 4.39; 95% CI, 1.90 to 10.32), longer symptom duration (aOR, 2.17; 95% CI, 1.57 to 3.08), high cholesterol (aOR, 4.70; 95% CI, 1.78 to 12.77), National Institutes of Health Stroke Scale score (aOR, 1.44; 95% CI, 1.08 to 1.91), and high systolic blood pressure (aOR, 1.01; 95% CI, 1.00 to 1.02) were associated with a higher incidence of lesions with delayed appearance. Regarding the location of lesions on follow-up DWI, 34.6% and 21.2% were in the cortex and brainstem, respectively.
In DWI-negative stroke/TIA, positive conversion is associated with a higher risk of recurrent stroke. DWI-negative stroke with factors related to positive conversion may require follow-up MRI for a definitive diagnosis.
在最初弥散加权成像（DWI）为阴性但临床上疑似中风的患者中，随访磁共振成像（MRI）时偶尔会出现DWI病变。我们确定了DWI阴性中风患者中阳性转化的发生率，并确定了与之相关的临床因素。
这项回顾性、观察性、单中心研究纳入了2010年至2017年期间在一家大学医院因中风/短暂性脑缺血发作（TIA）住院的5271例患者。无初始DWI病变的患者按常规进行随访DWI成像。使用Cox比例风险回归确定根据阳性转化的复发性中风风险的调整后风险比（aHRs）。估计初始DWI阴性患者中阳性转化的调整后优势比（aORs）和95%置信区间（CIs）。
共有694例（13.2%）患者（平均±标准差年龄，62.9±13.7岁；男性，404例[58.2%]）最初DWI为阴性。其中，22.5%在随访DWI时出现阳性转化。阳性转化与复发性中风风险较高相关（aHR，3.12；95%CI，1.56至6.26）。早期神经功能恶化（aOR，15.1；95%CI，5.71至47.66）、心房颤动（aOR，6.17；95%CI，3.23至12.01）、吸烟（aOR，3.76；95%CI，2.19至6.63）、中风前依赖（aOR，1.62；95%CI，1.15至2.27）、客观偏瘫（aOR，4.39；95%CI，1.90至10.32）、症状持续时间较长（aOR，2.17；95%CI，1.57至3.08）、高胆固醇（aOR，4.70；95%CI，1.78至12.77）、美国国立卫生研究院卒中量表评分（aOR，1.44；95%CI，1.08至1.91）和高收缩压（aOR，1.01；95%CI，1.00至1.02）与延迟出现病变的发生率较高相关。关于随访DWI上病变的位置，分别有34.6%和21.2%位于皮质和脑干。
在DWI阴性的中风/TIA中，阳性转化与复发性中风风险较高相关。具有与阳性转化相关因素的DWI阴性中风可能需要进行随访MRI以明确诊断。
