急性大血管闭塞性脑卒中成功再通后发生恶性脑水肿的早期影像学预测因素分析及与临床结局的关系

Analysis of early imaging predictors of malignant brain edema after successful recanalization of acute large vessel occlusive stroke and relationship to clinical outcome

目的分析急性大血管闭塞性脑卒中(Acute large vascular occlusive stroke,ALVOS)成功再通后发生恶性脑水肿(Malignant brain edema,MBE)的早期影像学预测因素及临床结局。方法纳入急性大血管闭塞性脑卒中成功再通患者149例,术后即刻非增强计算机断层扫描(Non-contrast computed tomography,NCCT)评估介入后高密度影(Postinterventional cerebral hyperdensities,PCHDs),根据PCHDs的分布特点及范围提出一种征象即绸带征,定义为术后即刻NCCT上最大面积的高密度改变呈沿脑回的带状高密度影;根据术后72 h内是否发生恶性脑水肿分组;采用单因素和多因素Logistic回归分析MBE的预测因素,并绘制受试者工作特征(Receiver operating characteristic,ROC)曲线来检验绸带征的性能。结果共纳入149例患者(男性60.40%),其中27例(18.12%)发生MBE,108例(72.50%)发生PCHDs,50例(33.60%)发生绸带征;在调整混杂因素后术后美国国立卫生研究院卒中量表(National institutes of health stroke scale,NIHSS)评分(OR=1.228,95%CI=1.064~1.417,P=0.005)、绸带征(OR=19.007,95%CI=4.123~87.615,P<0.001)、术后白细胞数(OR=1.444,95%CI=1.06~1.966,P=0.020)是ALVOS成功再通后发生MBE的独立危险因素;绸带征([曲线下面积(Area under the curve,AUC)]=0.815,95%CI=0.726~0.904,P<0.001)对ALVOS成功再通后发生MBE的预测价值高于术后NIHSS评分(AUC=0.812,95%CI=0.722~0.902,P<0.001)和术后白细胞数(AUC=0.719,95%CI=0.620~0.818,P<0.001)。结论急性大血管闭塞性脑卒中成功再通后仍有较高的MBE发生率,并与不良的功能预后相关,绸带征作为术后影像学的标志物是血管内治疗术成功再通后发生MBE的独立危险因素,有助于临床医师的诊疗决策。

Objective To analysis of early imaging predictors and clinical outcome of malignant brain edema(MBE)after successful recanalization of acute large vessel occlusive stroke(ALVOS).Methods 149 patients with anterior circulation ALVOS who were successfully recanalized were selected for the study.Immediate postoperative non-contrast computed tomography(NCCT)was used to evaluate postinterventional cerebral hyperdensities(PCHDs).Based on the distribution characteristics and range of PCHDs,we propose a sign,the lace sign.The lace sign is defined as the largest area of high-density change on the NCCT immediately postoperatively showing a band of high-density shadow along the cerebral gyrus.According to the results of NCCT within postoperative 72 hours,the patients were divided into malignant brain edema group(MBE group)and non-malignant brain edema group(non-MBE group).Univariate and multivariate logistic regression were used to analyze the predictors of MBE and ROC curves were drawn to examine the performance of the lace sign.Results A total of 149 patients with successful recanalization(male,60.40%)were included,of whom 27(18.12%)developed MBE,108(72.50%)developed PCHDs and 50(33.60%)developed the lace sign.After adjustment for confounders,postoperative NIHSS score(OR=1.228,95%CI=1.064~1.417,P=0.005),the lace sign(OR=19.007,95%CI=4.123~87.615,P<0.001),and postoperative leukocyte count(OR=1.444,95%CI=1.06~1.966,P=0.020)were independent risk factors for the development of MBE after successful recanalization of ALVOS.The lace sign(AUC=0.815,95%CI=0.726~0.904,P<0.001)was a better predictor of MBE than the postoperative NIHSS score(AUC=0.812,95%CI=0.722~0.902,P<0.001)or post-operative leukocyte count(AUC=0.719,95%CI=0.620~0.818,P<0.001).Conclusion Acute large vessel occlusive stroke is not uncommon in MBE after successful recanalization and is associated with poor functional outcomes.The lace sign which is used as a marker for postoperative imaging is an independent risk factor for the development of MBE after successful recanalization with endovascular therapy that helps clinicians in their treatment decisions.