探讨静脉溶栓后神经功能改善：发病时间与基于影像的组织时钟的影响。
Investigating Neurologic Improvement After IV Thrombolysis: The Effect of Time From Stroke Onset vs Imaging-Based Tissue Clock.
机构信息
From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany.
出版信息
Neurology. 2023 Oct 24;101(17):e1678-e1686. doi: 10.1212/WNL.0000000000207714. Epub 2023 Sep 1.
BACKGROUND AND OBJECTIVES
Time from stroke onset is associated with clinical response to intravenous thrombolysis (IVT) with alteplase and is therefore used to select patients for treatment. Alternatively, neuroimaging may be used for treatment in the uncertain or extended time window. We hypothesized that the patient-specific imaging indicator of ischemic lesion progression ("tissue clock") using CT perfusion (CTP) or quantitative net water uptake (NWU) is a predictor of early neurologic improvement (ENI) independent of time.
METHODS
Observational study of anterior circulation ischemic stroke patients with proximal vessel occlusion and known time from symptom onset triaged by multimodal CT undergoing endovascular treatment. Quantitative NWU using an established threshold (11.5%) or CTP lesion core mismatch (EXTEND criteria) was used to estimate ischemic lesion progression. The treatment effect of IVT depending on lesion progression defined by tissue clock vs time clock was assessed by inverse probability weighting (IPW). End points were binarized ENI and functional independence at day 90.
RESULTS
Four hundred nine patients were included, of which 223 (54.5%) received IVT. The proportion of patients within an early time window (<4.5 hours), low NWU, and CTP mismatch were 45.0%, 86.5%, and 80.3%. In IPW, IVT was associated with higher rates of ENI (%-difference: 7.3%, = 0.02). For patients with CTP mismatch or low NWU, IVT was associated with a 9.6% or 7.2% higher rate of ENI, which was different than the effect of IVT in patients without CTP mismatch or high NWU (-9.3%/-7.3%; = 0.004/ = 0.03), whereas early treatment window did not modify the effect of IVT.
DISCUSSION
CT-based measures of the "tissue clock" might identify patients who benefit from IVT more accurately than conventional time windows. Considering the high number of patients with early "tissue clock" (low NWU/CTP mismatch) within an extended time window, considerable benefit from IVT using imaging indicators of the "tissue clock" may be achieved.
背景与目的
从卒中发病到接受阿替普酶静脉溶栓治疗的时间与临床反应相关，因此，该时间被用于筛选治疗患者。或者，也可以使用神经影像学检查在不确定或延长的时间窗内进行治疗。我们假设，使用 CT 灌注（CTP）或定量净水分摄取（NWU）的缺血性病灶进展的患者特异性影像学指标（“组织钟”），是独立于时间的早期神经改善（ENI）的预测因子。
方法
对接受血管内治疗的前循环缺血性卒中伴近端血管闭塞和已知发病时间的患者进行多模态 CT 检查，以进行分诊。使用定量 NWU（11.5%）或 CTP 病灶核心不匹配（EXTEND 标准）来估计缺血性病灶进展。根据组织钟定义的病变进展和时间钟定义的病变进展来评估 IVT 的治疗效果，采用逆概率加权（IPW）法进行评估。终点为第 90 天的二分法 ENI 和功能独立性。
结果
共纳入 409 例患者，其中 223 例（54.5%）接受了 IVT。在<4.5 小时的早期时间窗内、NWU 低和 CTP 不匹配的患者比例分别为 45.0%、86.5%和 80.3%。在 IPW 中，IVT 与更高的 ENI 率相关（%-差异：7.3%， = 0.02）。对于 CTP 不匹配或 NWU 低的患者，IVT 与 9.6%或 7.2%更高的 ENI 率相关，与 CTP 不匹配或 NWU 高的患者中 IVT 的作用不同（-9.3%/-7.2%， = 0.004/ = 0.03），而早期治疗窗并未改变 IVT 的作用。
讨论
基于 CT 的“组织钟”指标可能比传统的时间窗更准确地识别出从 IVT 中获益的患者。考虑到在延长的时间窗内有大量的早期“组织钟”（NWU 低/CTP 不匹配）患者，使用“组织钟”的影像学指标进行 IVT 可能会带来相当大的获益。
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