de Havenon Adam, Mickolio Kole, O'Donnell Steven, Stoddard Greg, McNally J Scott, Alexander Matthew, Taussky Philipp, Awad Al-Wala
Departments of1Neurology and.
2Department of Neurology, Valley Medical Center, Seattle, Washington; and Departments of.
J Neurosurg. 2021 Feb 26;135(4):1100-1104. doi: 10.3171/2020.8.JNS20386. Print 2021 Oct 1.
Endovascular thrombectomy (EVT) and tissue plasminogen activator (tPA) are effective ischemic stroke treatments in the initial treatment window. In the extended treatment window, these treatments may offer benefit, but CT and MR perfusion may be necessary to determine patient eligibility. Many hospitals do not have access to advanced imaging tools or EVT capability, and further patient care would require transfer to a facility with these capabilities. To assist transfer decisions, the authors developed risk indices that could identify patients eligible for extended-window EVT or tPA.
The authors retrospectively identified stroke patients who had concurrent CTA and perfusion and evaluated three potential outcomes that would suggest a benefit from patient transfer. The first outcome was large-vessel occlusion (LVO) and target mismatch (TM) in patients 5-23 hours from last known normal (LKN). The second outcome was TM in patients 5-15 hours from LKN with known LVO. The third outcome was TM in patients 4.5-12 hours from LKN. The authors created multivariable models using backward stepping with an α-error criterion of 0.05 and assessed them using C statistics.
The final predictors included the National Institutes of Health Stroke Scale (NIHSS), the Alberta Stroke Program Early CT Score (ASPECTS), and age. The prediction of the first outcome had a C statistic of 0.71 (n = 145), the second outcome had a C statistic of 0.85 (n = 56), and the third outcome had a C statistic of 0.86 (n = 54). With 1 point given for each predictor at different cutoffs, a score of 3 points had probabilities of true positive of 80%, 90%, and 94% for the first, second, and third outcomes, respectively.
Despite the limited sample size, compared with perfusion-based examinations, the clinical variables identified in this study accurately predicted which stroke patients would have salvageable penumbra (C statistic 71%-86%) in a range of clinical scenarios and treatment cutoffs. This prediction improved (C statistic 85%-86%) when utilized in patients with confirmed LVO or a less stringent tissue mismatch (TM < 1.2) cutoff. Larger patient registries should be used to validate and improve the predictive ability of these models.
血管内血栓切除术（EVT）和组织型纤溶酶原激活剂（tPA）在初始治疗窗内是有效的缺血性中风治疗方法。在延长治疗窗内，这些治疗可能有益，但可能需要进行CT和MR灌注以确定患者是否适合。许多医院无法使用先进的成像工具或具备EVT能力，进一步的患者护理需要转诊至具备这些能力的机构。为辅助转诊决策，作者开发了可识别适合延长窗EVT或tPA治疗患者的风险指数。
作者回顾性识别了同时进行CTA和灌注检查的中风患者，并评估了三项可能提示患者转诊有益的潜在结果。第一个结果是最后一次已知正常（LKN）后5至23小时的患者出现大血管闭塞（LVO）和靶区不匹配（TM）。第二个结果是已知LVO且LKN后5至15小时的患者出现TM。第三个结果是LKN后4.5至12小时的患者出现TM。作者使用向后逐步回归创建多变量模型，α错误标准为0.05，并使用C统计量对其进行评估。
最终预测因素包括美国国立卫生研究院卒中量表（NIHSS）、阿尔伯塔卒中项目早期CT评分（ASPECTS）和年龄。第一个结果的预测C统计量为0.71（n = 145），第二个结果为0.85（n = 56），第三个结果为0.86（n = 54）。在不同临界值下，每个预测因素得1分，得3分对于第一个、第二个和第三个结果的真阳性概率分别为80%、90%和94%。
尽管样本量有限，但与基于灌注的检查相比，本研究中确定的临床变量在一系列临床场景和治疗临界值下准确预测了哪些中风患者会有可挽救的半暗带（C统计量71%-86%）。当应用于确诊LVO或组织不匹配（TM < 1.2）临界值较宽松的患者时，这种预测得到改善（C统计量85%-86%）。应使用更大的患者登记库来验证和提高这些模型的预测能力。
