梗死核心容积预测急性前循环大血管闭塞患者机械取栓术后出血转化的价值

【摘要】 目的 探讨急性前循环大血管闭塞患者机械取栓术后梗死核心容积与出血转化（HT）的关系。 方法 回顾性分析2019年10月至2020年2月在南京医科大学第一附属医院接受机械取栓术治疗前循环大血管闭塞的急性缺血性脑卒中（AIS）患者临床和影像学资料。根据欧洲急性脑卒中协作研究（ECASS）Ⅱ标准,将患者分为HT组和Non-HT组,同时根据术后是否发生实质性血肿（PH）分为PH组和Non-PH组,分别比较两组患者临床资料。采用多因素logistic回归分析评估HT和PH独立危险因素,受试者工作特征曲线（ROC）分析梗死核心容积预测HT和PH的效能。 结果 共76例患者纳入分析。HT组26例, Non-HT组50例;PH组10例,Non-PH组66例。HT组梗死核心容积、美国国立卫生研究院卒中量表（NIHSS）评分及血糖水平均高于Non-HT组（P＜0.05）。PH组梗死核心容积、NIHSS评分均高于Non-PH组（P＜0.05）。多因素logistic回归分析显示,梗死核心容积较大是机械取栓术后发生HT的独立危险因素（OR=1.032,95%CI=1.003～1.061, P=0.028）,也是发生PH的独立危险因素（OR=1.045,95%CI=1.007～1.085,P=0.021）。梗死核心容积预测HT的灵敏度为57.7%,特异度为72.0%,ROC曲线下面积（AUC）为0.658,预测值为13.5 mL;预测PH的灵敏度为54.5%,特异度为93.8%,AUC为0.755,预测值为36 mL。 结论 梗死核心容积较大是AIS患者机械取栓术后发生HT、PH的独立危险因素。梗死核心容积对AIS患者取栓术后HT具有预测价值。     

后循环急性缺血性脑卒中患者经机械取栓完全复流后不良预后的影响因素分析

目的探索后循环急性缺血性脑卒中（PCS）患者经机械取栓并完全恢复前向血流后部分患者临床预后仍然不佳的影响因素。 方法连续纳入2017年1月至2020年9月于我院接受机械取栓治疗的PCS患者并进行回顾性分析。闭塞血管完全恢复前向血流定义为改良脑梗死溶栓血流分级（mTICI）达3级。90 d改良Rankin评分（mRS）> 2分则被定义为预后不良。将患者基线资料、治疗相关指标纳入多因素分析,并采用受试者工作特征曲线（ROC）来确定最佳界值。 结果共纳入39例经机械取栓治疗后完全恢复前向血流（mTICI 3级）的PCS患者。其中,预后不良患者共20例（51.3%）。采用逐步Logistic回归分析显示,入院时美国国立卫生研究院卒中量表（NIHSS）评分较高（OR = 1.21,95%CI = 1.037~1.414,P = 0.016）、后交通动脉（PcomA）未开放（OR = 0.052,95%CI = 0.005~0.557,P = 0.014）为90 d不良预后的独立预测因素。基于ROC曲线分析显示,入院时NIHSS评分曲线下面积为0.762,截断值为20分,敏感度为70.0%,特异度为84.2%。 结论入院时NIHSS评分高、后交通动脉未开放,是后循环急性缺血性脑卒中患者接受机械取栓治疗并完全恢复前向血流后临床预后仍不佳的相关因素。     

急性缺血性脑卒中机械取栓后大面积脑梗死发生及其影响因素分析

【摘要】 目的 探讨前循环急性缺血性脑卒中（AIS）患者机械取栓后大面积脑梗死（LHI）发生及其影响因素。方法 回顾性分析2015年1月至2018年12月于南京医科大学第一附属医院接受机械取栓治疗的前循环AIS患者临床资料。主要观察指标是术后5～7 d LHI,即头颅影像学检查所示梗死面积大于大脑中动脉供血区1/3。采用单因素和多因素logistic回归分析明确LHI发生相关因素,并分析LHI与90 d改良Rankin量表（mRS）评分相关性。结果 共计纳入227例患者。其中107例（47.1%）术后发生LHI。单因素和多因素logistic回归分析显示,基线高美国国立卫生研究院卒中量表（NIHSS）评分、低Alberta卒中项目早期CT评分（ASPECTS）、侧支代偿差及再灌注欠佳是LHI发生的独立危险因素（P＜0.05）。与非LHI组相比,LHI组患者90 d良好预后率更低（17.8%对72.5%,χ2=68.102,P＜0.001）。 结论 基线高NIHSS评分、低ASPECTS、侧支代偿差及再灌注欠佳是LHI发生的独立危险因素。LHI发生与临床预后不佳相关。     

院内急性缺血性脑卒中机械取栓治疗效果和预后因素分析

目的 探讨机械取栓治疗院内急性缺血性脑卒中患者临床效果及其预后因素.方法 回顾性分析2015年1月至2019年1月南京医科大学第一附属医院采用机械取栓治疗的连续院内急性缺血性脑卒中患者临床资料.主要观察指标为90 d改良Rankin量表(mRS)评分.根据90 d mRS评分将患者分为预后良好(mRS评分≤2)组和预后...     

大核心缺血性脑卒中机械取栓现状及相关研究进展

机械取栓是近年来急性脑梗死治疗的最重要研究进展,特别是在2015年五大血管内治疗研究的阳性结果改写了临床指南,但是其研究的重点主要针对小核心脑梗死患者（small vessel infarction,SVI）,其入选标准：ASPECTS≥6分,Alberta卒中项目早期CT评分（Alberta Stroke Program Early CT Score）卒中发作6 h内;卒中发作6～24 h内,梗死体积小于70 mL,且存在影像错配或存在临床与灌注影像不匹配。上述研究均排除了大核心脑梗死（large core infarction,LCI）ASPECTS<6分或梗死体积≥70 mL的患者,而随着急性缺血性脑卒中（acute ischemic stroke,AIS）血管内治疗研究的不断进展,机械取栓从“时间窗”跨向“组织窗”,同时也从小核心脑梗死跨向了最近非常热门的大核心梗死时代。对于大核心梗死患者血管内治疗是否有益,目前仍不确定。本文主要针对前循环大核心缺血性脑卒中血管内治疗的相关研究进展进行综述,比如大核心脑梗死影像判定及研究入选标准、术后血压管理、无效再通及预后影响因素等。     

支架取栓与动脉溶栓治疗急性缺血性脑卒中比较

目的 探讨Solitaire AB支架取栓联合动脉内溶栓治疗急性缺血性脑卒中(AIS)的效果及安全性.方法 选取2010年6月至2015年6月采用动脉内治疗AIS患者60例,其中30例接受微导管置于阻塞血管近端或阻塞血管血栓内的尿激酶溶栓治疗(单纯溶栓组),30例接受Solitaire AB支架取栓联合微导管注入尿激酶溶栓治疗(支架取栓组).观察两组治疗前后美国国立卫生研究院卒中量表(NIHSS)评分、术后血管再通率、颅内出血率、90 d内病死率及90 d后改良Rankin量表(mRS)评分.结果 支架取栓组和单纯溶栓组治疗前、治疗后14 d NIHSS评分分别为(21.89±5.62)分、(7.78±2.36)分(P＜0.001)和(18.40±6.59)分、(7.00±2.28)分(P＜0.001),组间差异均无统计学意义(P＞0.05);血管再通率分别为86.67％ (26/30)、63.33％(19/30)(X2=4.356,P＜0.05);颅内出血发生率分别为10.00％(3/30)、13.33％ (4/30)(x2=0.162,P＞0.05);90 d内病死率分别为13.33％ (4/30)、16.67％(5/30) (x2=0.131,P＞0.05);术后90 d预后良好(mRS评分＜2)分别为66.67％ (20/30)、36.67％ (11/30)(x2=5.406,P＜0.05).结论 Solitaire AB支架取栓联合动脉内溶栓治疗大血管闭塞的AIS后血管再通率及90 d预后均显著优于单纯动脉内溶栓治疗,但远期疗效及安全性尚需更多病例的多中心前瞻性随机对照研究验证.     

机械取栓在急性血栓性脑卒中中的应用

急性血栓性脑卒中是严重威胁人类健康的常见病,其治疗方法主要有静脉溶栓、动脉溶栓和机械取栓.近年来,对于不适合静脉溶栓或静脉溶栓失败的患者,机械取栓由于其所取得的较好的效果受到越来越多的关注,现就其有关方面予以综述.     

急性缺血性脑卒中支架取栓首次成功再灌注的影响因素分析

目的 探讨前循环急性缺血性脑卒中(AIS)患者支架取栓术首次成功再灌注(FPR)的影响因素.方法 回顾性分析2018年1月至2020年3月在南京医科大学第一附属医院接受Solitaire AB支架取栓治疗的前循环AIS患者临床资料.根据首次支架取栓后闭塞血管再通程度是否达到改良溶栓治疗脑梗死(mTICI)血流分级2c/...     

多模式CT预测急性缺血性脑卒中出血转化风险的研究进展

出血转化是急性缺血性脑卒中自然转归过程之一,也可发生在溶栓或抗凝药物治疗之后。血脑屏障破坏、缺血再灌注、侧支循环的建立等与之密切相关。早期预测急性缺血性脑卒中出血转化风险对其治疗方案的选择及预后具有重要意义。CT平扫、CT灌注成像及CT血管成像检查对于出血转化高风险人群的检出具有较大价值。就多模式CT参数及其阈值预测出血转化的研究进展予以综述。     

Mechanical thrombectomy with snare in patients with acute ischemic stroke

Introduction We evaluated the efficacy and safety of thrombus extraction using a microsnare in patients with acute ischemic stroke (AIS). Methods This was a prospective, observational, cohort study in which consecutive patients with AIS (<6 hours of ischemia for anterior circulation and <24 hours for posterior circulation) who had been previously excluded from intravenous tissue plasminogen activator (tPA) thrombolysis were included and followed-up for 3 months. Mechanical embolectomy with a microsnare of 2–4 mm was undertaken as the first treatment. Low-dose intraarterial thrombolysis or angioplasty was used if needed. TIMI grade and modified Rankin stroke scale (mRSS) score were used to evaluate vessel recanalization and clinical efficacy, respectively. Results Nine patients (mean age 55 years, range 17–69 years) were included. Their basal mean NIHSS score was 16 (range 12–24). In seven out of the nine patients (77.8%) the clot was removed, giving a TIMI grade of 3 in four patients and TIMI grade 2 in three patients. Occlusion sites were: middle cerebral artery (four), basilar artery (two) and anterior cerebral artery plus middle cerebral artery (one). The mean time for recanalization from the start of the procedure was 50 min (range 50–75 min). At 3 months, the mRSS score was 0 in two patients and 3–4 in three patients (two patients died). Conclusion According to our results, the microsnare is a safe procedure for mechanical thrombectomy with a good recanalization rate. Further studies are required to determine the role of the microsnare in the treatment of AIS.     

急性脑梗死机械取栓后引流静脉早显与脑出血转化的关系

目的探讨急性脑梗死机械取栓术后血管造影显示引流静脉早显(EVF)与脑出血转化(HT)的关系。方法回顾性分析2015年1月至2018年11月,扬州大学附属医院经机械取栓的急性前循环大血管闭塞患者的影像及人口统计资料、血管危险因素及其他临床资料。参照欧洲协作急性卒中研究Ⅱ(ECASSⅡ),对机械取栓术后HT进行改良分型(HT阴性、HT-Ⅰ型和HT-Ⅱ型),并对其EVF发生率、基线特征及临床预后进行比较。应用多变量logistic回归分析HT和临床预后的独立危险因素。采用受试者操作特征曲线(ROC)分析EVF预测HT-Ⅱ型的效能。结果98例接受机械取栓患者纳入分析,其中HT阴性48例(49.0%,48/98)、HT-Ⅰ型40例(40.8%,40/98)、HT-Ⅱ型10例(10.2%,10/98)。3组患者的年龄及心房颤动、EVF、预后不良发生率的差异具有统计学意义(P<0.05)。多变量logistic回归分析显示EVF[优势比(OR)5.962,95%CI 1.750~8.964,P=0.001]和心房颤动(OR 3.485,95%CI 1.962~18.986,P=0.028)是发生HT-Ⅱ的独立危险因素;未发现HT-Ⅰ的独立危险因素;基线美国国立卫生研究院卒中量表(NIHSS)评分(OR 1.162,95%CI 1.021~1.345,P=0.038)、EVF(OR 5.358,95%CI 1.665~13.653,P=0.006)和HT-Ⅱ(OR 1.326,95%CI 1.226~2.038,P=0.032)是预后不良的独立危险因素。EVF预测HT-Ⅱ的灵敏度、特异度分别为80.0%、86.4%,ROC曲线下面积为0.832。结论急性脑梗死机械取栓后血管造影出现EVF预示再通后HT-Ⅱ型出血转化风险增加及预后不良。     

急性缺血性脑卒中介入取栓治疗的预后及其影响因素

 目的 探讨急性缺血性脑卒中(acute ischemic stroke,AIS)介入取栓治疗的预后及其影响因素。方法 选取2017-01至2019-07在医院神经内科接受介入取栓治疗的106例AIS患者,根据术后3个月患者改良Rankin评分评估预后水平,分为预后良好组和预后不良组,对两组患者各项临床资料进行分析,对比预后的相关因素及危险因素,并对认知功能和预后血清神经相关因子表达水平进行对比。结果 患者年龄大、合并冠心病、术前血清CRP及Hcy高、阻塞血管再通时间较长、术后36 h存在部分再通均为AIS介入治疗预后不良的危险因素(OR>1,P<0.05);预后良好组的认知功能、运动功能、语言功能均优于预后不良组,差异有统计学意义(P<0.05);两组患者吞咽功能差异无统计学意义。预后良好组血清神经相关因子表达水平均优于预后不良组,差异有统计学意义(P<0.05)。结论 预后良好AIS患者各项功能与血清神经相关因子表达水平状态均较好,对年龄较大、发病至就诊时间较长、合并冠心病,且术前血清CRP、Hcy、NIHSS评分偏高,阻塞血管再通时间较长及术后36 h内仅达到部分再通的患者应给予充分重视,对危险因素积极预防,提高预后水平。     

Predictive factors of outcome and hemorrhage after acute ischemic stroke treated by mechanical thrombectomy with a stent-retriever

Introduction

The study attempts to identify notable factors predicting poor outcome, death, and intracranial hemorrhage in patients with acute ischemic stroke undergoing mechanical thrombectomy with stent retriever. These data could be useful to improve the selection of patients for thrombectomy.

Methods

Patients with acute ischemic stroke treated with the Solitaire FR device were retrospectively analyzed from a prospectively collected database. We assessed the effect of selected demographic characteristics, clinical and imaging factors on poor outcome at 3 months (modified Rankin score 3–6), mortality at 3 months, and hemorrhage at day 1 (symptomatic and asymptomatic).

Results

From May 2010 to April 2012, 59 consecutive patients with an acute ischemic stroke underwent mechanical thrombectomy. At 3 months, 57.6 % of the patients were functionally independent (modified Rankin Scale 0–2) and mortality was 20.4 %. Multivariate analyses revealed that a thrombus length?>?14 mm (p?=?0.02; OR 7.55; 95 % CI 1.35–42.31) and longer endovascular procedure duration (p?=?0.01; OR 1.04; 95 % CI 1.01–1.07) were independently associated with poor outcome. A higher baseline Alberta Stroke Program Early CT (ASPECT) score (p?=?0.04; OR 0.79 per point; 95 % CI 0.63–0.99) and successful recanalization (p?=?0.02; OR 0.07; 95 % CI 0.01–0.72) were independent predictors of good functional outcome. Baseline ASPECT score (p?<?0.01; OR 0.65; 95 % CI 0.54–0.78) independently predicted symptomatic intracranial hemorrhage at day 1.

Conclusion

Absolute baseline ASPECT score reflects early symptomatic hemorrhage risk and functional outcome at 3 months. Thrombus length measured on MRI play an important role on functional outcome at 3 months after thrombectomy. Further analyses are needed to determine its importance in the selection of patients for mechanical thrombectomy.     

Expanding the treatment window with mechanical thrombectomy in acute ischemic stroke

Introduction Acute ischemic stroke is a common disease associated with high mortality and significant long-term disability. Treatment options for acute ischemic stroke continue to evolve and include pharmaceutical and mechanical therapies. With the recent US Food and Drug Administration approval of a new device for mechanical thrombectomy, the options available for treatment of acute ischemic stroke have been expanded. Thrombolytic therapy is generally given intravenously in the first 3 h and up to 6 h via the intraarterial route for pharmacological clot disruption. The maximum time-frame for mechanical thrombectomy devices has yet to be determined.Methods A 78-year-old female presented to the emergency room with a dense right hemiparesis, leftward gaze preference and dense global aphasia. Eight hours after symptom onset, left carotid angiography confirmed a left internal carotid artery terminus occlusion. A single pass was made through the clot with an X6 Merci Retriever device.Results After a single pass, the vessel was reopened and normal flow in the left internal carotid artery was demonstrated. At the time of discharge, her neurological deficits had improved significantly. Furthermore, the final infarct area, as demonstrated on magnetic resonance imaging, was probably much smaller than it would have been if the vessel had not been recanalized.Conclusion We report the use of a new mechanical thrombectomy device 8 h after onset of ischemic symptoms, with substantial subsequent improvement in neurological outcome. In selected cases, use of the Merci Retriever can result in improved outcomes beyond the traditional 6-hwindow used for intraarterial pharmacological thrombolysis.     

MRI预测急性脑梗死后出血的价值

目的探讨急性脑梗死患者MR早期增强T1WI中脑实质强化及大脑中动脉高信号（HMCA）征与继发性脑出血（HT）的关系。方法回顾性分析24例发病6．0h内[平均（4．3±1．4）h]的急性脑梗死患者首次T1WI及随后1周内复查的MRI和（或）CT资料，了解首次增强T1WI脑实质强化和HMCA征与HT的关系。早期脑实质强化为脑梗死6．0h内缺血的脑组织区域在增强T1WI出现高信号；HMCA征为增强T1WI上大脑中动脉增粗（与对侧相比）、出现边缘模糊的高信号。结果24例患者中10例发展为HT（出血组），其中6例首次T1WI可见脑实质强化，5例出现HMCA征；14例未出现HT（无出血组），均未发现脑实质强化和（或）HMCA征。2组相比，T1WI脑实质强化、HMCA征出现率差异均有统计学意义（P值均〈0．01）。结论T1WI早期脑实质强化和HMCA征有可能预测急性脑梗死后HT。     

MR imaging enhancement patterns as predictors of hemorrhagic transformation in acute ischemic stroke

BACKGROUND AND PURPOSE: Early parenchymal gadolinium enhancement on T1-weighted MR images is predictive of hemorrhagic transformation (HT) in rodent focal ischemia models, but its value in humans is unknown. We sought to investigate gadolinium enhancement in acute ischemic stroke patients to determine their association with subsequent HT. METHODS: We retrospectively examined 22 patients with ischemic stroke who underwent MR imaging within 4.9 hours (+/-1.4) of symptom onset. Patients receiving intravenous tissue plasminogen activator (tPA) (n = 6) were included. Twenty-one patients underwent repeat MR studies at 48 hours, 13 underwent additional MR imaging at 1 week, and one underwent follow-up head CT at 24 hours. Initial images were analyzed for enhancement patterns (vascular, meningeal, parenchymal). Follow-up T2- and T2*-weighted images were evaluated for hemorrhage. RESULTS: In all patients, initial MR images showed vascular enhancement in the vascular territory of the stroke lesion: 19 with vascular enhancement alone and three with vascular and parenchymal enhancement. All three patients with both enhancement patterns had HT: two large and symptomatic, and one asymptomatic (petechial hemorrhage). They received tPA before MR imaging. None of the patients without early parenchymal enhancement developed symptomatic hemorrhage. Six (32%) patients with vascular enhancement alone had petechial hemorrhage at follow-up imaging. In this limited sample, initial mean volumes on diffusion-weighted images, National Institute of Health Stroke Scale scores, and intervals from stroke onset to imaging did not differ between patients with vascular and parenchymal enhancement versus those with vascular enhancement alone. CONCLUSION: Early parenchymal enhancement of stroke lesions may be a good predictor of subsequent symptomatic HT may help identify patients at risk, especially after thrombolytic therapy.