血管内治疗对液体衰减反转恢复成像高信号血管征筛选的超时间窗急性缺血性卒中患者预后的影响

Effects on prognosis of endovascular treatment beyond time windows in selected patients with acute ischemic stroke and hyperintense vessels sign on fluid-attenuated inversion recovery imaging

目的探讨血管内治疗对液体衰减反转恢复(FLAIR)成像高信号血管征(HVS)筛选的超时间窗急性缺血性卒中(AIS)患者预后的影响。方法回顾性连续纳入2016年2月至2020年1月武汉市第一医院神经内科AIS患者74例,均为发病>24~72 h、MRI示存在HVS、大脑中动脉M1段闭塞且伴有小核心梗死体积。根据治疗方式的不同,将74例患者分为标准药物组(48例)和联合治疗(血管内治疗联合标准药物)组(26例)。记录并比较两组患者的基线资料[年龄、性别、脑血管病危险因素(高血压病、糖尿病、高脂血症、吸烟史)、发病至完成MRI时间、美国国立卫生研究院卒中量表(NIHSS)评分及基于磁共振扩散加权成像的Alberta卒中项目早期CT评分(ASPECTS)]、急性卒中Org 10172治疗试验(TOAST)分型、静脉溶栓比例、进展型卒中比例及临床预后。对联合治疗组患者的围手术期资料进行分析。良好预后定义为改良Rankin量表(mRS)评分≤2分。血流重建成功定义为改良脑梗死溶栓(modified thrombolysis in cerebral infarction,mTICI)分级2 b^3级。结果(1)联合治疗组发病至完成MRI时间短于标准药物组,组间差异有统计学意义[20.0(6.4,41.3)h比30.0(11.3,59.8)h,P<0.05];两组患者性别、高血压病、糖尿病、高脂血症、吸烟史、年龄、基于磁共振扩散加权成像的ASPECTS、NIHSS评分、静脉溶栓、进展性卒中、TOAST分型的差异均无统计学意义(均P>0.05)。(2)联合治疗组患者中,心源性栓塞和动脉粥样硬化性大脑中动脉M1段闭塞的比例分别为11.5%(3/26)和88.5%(23/26);卒中发病至股动脉穿刺的中位时间为38(11,58)h,且分布于48 h内的比例为73.1%(19/26);血流重建成功(m TICI分级2b^3级)率为92.3%(24/26)。(3)联合治疗组无症状颅内出血发生率为11.5%(3/26),出院时及随访期间两组均无死亡者。联合治疗组良好预后率高于标准药物组,组间差异有统计学意义[88.5%(23/26)比54.2%(26/48),P<0.01]。结论与标准药物治疗相比,血管内治疗能改善以FLAIR-HVS筛选的超时间窗、大脑中动脉M1段闭塞且伴有小核心梗死体积的AIS患者的临床预后。

Objective To evaluate the effects on prognosis of endovascular treatment beyond time window in selected patients with acute ischemic stroke(AIS)and hyperintense vessels sign(HVS)on fluid-attenuated inversion recovery(FLAIR)imaging.Methods A total of 74 AIS patients were enrolled retrospectively from February 2016 to January 2020 in the Department of Neurology,Wuhan First Hospital.All the patients were onset more than 24 hours and within 72 hours,and magnetic resonance imaging(MRI)showed the M1 occlusion of middle cerebral artery and the presence of HVS with small core infarct volume.According to the type of treatment,the included patients were divided into a standard drug group(48 cases)and a combination therapy(endovascular treatment combined with standard drugs)group(26 cases).We recorded and compared the baseline data of patients such as age,gender,cerebrovascular disease risk factors(hypertension,diabetes,hyperlipidemia,smoking),time from onset to completion of MRI,National Institutes of Health Stroke Scale(NIHSS)score and Alberta stroke project early CT score(ASPECTS)based on MRI diffusion-weighted imaging and acute stroke Org 10172 treatment trial(TOAST)classification,intravenous thrombolysis ratio,the proportion of progressive stroke,and clinical outcomes in the two group.Then,the perioperative data of patients in the combined treatment group were analyzed,good clinical outcome was defined as a modified Rankin Scale(mRS)score≤2 points.The successful reconstruction was defined as the modified thrombolysis in cerebral infarction(mTICI)grade 2 b-3.Results(1)The time from onset to completion of MRI in the combination treatment group was shorter than that in the standard drug group,which was statistically significant 20.0([6.4,41.3]h vs.30.0[11.3,59.8]h,P<0.05).There was no significant difference in gender,Hypertension,diabetes,hyperlipidemia,smoking,age,ASPECTS,NIHSS score,intravenous thrombolysis,progressive stroke,TOAST between two groups(all P>0.05).(2)The proportions of cardiogenic embolism and atherosclerotic M1 occlusion of the middle cerebral artery were 11.5%(3/26)and 88.5%(23/26)in the combined treatment group,respectively.The median time of onset to puncture was 38(11,58)h,and 73.1%(19/26)of them≤48 h.The success rate of blood flow reconstruction was 92.3%(24/26).(3)The rate of asymptomatic intracranial hemorrhage in the combined treatment group was 11.5%(3/26).There was no death case in both groups at the time of discharge and follow-up.The rate of the good clinical outcome in the combined treatment group was higher than that in the standard drug group with significant difference(88.5%[23/26]vs.54.2%[26/48],P<0.05).Conclusion Compared with standard drug therapy,endovascular treatment beyond time window can improve the clinical outcome of AIS patients caused by M1 occlusion of the middle cerebral artery with small core infarct volume selected by HVS on FLAIR.