弥散加权成像与液体衰减反转恢复序列不匹配指导超过4.5 h时间窗缺血性卒中患者的静脉溶栓治疗

Diffusion-weighted imaging and fluid-attenuated inversion recovery mismatch guide intravenous thrombolysis in patients with ischemic stroke beyond a 4.5-h time window

目的探讨利用弥散加权成像(diffusion-weighted imaging,DWI)与液体衰减反转恢复序列(fluid-attenuated inversion recovery,FLAIR)不匹配指导超过4.5 h时间窗的缺血性卒中患者进行静脉溶栓治疗的有效性和安全性。方法回顾性纳入2019年7月至2021年6月在合肥市第二人民医院卒中中心接受阿替普酶静脉溶栓治疗的急性缺血性卒中患者。根据发病时间分为时间窗组与超时间窗组,记录并比较两组人口统计学和基线临床资料。主要转归指标为发病后90 d时应用改良Rankin量表(modified Rankin Scale,mRS)评估的临床转归,0~2分定义为转归良好,>2分定义为转归不良;次要转归指标为有症状颅内出血。应用多变量logistic回归分析确定转归不良的独立危险因素。结果共纳入244例急性缺血性卒中患者,男性146例(58.8%),年龄(61.4±8.47)岁,中位发病至溶栓时间为142 min,中位基线美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分为7分。36例(14.8%)患者超出4.5 h时间窗,69例(28.3%)患者转归不良。时间窗组转归良好率(71.2%对75.0%;χ^(2)=0.224,P=0.636)、任何颅内出血(9.6%对13.9%;χ^(2)=0.233,P=0.629)和有症状颅内出血发生率(5.3%对5.6%;χ^(2)=0.000,P=1.000)与超时间窗组均差异无统计学意义。单变量分析表明,转归不良组心房颤动和心源性栓塞患者的构成比以及NIHSS评分显著高于转归良好组(P均<0.05),而超时间窗接受静脉溶栓治疗的患者构成比与转归不良组差异无统计学意义。多变量logistic回归分析显示,仅基线NIHSS评分是患者转归不良的独立危险因素(优势比1.681,95%置信区间1.457~1.940;P<0.001)。结论与在发病后4.5 h内进行静脉溶栓治疗的患者相比,利用DWI-FLAIR不匹配指导的超过4.5 h时间窗的急性缺血性卒中患者进行静脉溶栓治疗能获得相似的临床转归,而且不会增高颅内出血发生率。

Objective To investigate the efficacy and safety of using diffusion-weighted imaging(DWI)and fluid-attenuated inversion recovery(FLAIR)mismatch to guide intravenous thrombolysis in patients with ischemic stroke beyond a 4.5-h time window.Methods Patients with acute ischemic stroke received intravenous thrombolysis with alteplase in the Stroke Center of Hefei Second People's Hospital from July 2019 to June 2021 were retrospectively enrolled.According to the time of onset,they were divided into the time window group and the beyond time window group.The demographic and baseline clinical data of both groups were recorded and compared.The primary outcome measure was the clinical outcome assessed by the modified Rankin Scale(mRS)at 90 d after onset.0-2 points were defined as good outcome,and>2 were defined as poor outcome.The secondary outcome measure was symptomatic intracranial hemorrhage(sICH).Multivariate logistic regression analysis was used to determine the independent risk factors for poor outcomes.Results A total of 244 patients with acute ischemic stroke were enrollded,including 146 males(58.8%),aged 61.4±8.47 years.The median time from onset to thrombolysis was 142 min,and the median baseline National Institutes of Health Stroke Scale(NIHSS)score was 7.Thirty-six(14.8%)patients exceeded the 4.5 h time window,and 69(28.3%)patients had poor outcomes.There were no significant differences in the good outcome rate(71.2%vs.75.0%;χ^(2)=0.224,P=0.636),any intracranial hemorrhage(9.6%vs.13.9%;χ^(2)=0.233,P=0.629)and the incidence of sICH(5.3%vs.5.6%;χ^(2)=0.000,P=1.000)between the time window group and the beyond time window group.Univariate analysis showed that the proportion of patients with atrial fibrillation or cardiogenic embolism and the baseline NIHSS score in the poor outcome group were significantly higher than those in the good outcome group(all P<0.05),while there was no statistical difference in the proportion of patients receiving intravenous thrombolysis beyond the time window.Multivariate logistic regression analysis showed that only the baseline NIHSS score was an independent risk factor for poor outcomes(odds ratio 1.681,95%confidence interval 1.457-1.940;P<0.001).Conclusions Compared with the patients who received intravenous thrombolysis within 4.5 h after onset,intravenous thrombolysis in patients with acute ischemic stroke beyond the 4.5 h time window guided by DWI-FLAIR mismatch results in similar clinical outcomes,and does not increase the incidence of intracranial hemorrhage.