Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.).
Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston (D.A.L., A.A.D.).
Stroke. 2024 Oct;55(10):2409-2419. doi: 10.1161/STROKEAHA.124.047483. Epub 2024 Aug 26.
Recent large core trials have highlighted the effectiveness of mechanical thrombectomy (MT) in acute ischemic stroke with large vessel occlusion. Variable perfusion-imaging thresholds and poor Alberta Stroke Program Early Computed Tomography Score reliability underline the need for more standardized, quantitative ischemia measures for MT patient selection. We aimed to identify the computed tomography perfusion parameter most strongly associated with poor outcomes in patients with acute ischemic stroke-large vessel occlusion with significant ischemic cores.
In this study from 2 comprehensive stroke centers from 2 comprehensive stroke centers within the Johns Hopkins Medical Enterprise (Johns Hopkins Hospita-East Baltimore and Bayview Medical Campus) from July 29, 2019 to January 29, 2023 in a continuously maintained database, we included patients with acute ischemic stroke-large vessel occlusion with ischemic core volumes defined as relative cerebral blood flow <30% and ≥50 mL on computed tomography perfusion or Alberta Stroke Program Early Computed Tomography Score <6. We used receiver operating characteristics to find the optimal cutoff for parameters like cerebral blood volume (CBV) <34%, 38%, 42%, and relative cerebral blood flow >20%, 30%, 34%, 38%, and time-to-maximum >4, 6, 8, and 10 seconds. The primary outcome was unfavorable outcomes (90-day modified Rankin Scale score 4-6). Multivariable models were adjusted for age, sex, diabetes, baseline National Institutes of Health Stroke Scale, intravenous thrombolysis, and MT.
We identified 59 patients with large ischemic cores. A receiver operating characteristic curve analysis showed that CBV<42% ≥68 mL is associated with unfavorable outcomes (90-day modified Rankin Scale score 4-6) with an area under the curve of 0.90 (95% CI, 0.82-0.99) in the total and MT-only cohorts. Dichotomizing at this CBV threshold, patients in the ≥68 mL group exhibited significantly higher relative cerebral blood flow, time-to-maximum >8 and 10 seconds volumes, higher CBV volumes, higher HIR, and lower CBV index. The multivariable model incorporating CBV<42% ≥68 mL predicted poor outcomes robustly in both cohorts (area under the curve for MT-only subgroup was 0.87 [95% CI, 0.75-1.00]).
CBV<42% ≥68 mL most effectively forecasts poor outcomes in patients with large-core stroke, confirming its value alongside other parameters like time-to-maximum in managing acute ischemic stroke-large vessel occlusion.
最近的大型核心试验强调了机械血栓切除术（MT）在伴有大血管闭塞的急性缺血性卒中中的有效性。不同的灌注成像阈值和较差的阿尔伯塔卒中项目早期计算机断层扫描评分（Alberta Stroke Program Early Computed Tomography Score，ASPECTS）可靠性突显了需要更标准化、定量的缺血指标来选择 MT 患者。我们旨在确定与大血管闭塞性急性缺血性卒中伴有明显缺血核心的患者不良预后最相关的 CT 灌注参数。
本研究纳入了 2019 年 7 月 29 日至 2023 年 1 月 29 日期间，来自约翰霍普金斯医疗企业（约翰霍普金斯医院东巴尔的摩院区和贝维尤医疗校区）2 个综合卒中中心的连续数据库中，伴有大血管闭塞且缺血核心体积定义为 CT 灌注相对脑血流量（cerebral blood flow，CBV）＜30%和≥50 mL，或 ASPECTS＜6 的急性缺血性卒中患者。我们使用受试者工作特征（receiver operating characteristic，ROC）曲线寻找 CBV＜34%、38%、42%，以及相对 CBV＞20%、30%、34%、38%和达峰时间＞4、6、8 和 10 秒等参数的最佳截断值。主要结局为不良结局（90 天改良Rankin 量表评分 4-6 分）。多变量模型调整了年龄、性别、糖尿病、基线国立卫生研究院卒中量表（National Institutes of Health Stroke Scale，NIHSS）评分、静脉溶栓和 MT。
我们共纳入 59 例大缺血核心患者。ROC 曲线分析显示，CBV＜42%且≥68 mL 与不良结局（90 天改良Rankin 量表评分 4-6 分）相关，在总人群和 MT 亚组中的曲线下面积分别为 0.90（95%置信区间，0.82-0.99）。将该 CBV 阈值分为二项，≥68 mL 组患者的相对 CBV 更高，达峰时间＞8 秒和＞10 秒的体积更大，CBV 体积更高，脑血容量指数（hyperintense volume ratio，HIR）更高，CBV 指数更低。多变量模型纳入 CBV＜42%且≥68 mL 能够在两个队列中可靠地预测不良结局（MT 亚组的曲线下面积为 0.87 [95%置信区间，0.75-1.00]）。
CBV＜42%且≥68 mL 最有效地预测了大核心卒中患者的不良结局，证实了其与达峰时间等其他参数结合在管理急性大血管闭塞性缺血性卒中中的价值。
