CT灌注成像参数与前循环急性缺血性脑卒中静脉溶栓患者临床转归的相关性

Correlation between CTP parameters and clinical outcomes in patients with acute anterior circulation ischemic stroke after intravenous thrombolysis

摘要:

目的 分析CT灌注成像参数与前循环急性缺血性脑卒中静脉溶栓患者临床转归的相关性。方法 选取2019年10月—2021年10月于海南医学院第二附属医院接受静脉溶栓治疗并完成CT灌注成像检查及MIStar软件后处理的105例前循环急性缺血性脑卒中患者作为研究对象，根据发病后3个月时改良Rankin量表（mRS）评分分为转归良好组和转归不良组。收集所有患者临床资料，收集CT灌注成像参数包括灌注缺损（延迟时间> 3 s）体积、缺血核心（相对脑血流量< 30%）体积和缺血半暗带体积（灌注缺损体积-缺血核心体积）。采用多因素Logistic回归模型分析CT灌注成像参数与临床转归的相关性，采用受试者工作特征（ROC）曲线评价CT灌注成像参数对临床转归的预测价值。结果 105例前循环急性缺血性脑卒中患者mRS评分≤ 2分者63例，> 2分者42例。两组患者的性别构成、体重、高脂血症、房颤、溶栓前舒张压、糖化血红蛋白、白细胞计数、红细胞、中性粒细胞计数及缺血半暗带体积比较，差异无统计学意义（P >0.05），两组患者的年龄、吸烟、高血压、糖尿病、溶栓前收缩压、基线随机血糖、血红蛋白、入院至静脉溶栓时间（DNT）、发病至静脉溶栓时间（ONT）、灌注缺损体积、缺血核心体积、mRS评分及美国国立卫生研究院卒中量表（NIHSS）评分比较，差异有统计学意义（P <0.05）。溶栓前收缩压［O^R=3.992（95% CI：1.496，10.652）］是影响前循环急性缺血性脑卒中患者临床转归的危险因素（P <0.05）；NIHSS评分［O^R=0.840（95% CI：0.711，0.991）］和灌注缺损体积［O^R=1.081（95% CI：1.059，1.104）］是影响前循环急性缺血性脑卒中患者临床转归的保护因素（P <0.05）。溶栓前收缩压、NHISS评分和灌注缺损体积及三者联合预测患者临床转归的敏感性分别为76.25%（95% CI：0.633，1.395）、83.75%（95% CI：0.721，1.554）、85.00%（95% CI：0.778，1.656）、86.30%（95% CI：0.812，1.714），特异性分别为81.95%（95% CI：0.713，1.522）、89.66%（95% CI：0.811，1.700）、90.80%（95% CI：0.835，0.953）和92.00%（95% CI：0.854，1.775），以三者联合检测的特异性最高，其中三指标单独检测以灌注缺损体积的特异性最高。同时，ROC曲线分析显示，灌注缺损体积预测转归不良的曲线下面积为0.866（95% CI：0.803，0.928）；最佳截断值为109.37 mL。结论 溶栓前收缩压是影响前循环急性缺血性脑卒中患者临床转归不良的独立危险因素，NIHSS评分、灌注缺损体积是前循环急性急性脑卒中患者临床转归良好的保护因素，但缺血核心体积和缺血半暗带体积与患者临床转归无关。CT灌注成像参数灌注缺损体积评估前循环急性缺血性脑卒中患者静脉溶栓治疗后转归不良的价值较高。

Abstract:

Objective To analyze the correlation between ct perfusion imaging (CTP) parameters and clinical outcomes of patients with acute anterior circulation ischemic stroke after intravenous thrombolysis.Methods A total of 105 patients who received intravenous thrombolytic therapy in our hospital and completed CTP examination and post-processing with MIStar software from October 2019 to October 2021 were selected as the research subjects. They were divided into the good outcome group and the bad outcome group according to the modified Rankin scale score (mRS) 3 months after the onset. Clinical data of all patients were collected, and CTP parameters including perfusion defect (delay time > 3 s) volume, ischemic core (relative to cerebral blood flow < 30%) volume, and ischemic penumbra volume (perfusion defect volume–ischemic core volume) were collected. Multivariate logistic regression model was used to analyze the correlation between CTP parameters and clinical outcomes, and receiver operating characteristic curve (ROC) was used to evaluate the predictive value of CTP parameters for clinical outcomes.Results Among the 105 patients with acute anterior circulation ischemic stroke, 63 had mRS scores ≤ 2 points and 42 had MRS scores > 2 points. There was no significant difference in gender, weight, hyperlipidemia history, atrial fibrillation history, diastolic blood pressure before thrombolysis, glycosylated hemoglobin, white blood cell count, red blood cell and neutrophil count, hemoglobin and ischemic penumbra volume between the two groups (P > 0.05). The differences in age, smoking history, hypertension history, diabetes history, systolic blood pressure before thrombolysis, baseline blood glucose value, baseline mRS, baseline NIHSS, DNT, ONT, hemoglobin, perfusion defect volume and ischemic core volume between the two groups were statistically significant (P < 0.05). Systolic blood pressure before thrombolysis [O^R = 3.992 (95% CI: 1.496, 10.652)] was a risk factor for clinical outcome of patients with acute anterior circulation ischemic stroke (P < 0.05). Baseline NIHSS [O^R = 0.840 (95% CI: 0.711, 0.991) ] and perfusion defect volume [O^R = 1.081 (95% CI: 1.059, 1.104) ] were protective factors affecting clinical outcomes in patients with acute anterior circulation ischemic stroke (P < 0.05). The sensitivity and specificity of systolic blood pressure before thrombolysis, baseline NHISS and perfusion defect volume as well as the combination of the three in predicting the clinical outcome of patients were 76.25%/81.95%, 83.75%/89.66%, 85.00%/90.80% and 86.30%/92.00%, respectively, with the combination having the highest specificity, and the specificity of perfusion defect volume when the three indicators were tested separately was the highest. Meanwhile, ROC curve analysis showed that the area under the curve for poor prognosis prediction of perfusion defect volume was 0.866 (95% CI: 0.803, 0.928, all P < 0.05). The optimal cutoff is 109.37 mL.Conclusion Pre-thrombolytic systolic blood pressure was an independent risk factor for poor clinical outcome in patients with acute anterior circulation ischemic stroke, while baseline NIHSS and perfusion defect volume were protective factors for good clinical outcome in patients with acute anterior circulation ischemic stroke. However, ischemic core volume and ischemic penumbra volume were not associated with clinical outcome. CTP parameter perfusion defect volume has a high value in the evaluation of poor outcomes in patients with acute anterior circulation ischemic stroke after intravenous thrombolysis.