不同病因型急性前循环大血管闭塞性缺血性卒中患者机械取栓术后定量数字减影血管造影参数的预后预测价值

Prognostic prediction value of quantitative digital subtraction angiography parameters after mechanical thrombectomy in patients with acute ischemic stroke with large vessel occlusion in the anterior circulation of different etiology

目的探究定量数字减影血管造影(DSA)参数在接受机械取栓治疗的急性前循环缺血性脑卒中患者中的预后预测价值,并分析对于不同病因型卒中患者其临床价值是否存在差异。方法对前瞻性多中心Captor试验进行事后分析,纳入于2018年4月至2019年7月成功再通的急性前循环大血管闭塞患者。对其再通后DSA造影序列进行后处理分析,于靶血管选定4个感兴趣区:感兴趣区1(颈内动脉C2段近端)、感兴趣区2(颈内动脉C7段起点)、感兴趣区3(大脑中动脉M1段末端)和感兴趣区4(大脑中动脉M2段末端)。达峰时间定义为感兴趣区内对比剂浓度达到峰值所对应的时间,相对达峰时间(rTTP)定义为所选感兴趣区与感兴趣区1的达峰时间差值。成功再通定义为术后改良脑梗死溶栓(mTICI)分级≥2b级,良好功能预后定义为术后3个月改良Rankin量表评分0~2分。根据改良Rankin量表评分将患者分为预后良好组和预后不良组,比较两组患者的临床特征、术后血流动力学参数等数据之间的差异。利用单因素、多因素Logistic回归分析良好预后的相关因素,并探究不同急性卒中Org10172治疗试验病因分型中血流动力学参数的预后预测价值。结果共收集245例患者,161例最终纳入分析[年龄69(60,76)岁,男性92例(57.1%)],其中大动脉粥样硬化(LAA)型卒中36例,心源性栓塞(CE)型76例,其他病因卒中49例。71例(44.1%)患者神经功能预后良好。术后血流动力学分析发现,预后良好患者(71例)比预后不良患者(90例)具有更高的术后mTICI 3级者比例[54/71(76.1%)比41/90(45.6%),χ^(2)=15.26,P<0.001]和更低的rTTP31[即达峰时间感兴趣区3-达峰时间感兴趣区1;0.33(0.23,0.54)s比0.47(0.31,0.65)s,Z=-2.71,P=0.007]。根据mTICI分级和rTTP31分别建立多因素回归模型,结果显示mTICI 3级(校正OR=5.97,95%CI 2.49~14.27,P<0.001)与rTTP31(校正OR=0.24,95%CI 0.06~0.99,P=0.048)都和患者良好的功能预后显著相关,受试者工作特征曲线下面积差异无统计学意义(P=0.170)。亚组分析显示,rTTP31与LAA型卒中患者预后显著相关(OR=0,95%CI 0~0.25,P=0.014),而mTICI分级与CE型(OR=3.91,95%CI 1.40~10.91,P=0.009)和其他原因卒中患者(OR=7.35,95%CI 1.92~28.14,P=0.004)预后相关。结论在机械取栓成功再通的急性前循环缺血性卒中患者中,术后mTICI分级和rTTP31对患者术后3个月良好神经功能预后都具有显著的预测价值。在不同病因的卒中患者中,rTTP31与LAA型卒中患者预后显著相关,而mTICI分级与CE型和其他原因型卒中患者预后显著相关。

Objective To explore the prognostic prediction value of quantitative digital subtraction angiography(DSA)parameters in patients with acute anterior circulation ischemic stroke undergoing mechanical thrombectomy,and whether the clinical values vary by stroke etiology.Methods This study was a post hoc analysis of the Multicenter Prospective Captor Trial.Patients with acute anterior circulation large-vessel occlusion and successful recanalization from April 2018 to July 2019 were screened.Post-processing analysis was performed on the DSA imaging sequence after recanalization,and 4 regions of interest(ROI)were selected in the target vessel:ROI1(the proximal of the internal carotid artery-C2 segment),ROI2(the starting point of the internal carotid artery-C7 segment),ROI3(the end of the middle cerebral artery-M1 segment),and ROI4(the end of the middle cerebral artery-M2 segment).Time to peak(TTP)was defined as the time at contrast concentration of selected ROI reached its maximum.Relative TTP(rTTP)was calculated by subtracting the TTP of ROI1 from the TTP of distalis ROIs.Successful recanalization was defined as modified Thrombolysis In Cerebral Infarction(mTICI)grade≥2b.Favorable outcomes at 3 months were defined as the modified Rankin Scale score≤2.According to the modified Rankin Scale score,the patients were divided into good prognosis group and poor prognosis group.The differences in clinical characteristics,postoperative hemodynamic parameters,and other data were compared between patients with good and poor prognoses.Univariate and multivariate Logistic regression was used to analyze factors related to a good prognosis.Finally,the prognostic prediction value of hemodynamic parameters was analyzed in patients with different Trial of Org10172 in Acute Stroke Treatment etiological classifications.Results A total of 245 patients were collected,of which 161 patients[age 69(60,76)years,92(57.1%)male]were finally included in the analysis,including 36 cases of large artery atherosclerosis(LAA)stroke,76 cases of cardiogenic embolism(CE),and 49 cases of other causes of stroke.Seventy-one(44.1%)patients had favorable outcomes at 3 months.The post-operative hemodynamic analysis indicated that patients with favorable outcomes(n=71)had a higher proportion of mTICI grade 3[54/71(76.1%)vs 41/90(45.6%),χ^(2)=15.26,P<0.001]and lower rTTP31[means TTPROI3-TTPROI1;0.33(0.23,0.54)s vs 0.47(0.31,0.65)s,Z=-2.71,P=0.007]than patients with unfavorable outcomes(n=90).The mTICI score and rTTP31 were respectively included in multivariate Logistic regression models.It was shown that mTICI grade 3(adjusted OR=5.97,95%CI 2.49-14.27,P<0.001)and rTTP31(adjusted OR=0.24,95%CI 0.06-0.99,P=0.048)were significantly associated with favorable outcomes,and the area under the receiver operating characteristic curve of the models had no statistically significant difference(P=0.170).Subgroup analysis showed that rTTP31 was significantly associated with the prognosis of patients with LAA stroke(OR=0,95%CI 0-0.25,P=0.014),while mTICI grade was associated with the prognosis of patients with CE(OR=3.91,95%CI 1.40-10.91,P=0.009)and other etiologies(OR=7.35,95%CI 1.92-28.14,P=0.004).Conclusions In patients with acute anterior circulation ischemic stroke and successful recanalization,both mTICI score and rTTP31 had significant predictive value for favorable outcomes at 3 months.Moreover,rTTP31 was significantly associated with the prognosis of patients with LAA stroke,while mTICI score was significantly related to the prognosis of patients with CE and other causes of stroke.