Department of Neurology (P.J.K., M.M., G.R., B.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany.
Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Germany (P.J.K., T.F.M., G.R., B.M.).
Stroke. 2023 Dec;54(12):3081-3089. doi: 10.1161/STROKEAHA.123.044221. Epub 2023 Nov 27.
The indication for mechanical thrombectomy (MT) in stroke patients with large vessel occlusion has been constantly expanded over the past years. Despite remarkable treatment effects at the group level in clinical trials, many patients remain severely disabled even after successful recanalization. A better understanding of this outcome variability will help to improve clinical decision-making on MT in the acute stage. Here, we test whether current outcome models can be refined by integrating information on the preservation of the corticospinal tract as a functionally crucial white matter tract derived from acute perfusion imaging.
We retrospectively analyzed 162 patients with stroke and large vessel occlusion of the anterior circulation who were admitted to the University Medical Center Lübeck between 2014 and 2020 and underwent MT. The ischemic core was defined as fully automatized based on the acute computed tomography perfusion with cerebral blood volume data using outlier detection and clustering algorithms. Normative whole-brain structural connectivity data were used to infer whether the corticospinal tract was affected by the ischemic core or preserved. Ordinal logistic regression models were used to correlate this information with the modified Rankin Scale after 90 days.
The preservation of the corticospinal tract was associated with a reduced risk of a worse functional outcome in large vessel occlusion-stroke patients undergoing MT, with an odds ratio of 0.28 (95% CI, 0.15-0.53). This association was still significant after adjusting for multiple confounding covariables, such as age, lesion load, initial symptom severity, sex, stroke side, and recanalization status.
A preinterventional computed tomography perfusion-based surrogate of corticospinal tract preservation or disconnectivity is strongly associated with functional outcomes after MT. If validated in independent samples this concept could serve as a novel tool to improve current outcome models to better understand intersubject variability after MT in large vessel occlusion stroke.
近年来，机械血栓切除术（MT）在伴有大血管闭塞的中风患者中的适应证不断扩大。尽管临床试验在群体水平上取得了显著的治疗效果，但许多患者即使在成功再通后仍严重残疾。更好地了解这种结果的变异性将有助于改善急性 MT 阶段的临床决策。在这里，我们通过整合急性灌注成像中作为功能关键的白质束的皮质脊髓束保留信息，来检验当前的结果模型是否可以通过整合信息进行改进。
我们回顾性分析了 2014 年至 2020 年期间在吕贝克大学医学中心就诊的 162 例伴有前循环大血管闭塞的中风患者，并进行了 MT。使用离群值检测和聚类算法，根据急性 CT 灌注脑血容量数据自动定义缺血核心。使用正常全脑结构连接数据推断皮质脊髓束是否受缺血核心影响或保留。有序逻辑回归模型用于在 90 天后将此信息与改良的 Rankin 量表相关联。
在接受 MT 的大血管闭塞性中风患者中，皮质脊髓束的保留与功能结局恶化的风险降低相关，优势比为 0.28（95%CI，0.15-0.53）。在调整了年龄、病变负荷、初始症状严重程度、性别、中风侧和再通状态等多个混杂协变量后，这种相关性仍然显著。
基于预介入 CT 灌注的皮质脊髓束保留或不连接的替代指标与 MT 后功能结果密切相关。如果在独立样本中得到验证，该概念可以作为一种新的工具，以改善当前的结果模型，更好地理解 MT 后大血管闭塞性中风的个体间变异性。
