Niktabe Arash, Martinez-Gutierrez Juan Carlos, Salazar-Marioni Sergio, Abdelkhaleq Rania, Rodriguez Quintero Juan Carlos, Jeevarajan Jerome A, Tariq Muhammad Bilal, Iyyangar Ananya S, Azeem Hussain M, Ballekere Anjan Nagesh, Mai Le Ngoc, McCullough Louise D, Sheth Sunil A, Kim Youngran
Department of Neurology, UTHealth McGovern Medical School, Houston, Texas.
Department of Neurosurgery, UTHealth McGovern Medical School, Houston, Texas.
Stroke Vasc Interv Neurol. 2024 Jul;4(4). doi: 10.1161/SVIN.123.001278. Epub 2024 Apr 12.
CT Perfusion (CTP) predictions of infarct core play an important role in the determination of treatment eligibility in large vessel occlusion (LVO) acute ischemic stroke (AIS). Prior studies have demonstrated that blood glucose can affect cerebral blood flow (CBF). Here we examine the influence of acute and chronic hyperglycemia on CTP estimations of infarct core.
From our prospectively collected multi-center observational cohort, we identified patients with LVO AIS who underwent CTP with RAPID (IschemaView, Stanford, CA) post-processing, followed by endovascular therapy with substantial reperfusion (TICI 2b-3) within 90 minutes, and final infarct volume (FIV) determination by MRI 48-72 hours post-treatment. Core volume over- and under-estimations were defined as a difference of at least 20 mL between CTP-RAPID predicted infarct core and DWI FIV. Primary outcome was the association of presentation glucose and HgbA1c with underestimation (UE) of core volume and was measured using multivariable logistic regression adjusted for comorbidities and presentation characteristics. Secondary outcomes included frequency of overestimation (OE) of infarct core.
Among 256 patients meeting inclusion criteria, median age was 67 [IQR 57-77], 51.6% were female, and 132 (51.6%) and 93 (36.3%) had elevated presentation glucose and elevated HgbA1c, respectively. Median CTP-predicted core was 6 mL [IQR 0-30], median DWI FIV was 14 mL [IQR 6-43] and median difference was 12 mL [IQR 5-35]. Twenty-eight (10.9%) patients had infarct core OE and 68 (26.6%) had UE. Compared to those with no UE, patients with UE had elevated blood glucose (median 119 [103-155] vs 138 [117-195], p=0.002) and HgbA1c (median 5.80 [5.40-6.40] vs 6.40 [5.50-7.90], p=0.009). In multivariable analysis, UE was independently associated with elevated glucose (aOR 2.10, p=0.038) and HgbA1c (aOR 2.37, p=0.012). OE was associated with lower presentation blood glucose (median 109 [ 99-132] in OE vs 127 [107-172] in no OE, p=0.003) and HgbA1c (5.6 [IQR 5.1 - 6.2] in OE vs 5.90 [5.50-6.70] in no OE, p=0.012).
Acute and chronic hyperglycemia were strongly associated with CTP UE in patients with LVO AIS undergoing EVT. Glycemic state should be considered when interpreting CTP findings in patients with LVO AIS.
CT灌注（CTP）对梗死核心的预测在大血管闭塞（LVO）急性缺血性卒中（AIS）治疗资格的判定中起着重要作用。既往研究表明血糖可影响脑血流量（CBF）。在此，我们研究急性和慢性高血糖对梗死核心CTP估计值的影响。
从我们前瞻性收集的多中心观察性队列中，我们确定了LVO AIS患者，这些患者接受了经RAPID（IschemaView，加利福尼亚州斯坦福）后处理的CTP检查，随后在90分钟内接受了具有实质性再灌注（TICI 2b - 3）的血管内治疗，并在治疗后48 - 72小时通过MRI确定最终梗死体积（FIV）。核心体积高估和低估定义为CTP - RAPID预测的梗死核心与DWI FIV之间至少相差20 mL。主要结局是就诊时血糖和糖化血红蛋白（HgbA1c）与核心体积低估（UE）的关联，并使用针对合并症和就诊特征进行调整的多变量逻辑回归进行测量。次要结局包括梗死核心高估（OE）的频率。
在256例符合纳入标准的患者中，中位年龄为67岁[四分位间距（IQR）57 - 77]，51.6%为女性，就诊时血糖升高和HgbA1c升高的患者分别有132例（51.6%）和93例（36.3%）。CTP预测的核心体积中位数为6 mL[IQR 0 - 30]，DWI FIV中位数为14 mL[IQR 6 - 43]，中位数差异为12 mL[IQR 5 - 35]。28例（10.9%）患者出现梗死核心OE，68例（26.6%）患者出现UE。与无UE的患者相比，有UE的患者血糖（中位数119[103 - 155] vs 138[117 - 195]，p = 0.002）和HgbA1c（中位数5.80[5.40 - 6.40] vs 6.40[5.50 - 7.90]，p = 0.009）升高。在多变量分析中，UE与血糖升高（调整后比值比[aOR]2.10，p = 0.038）和HgbA1c升高（aOR 2.37，p = 0.012）独立相关。OE与就诊时较低的血糖（OE患者中位数为109[99 - 132]，无OE患者为127[107 - 172]，p = 0.003）和HgbA1c（OE患者为5.6[IQR 5.1 - 6.2]，无OE患者为5.90[5.50 - 6.70]，p = 0.012）相关。
在接受血管内治疗（EVT）的LVO AIS患者中，急性和慢性高血糖与CTP UE密切相关。在解读LVO AIS患者的CTP结果时应考虑血糖状态。
