Zimmerman William, Pergakis Melissa, Ahmad Ghasan, Morris Nicholas A, Podell Jamie, Chang Wan-Tsu, Motta Melissa, Chen Hegang, Jindal Gaurav, Bodanapally Uttam, Marc Simard J, Badjatia Neeraj, Parikh Gunjan Y
Department of Neurology, University of Maryland School of Medicine, 22 S. Greene St., G7K18, Baltimore, MD, 21201, USA.
Program in Trauma, R Adams Cowley Shock Trauma Hospital, Baltimore, MD, USA.
Neurocrit Care. 2024 Oct 24. doi: 10.1007/s12028-024-02137-5.
Patients with severe stroke are at high risk of secondary neurologic decline (ND) from the development of malignant cerebral edema (MCE). However, early infarcts are hard to diagnose on conventional head computed tomography (CT). We hypothesize that high-energy (190 keV) virtual monochromatic imaging (VMI) from dual-energy CT (DECT) imaging enables earlier detection of ND from MCE.
Consecutive patients with severe stroke with National Institute of Health Stroke Scale (NIHSS) scores > 15 and DECT within 10 h of mechanical thrombectomy from May 2020 to March 2022 were included. We excluded patients with parenchymal hematoma type 2 transformation. Retrospective analysis of clinical and novel variables included the VMI Alberta Stroke Program Early CT Score (ASPECTS), total iodine content, and VMI infarct volume. The primary outcome was secondary ND, defined using a composite outcome variable of clinical worsening (increase in NIHSS score ≥ 4 or decrease in Glasgow Coma Scale score > 2) or malignant radiographical edema (midline shift ≥ 5 mm at the level of the septum pellucidum). Fisher's exact test and Wilcoxon's test were used for univariate analysis. Logistic regression was used to develop prediction models for categorical outcomes.
Eighty-four patients with severe stroke with a median age of 67.5 (interquartile range [IQR] 57-78) years and an NIHSS score of 22 (IQR 18-25) were included. Twenty-nine patients had ND. The VMI ASPECTS, total iodine content, and VMI infarct volume were associated with ND. The VMI ASPECTS, VMI infarct volume, and total iodine content were predictors of ND after adjusting for age, sex, initial NIHSS score, and tissue plasminogen activator administration, with areas under the receiver operating characteristic curve (AUROC) of 0.691 (95% confidence interval [CI] 0.572-0.810), 0.877 (95% CI 0.800-0.954), and 0.845 (95% CI 0.750-0.940). By including all three predictors, the model achieved an AUROC of 0.903 (95% CI 0.84-0.97) and was cross-validated by the leave one out method, with an AUROC of 0.827.
The VMI ASPECTS and VMI infarct volume from DECT are superior to the conventional CT ASPECTS and are novel predictors for secondary ND due to MCE after severe stroke. Clinical trial registration ClinicalTrials.gov identifier: NCT04189471.
重症中风患者因发生恶性脑水肿（MCE）而出现继发性神经功能衰退（ND）的风险很高。然而，早期梗死灶在传统头部计算机断层扫描（CT）上很难诊断。我们推测，双能CT（DECT）成像中的高能（190 keV）虚拟单色成像（VMI）能够更早地检测出MCE导致的ND。
纳入2020年5月至2022年3月期间接受机械取栓且在10小时内进行DECT检查、美国国立卫生研究院卒中量表（NIHSS）评分>15的连续重症中风患者。我们排除了2型实质性血肿转化的患者。对临床和新变量进行回顾性分析，包括VMI阿尔伯塔卒中项目早期CT评分（ASPECTS）、总碘含量和VMI梗死体积。主要结局是继发性ND，使用临床恶化（NIHSS评分增加≥4或格拉斯哥昏迷量表评分降低>2）或恶性影像学水肿（透明隔水平中线移位≥5 mm）的复合结局变量来定义。采用Fisher精确检验和Wilcoxon检验进行单因素分析。使用逻辑回归建立分类结局的预测模型。
纳入84例重症中风患者，中位年龄为67.5（四分位间距[IQR]57 - 78）岁，NIHSS评分为22（IQR 18 - 25）。29例患者发生ND。VMI ASPECTS、总碘含量和VMI梗死体积与ND相关。在调整年龄、性别、初始NIHSS评分和组织纤溶酶原激活剂使用情况后，VMI ASPECTS、VMI梗死体积和总碘含量是ND的预测指标，受试者操作特征曲线（AUROC）下面积分别为0.691（95%置信区间[CI]0.572 - 0.810）、0.877（95% CI 0.800 - 0.954）和0.845（95% CI 0.750 - 0.940）。通过纳入所有三个预测指标，该模型的AUROC为0.903（95% CI 0.84 - 0.97），并采用留一法进行交叉验证，AUROC为0.827。
DECT的VMI ASPECTS和VMI梗死体积优于传统CT ASPECTS，是重症中风后MCE所致继发性ND的新预测指标。临床试验注册ClinicalTrials.gov标识符：NCT04189471。
