Rodrigues Gabriel M, Mohammaden Mahmoud H, Haussen Diogo C, Bouslama Mehdi, Ravindran Krishnan, Pisani Leonardo, Prater Adam, Frankel Michael R, Nogueira Raul G
Marcus Stroke & Neuroscience Center, Grady Memorial Hospital and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
Int J Stroke. 2021 Nov 19:17474930211056228. doi: 10.1177/17474930211056228.
Computed tomography perfusion (CTP) has been increasingly used for patient selection in mechanical thrombectomy for stroke. However, previous studies suggested that CTP might overestimate the infarct size. The term ghost infarct core (GIC) has been used to describe an overestimation of the final infarct volumes by pre-treatment CTP of >10 ml.
We sought to study the frequency and predictors of GIC.
A prospectively collected mechanical thrombectomy database at a comprehensive stroke center between September 2010 and August 2020 was reviewed. Patients were included if they had a successful reperfusion (mTICI2b-3), a pre-procedure CTP, and final infarct volume measured on follow-up magnetic resonance imaging. Uni- and multivariable analyses were performed to identify predictors of GIC.
Among 923 eligible patients (median [IQR] age, 64 [55-75] years; NIHSS, 16 [11-21]; onset to reperfusion time, 436.5 [286-744.5] min), GIC was identified in 77 (8.3%) of the overall patients and in 14% (47/335) of those reperfused within 6 h of symptom onset. The median overestimation volume was 23.2 [16.4-38.3] mL. GIC was associated with higher NIHSS score, larger areas of infarct core and tissue at risk on CTP, unfavorable collateral scores, and shorter times from onset to image acquisition and to reperfusion as compared to non-GIC. Patients with GIC had smaller median final infarct volumes (10.7 vs. 27.1 ml, p < 0.001), higher chances of functional independence (76.2% vs. 55.5%, adjusted odds ratio (aOR) 3.829, 95% CI [1.505-9.737], p = 0.005), lower disability (one-point-mRS improvement, aOR 1.761, 95% CI [1.044-2.981], p = 0.03), and lower mortality (6.3% vs. 15%, aOR 0.119, 95% CI [0.014-0.984], p = 0.048) at 90 days. On multivariable analysis, time from onset to reperfusion ≤6 h (OR 3.184, 95% CI [1.743-5.815], p < 0.001), poor collaterals (OR 2.688, 95% CI [1.466-4.931], p = 0.001), and higher NIHSS score (OR 1.060, 95% CI [1.010-1.113], p = 0.018) were independent predictors of GIC.
GIC is a relatively common entity, particularly in patients with poor collateral status, higher baseline NIHSS score, and early presentation, and is associated with more favorable outcomes. Patients should not be excluded from reperfusion therapies on the sole basis of CTP findings, especially in the early window.
计算机断层扫描灌注成像（CTP）在急性缺血性卒中机械取栓患者的筛选中应用越来越广泛。然而，既往研究提示CTP可能高估梗死体积。“幽灵梗死核心”（GIC）这一术语用于描述治疗前CTP对最终梗死体积高估>10 ml的情况。
我们试图研究GIC的发生率及其预测因素。
回顾性分析2010年9月至2020年8月在一家综合卒中中心前瞻性收集的机械取栓数据库。纳入成功再灌注（改良脑梗死溶栓分级2b-3级）、术前有CTP检查以及随访磁共振成像测量最终梗死体积的患者。进行单因素和多因素分析以确定GIC的预测因素。
在923例符合条件的患者中（年龄中位数[四分位间距]为64[55-75]岁；美国国立卫生研究院卒中量表[NIHSS]评分中位数为16[11-21]；发病至再灌注时间中位数为436.5[286-744.5]分钟），77例（8.3%）患者存在GIC，症状发作6小时内再灌注的患者中14%（47/335）存在GIC。高估体积中位数为23.2[16.4-38.3]ml。与无GIC患者相比，GIC与较高的NIHSS评分、CTP上较大的梗死核心和梗死风险组织面积、较差的侧支循环评分以及较短的发病至图像采集时间和发病至再灌注时间相关。GIC患者最终梗死体积中位数较小（10.7 vs. 27.1 ml，p<0.001），90天时功能独立的可能性更高（76.2% vs. 55.5%，校正优势比[aOR] 3.829，95%可信区间[CI][1.505-9.737]，p=0.005），残疾程度更低（改良Rankin量表评分提高1分，aOR 1.761，95%CI[1.044-2.981]，p=0.03），死亡率更低（6.3% vs. 15%，aOR 0.119，95%CI[0.014-0.984]，p=0.048）。多因素分析显示，发病至再灌注时间≤6小时（OR 3.184，95%CI[1.743-5.815]，p<0.001）、侧支循环差（OR 2.688，95%CI[1.466-4.931]，p=0.001）和较高的NIHSS评分（OR 1.060，95%CI[1.010-1.113]，p=0.018）是GIC的独立预测因素。
GIC相对常见，尤其在侧支循环差、基线NIHSS评分较高和发病较早的患者中，且与更有利的预后相关。不应仅根据CTP结果排除患者接受再灌注治疗，尤其是在早期时间窗内。
