Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia.
Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.
Ann Neurol. 2024 Dec;96(6):1104-1114. doi: 10.1002/ana.27073. Epub 2024 Sep 3.
The no-reflow phenomenon is a potential contributor to poor outcome despite successful thrombectomy. There are multiple proposed imaging-based definitions of no-reflow leading to wide variations in reported prevalence. We investigated the agreement between existing imaging definitions and compared the characteristics and outcomes of patients identified as having no-reflow.
We performed an external validation of 4 existing published definitions of no-reflow in thrombectomy patients with extended Thrombolysis in Cerebral Infarction scale 2c to 3 (eTICI2c-3) angiographic reperfusion who underwent 24-hour perfusion imaging from 2 international randomized controlled trials (EXTEND-IA TNK part-1 and 2) and a multicenter prospective observational study. Receiver-operating-characteristic and Bayesian-information-criterion (BIC) analyses were performed with the outcome variable being dependent-or-dead at 90-days (modified Rankin Score [mRS] ≥3).
Of 131 patients analyzed, the prevalence of no-reflow significantly varied between definitions (0.8-22.1%; p < 0.001). There was poor agreement between definitions (kappa 5/6 comparisons <0.212). Among patients with no-reflow according to at least 1 definition, there were significant differences between definitions in the intralesional interside differences in cerebral blood flow (CBF) (p = 0.006), cerebral blood volume (CBV) (p < 0.001), and mean-transit-time (MTT) (p = 0.005). No-reflow defined by 3 definitions was associated with mRS ≥3 at 90 days. The definition of >15% CBV or CBF asymmetry was the only definition that improved model fit on BIC analysis (ΔBIC = -8.105) and demonstrated an association between no-reflow and clinical outcome among patients with eTICI3 reperfusion.
Existing imaging definitions of no-reflow varied significantly in prevalence and post-treatment perfusion imaging profile, potentially explaining the variable prevalence of no-reflow reported in literature. The definition of >15% CBV or CBF asymmetry best discriminated for functional outcome at 90 days, including patients with eTICI3 reperfusion. ANN NEUROL 2024;96:1104-1114.
未再通现象是尽管血栓切除术成功但预后不良的一个潜在因素。有多种基于影像学的无再通定义，导致报道的患病率差异很大。我们研究了现有的影像学定义之间的一致性，并比较了被确定为无再通的患者的特征和结局。
我们对来自 2 项国际随机对照试验（EXTEND-IA TNK 第 1 部分和第 2 部分）和一项多中心前瞻性观察性研究的接受 24 小时灌注成像的血栓切除术患者进行了 4 项已发表的无再通影像学定义的外部验证，这些患者的扩展血栓溶解治疗脑梗死评分 2c 至 3（eTICI2c-3）血管再通。使用依赖或死亡（改良 Rankin 评分 [mRS] ≥3）作为因变量，进行了受试者工作特征和贝叶斯信息准则（BIC）分析。
在分析的 131 名患者中，无再通的患病率在不同定义之间差异显著（0.8-22.1%；p<0.001）。定义之间的一致性较差（5/6 次kappa 比较<0.212）。根据至少 1 个定义，在无再通的患者中，大脑血液流量（CBF）（p=0.006）、脑血容量（CBV）（p<0.001）和平均通过时间（MTT）（p=0.005）的颅内侧间差异存在显著差异。3 个定义定义的无再通与 90 天 mRS≥3 相关。>15%CBV 或 CBF 不对称的定义是唯一能通过 BIC 分析改善模型拟合（ΔBIC=-8.105）并证明无再通与 eTICI3 再灌注患者临床结局之间存在关联的定义。
现有的无再通影像学定义在患病率和治疗后灌注成像特征方面差异很大，这可能解释了文献中报告的无再通患病率的差异。>15%CBV 或 CBF 不对称的定义最能区分 90 天的功能结局，包括 eTICI3 再灌注的患者。
