From the IRCCS Humanitas Research Hospital (U.P.); Department of Biomedical Sciences (U.P.), Humanitas University, Milan, Italy; Calgary Stroke Program (U.P., S.B., A.S., A.M.D., M.D.H.), Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada; Institute of Radiology (A.S.), Cantonal Hospital Münsterlingen, Switzerland; University of British Columbia (A.R.), Vancouver, Canada; Royal Adelaide Hospital (T.J.K.), Adelaide, Australia; Wellstar Health Systems (R.G.), Kennestone Hospital, Marietta, GA; Department of Neurology (G.T.) and Department of Neuroradiology (G.T.), University Medical Center Hamburg-Eppendorf, Germany; University College of Medicine (J.H.H.), Seoul, South Korea; and Department of Radiology (M.G., M.D.H., J.M.O.), Cumming School of Medicine, University of Calgary, Alberta, Canada.
Neurology. 2024 Nov 26;103(10):e209939. doi: 10.1212/WNL.0000000000209939. Epub 2024 Oct 21.
CT perfusion (CTP) maps can estimate the ischemic core in acute ischemic stroke based on distinctive cerebral blood flow thresholds. However, metabolic factors beyond perfusion influence the tissue tolerance to ischemia and the infarct growth rate. Underestimating the ischemic core volume (ICV) might result in overestimating the salvageable cerebral tissue and, consequently, overestimating the potential clinical benefits of reperfusion therapies. We aim to evaluate whether baseline hemoglobin and blood glucose levels influence the accuracy of baseline CTP ICV estimations.
Large vessel occlusion stroke patients investigated with baseline CTP undergoing thrombectomy with near-complete reperfusion and without parenchymal hemorrhage from the ESCAPE-NA1 trial were included. Patients were subdivided into anemic (hemoglobin <130 g/L for men and <120 g/L for women) and nonanemic groups, and hyperglycemic (blood glucose level >7 mmol/L) and normoglycemic groups. Ischemic core underestimated volume (ICuV) was calculated: final infarct volume minus CTP-based ICV. The primary outcome was the presence of "perfusion scotoma" defined as ICuV ≥10 mL. Presence of "perfusion scotoma" and median ICuV were compared between anemic vs nonanemic and hyperglycemic vs normoglycemic patients using nonparametric tests and multivariable binary logistic regression with adjustment for baseline variables.
One hundred sixty-two of 1,105 (15%) patients were included (median age 70.5 [interquartile range (IQR) 61-80.4], 50.6% women). The median ICuV was 7.26 mL (IQR 0-25.63). Seventy-eight (48%) patients demonstrated perfusion scotoma. Forty-two (25.7%) patients were anemic, and 65 (40.1%) were hyperglycemic. In univariable analysis, the hyperglycemic group had a higher prevalence of perfusion scotoma (65% [n = 40] vs 39% [n = 38], = 0.006) and larger ICuV (17.79 mL [IQR 1.57-42.75] vs 6 mL [-0.31 to 12.51], = 0.003) compared to normoglycemic patients. No significant ICuV differences between patients with and without anemia were seen. Multivariable regression analysis revealed an association between perfusion scotoma and hyperglycemia, adjusted odds ratio (OR) 2.48 (95% CI 1.25-4.92), and between perfusion scotoma and blood glucose levels, adjusted OR 1.19 (95% CI 1.03-1.39) per 1 mmol/L increase.
In our study, CTP-based ischemic core underestimation was common and associated with higher baseline blood glucose levels. Individual metabolic factors beyond perfusion that critically influence the infarct growth rate should be considered when interpreting baseline CTP estimations of ischemic core.
CT 灌注（CTP）图可根据独特的脑血流阈值来评估急性缺血性卒中的缺血核心区。然而，灌注以外的代谢因素会影响组织对缺血的耐受程度和梗死生长速度。低估缺血核心区体积（ICV）可能导致对可挽救脑组织的高估，进而对再灌注治疗的潜在临床获益的高估。我们旨在评估基线血红蛋白和血糖水平是否会影响基线 CTP-ICV 估计的准确性。
纳入 ESCAPE-NA1 试验中接受基线 CTP 检查并接受血栓切除术治疗的伴有大血管闭塞性卒中患者，这些患者达到了近乎完全再灌注且无实质内出血。将患者分为贫血（男性血红蛋白<130 g/L，女性血红蛋白<120 g/L）和非贫血组，以及高血糖（血糖水平>7 mmol/L）和血糖正常组。计算缺血核心低估体积（ICuV）：最终梗死体积减去基于 CTP 的 ICV。主要结局是存在“灌注暗区”，定义为 ICuV≥10 mL。使用非参数检验和多变量二元逻辑回归，在调整基线变量后，比较贫血与非贫血以及高血糖与血糖正常患者之间的“灌注暗区”存在情况和中位数 ICuV。
在 1105 例患者中，有 162 例（中位年龄 70.5[四分位距（IQR）61-80.4]，50.6%为女性）纳入了研究。中位 ICuV 为 7.26 mL（IQR 0-25.63）。78 例（48%）患者存在灌注暗区。42 例（25.7%）患者贫血，65 例（40.1%）患者高血糖。在单变量分析中，高血糖组灌注暗区的发生率更高（65%[n=40]与 39%[n=38]， = 0.006），ICuV 更大（17.79 mL[IQR 1.57-42.75]与 6 mL[-0.31 至 12.51]， = 0.003），与血糖正常患者相比。未观察到贫血患者与无贫血患者之间 ICuV 存在显著差异。多变量回归分析显示，与血糖正常患者相比，灌注暗区与高血糖之间存在关联，校正比值比（OR）为 2.48（95%CI 1.25-4.92），与灌注暗区与血糖水平之间存在关联，校正 OR 为 1.19（95%CI 1.03-1.39），每增加 1 mmol/L。
在我们的研究中，基于 CTP 的缺血核心低估是常见的，与较高的基线血糖水平相关。在解释基于 CTP 的缺血核心区的基线估计时，应考虑灌注以外的个体代谢因素，这些因素会严重影响梗死生长速度。
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