CT灌注成像结合Rapid软件评估急性前循环大血管闭塞卒中血管内治疗预后的价值.pdf

Neural InjuryAnd Functional Reconstruction,September 2023,Vol.18,No.9论著CT灌注成像结合Rapid软件评估急性前循环大血管闭塞卒中血管内治疗预后的价值李青青1，赵彦新2，赵芳卓2，朱天瑞2，刘爽2作者单位1.潍坊医学院山东 潍坊 2610422.济南市中心医院神经内科济南 250000收稿日期2023-01-09通讯作者刘爽摘要 目的：探讨CT灌注成像（CT perfusion，CTP）结合Rapid自动分析软件参数对前循环大血管近端闭塞（anterior circulation large vessel occlusion，ac-LVO）急性缺血性卒中（acute ischemic stroke，AIS）血管内治疗（endovascular treatment，EVT）患者预后的评估和预测因素分析。方法：回顾性分析ac-LVO AIS并行 EVT合并或不合并静脉溶栓治疗的患者，收集基线特征，及CTP成像后Rapid软件进行图像后处理得到的参数：包括脑血流量 30%的体积（VCBF30%），脑血流达峰时间4 s（VTmax4 s）、脑血流达峰时间6 s（VTmax6 s）、脑血流达峰时间8 s（VTmax8 s）、脑血流达峰时间10 s（VTmax10 s）的低灌注区体积，低灌注强度比值（hypoperfusionintensity ratio，HIR）、错配体积（mismatch Volume，MMV）、错配率（mismatch ratio，MMR）、CBV指数，及Al-berta卒中项目早期CT评分（Alberta stroke programme early CT score，ASPECTS）等，将患者术后90 d的随访情况按照改良Rankin量表（modified Rankin scale，mRS）评分进行分组，mRS 02分为预后良好组，mRS 36分为预后不良组。比较2组患者临床资料及CTP参数的差异。采用多因素Logistic回归分析来探讨与预后相关的独立预测因素，并采用受试者工作特征（ROC）曲线评价各预测因素对应的最佳阈值及其各自预测能力。结果：纳入患者158例，其中预后良好组 62 例，预后不良组 96 例。多因素Logistic回归分析显示，VCBF30%（OR=1.014，95%CI1.0011.026，P=0.028）、HIR（OR=8.655，95%CI1.80041.620，P=0.007）、入院时收缩压（OR=1.039，95%CI1.0171.062，P=0.001）、入院时 NIHSS（OR=1.125，95%CI1.0381.219，P=0.004）是ac-LVO卒中患者EVT后90 d预后的独立影响因素。ROC分析显示，HIR、VCBF30%、入院时收缩压、入院时NI-HSS评分的曲线下面积分别为0.738、0.704、0.658、0.600，预测不良预后的最佳截断值分别为：HIR0.355，VCBF30%25.5 mL，入院时收缩压151.5 mmHg，入院时NIHSS评分17分。结论：HIR、VCBF30%、入院时收缩压、入院时NIHSS评分为ac-LVO AIS患者EVT 90 d预后的独立影响因素（P0.05）。HIR、VCBF30%对于ac-LVOAIS患者EVT预后的预测能力优于NIHSS评分、入院时收缩压。关键词急性缺血性脑卒中；前循环；大血管闭塞；血管内治疗；计算机断层扫描灌注成像；预后中图分类号 R741；R743.3 文献标识码ADOI10.16780/ki.sjssgncj.20230037本文引用格式：李青青,赵彦新,赵芳卓,朱天瑞,刘爽.CT灌注成像结合Rapid软件评估急性前循环大血管闭塞卒中血管内治疗预后的价值J.神经损伤与功能重建,2023,18(9):508-513.Value of CT Perfusion Imaging Combined with Rapid Software in Assessing the Prognosis ofEndovascular Therapy of Large-vessel Occlusion in Acute Anterior CirculationLI Qingqing1,ZHAO Yanxin2,ZHAO Fangzhuo2,ZHU Tianrui2,LIU Shuang2.1.Weifang Medical College,Shandong 261042,China.2.Department of Neurology,Jinan Central Hospital,Jinan 250000,ChinaAbstract Objective:To explore prognostic and predictive values of CT perfusion imaging(CTP)combinedwith Rapid automatic analysis software parameters in patients suffering from acute ischemic stroke(AIS)withanterior circulation proximal large vessel occlusion(ac-LVO)and undertaking endovascular therapy(EVT).Methods:A retrospective analysis of AIS patients with ac-LVO underwent EVT with or without intravenousthrombolytic therapy was performed.The data used for analysis were baseline characteristics and the CTPparameters post-processed by Rapid software,including the volume of cerebral blood flow30%(VCBF4 s,6 s,8 s,10 s(VTmax4 s,VTmax6 s,VTmax8 s,VTmax10 s),hypoperfusion intensity ratio(HIR),mismatch volume(MMV),mismatch ratio(MMR),CBV index and Albertastroke program early CT score(ASPECTS score).According to the modified Rankin scale(mRS),the data of90-day follow-up was classified as good prognosis group with mRS of 02 and poor prognosis group with themRS of 36.The differences in clinical data and CTP analysis parameters between the two groups wereanalyzed.Multivariate logistic regression was used to analyze the relevant independent predictors,thecorresponding optimal thresholds of each predictor and their prediction capabilities by using the receiveroperating characteristic(ROC)curve.Results:There were 158 patients enrolled,including 62 in the goodprognosis group and 96 in the poor prognosis group.Multivariate Logistic regression analysis showed that VCBF30%(OR=1.014,95%CI1.0001.028,P=0.028),HIR(OR=8.655,95%CI1.80041.620,P=0.007),systolic bloodpressure(SBP)at admission(OR=1.039,95%CI1.0151.064,P=0.001)and NIHSS at admission(OR=1.125,95%CI1.0381.219,P=0.004)were independent predictors of prognosis.The analysis of ROC showed that the508神经损伤与功能重建2023年9月第18卷第9期area under the ROC curve of HIR,VCBF30%,systolic blood pressure at admission and NIHSS score at admission were 0.738,0.704,0.658and 0.600,respectively,and that the best cut-off values for predicting adverse prognosis were HIR 0.355,VCBF30%25.5 mL,SBP 151.5 mmHg on admission,and NIHSSs score17 on admission.Conclusion:HIR,VCBF30%,SBP at admission and NIHSS score atadmission were independent factors influencing patients with ac-LVO during the follow-up for 90 days.HIR,and VCBF4 s/mL,M(P25,P75)196(144,305.75)226(150.25,330)0.8550.393VTmax6 s/mL,M(P25,P75)97.5(56.75,151.25)146.5(74.25,188.25)2.4080.016组别预后良好组预后不良组Z值P值VTmax10 s/mL,M(P25,P75)26(0,72.25)80(40,121)4.4360.001HIR/M(P25,P75)0.26(0,0.55)0.59(0.42,0.73)5.0620.001CBV指数/M(P25,P75)0.8(0.7,1.0)0.7(0.5,0.9)1.9960.049MMV/mL,M(P25,P75)100(55.5,147.25)103(46,148)0.2240.822MMR/M(P25,P75)6.92(2.95,12.33)3.23(2.01,5.26)3.2890.001表2 预后良好组与预后不良组Rapid软件分析参数的比较VCBF30%HIR入院时收缩压入院时NIHSSB0.0142.1580.0390.118SE0.0060.8010.0110.041walds4.8057.25411.7598.239P值0.0280.0070.0010.004OR值1.0148.6551.0391.12595%CI1.0011.0261.80041.6201.0171.0621.0381.219表3 影响患者EVT后90 d预后的多因素Logistic回归分析VCBF30%HIR收缩压NIHSSAUC0.7040.7380.6580.60095%CI0.6240.7840.6560.8210.5730.7430.5100.689SE0.0410.0420.0430.046P值0.0010.0010.0010.035分界值25.50.355151.516.5敏感度0.6670.8130.510.385特异性0.7260.6290.7420.758约登指数0.3930.4420.2520.143表4 独立预测因素的ROC曲线分析511Neural InjuryAnd Functional Reconstruction,September 2023,Vol.18,No.9VCBF30%每增加 10 mL，预后良好率就会降低 20%30%。并且有研究报道，基线VCBF30%越大，则患者预后越差，当初始核心梗死体积超过一定体积时，可能导致术后症状性脑出血的几率增加，从而促进不良预后的发生20,21。目前针对VCBF30%对EVT后LVO-AIS患者预后影响的研究较少，进一步探索VCBF30%与预后的相关性对临床治疗有指导意义。本研究结果表明，入院时收缩压也能在一定程度上评估患者的90 d预后情况，ROC分析得到的AUC为0.658，最佳截断值为151.5 mmHg，即患者入院时收缩压151.5 mmHg时，行EVT患者的90 d预后可能不佳。研究发现，在接受EVT的LVO-AIS患者中，较高的入院收缩压会导致最终梗死体积增加并且可能降低3月的良好预后率22。国外的一项回顾性研究报道，收缩压150 mmHg 与 90 d 不良功能结局（OR=1.09，95%CI1.041.15）相关23。近期首都医科大学宣武医院的一项单中心回顾性研究与本研究结果相似，其ROC分析结果示入院时收缩压的AUC为0.611（95%CI0.5520.669，P0.05），最佳截断值为149.5 mmHg24。入院时收缩压与EVT预后相关的可能原因在于，AIS发作后24 h内较高的血压会增加AIS后快速脑水肿可能25，而早期脑水肿可能会增加残余血流通过血管的阻力，导致卒中的进展；另一方面，入院时收缩压的升高可能是由于闭塞动脉中血栓负荷较大所致，而较大的血栓负荷可能导致不良临床结果的发生26。本研究结果中，入院时收缩压对预后的预测性能有限，可能由于：对于入院前已服用降压药物的患者，其入院时测得的血压可能已失去价值；未连续跟踪记录入院时的血压以及EVT前和EVT期间的血压，因此无法评估此期间血压波动对预后的影响；未评估血栓负荷大小和血压之间的相关性以及它们对预后的影响。目前并无研究结果表明入院时收缩压与行EVT患者的预后之间存在明确相关机制，仍然需要大量多中心前瞻性随机对照试验进行验证。本研究表明，初始NIHSS评分17分时，患者预后不良的可能性更大。已有多项研究21,27-30得出相似结论，较高的入院NIHSS评分与不良预后相关。Cheng等31的研究认为较高NIHSS评分子项意识评分相比于整个NIHSS评分及其他分项对预后的预测能力更好。作者认为此原因可能在于NIHSS意识评分越高，意识障碍越严重，关键大脑实质区域的缺血越严重，导致预后更差。根据2019年美国急性缺血性卒中早期管理指南，NIHSS被推荐用于评估卒中严重程度和行EVT的筛选标准32。但是本研究中ROC分析得到NIHSS评分的AUC为0.600，对预后的预测能力一般，分析可能的原因有：本研究中纳入患者的NIHSS评分范围较大，有研究表明，当NIHSS10分时，患者从EVT中的获益较小30；NIHSS评分子项-意识评分相比于整个NIHSS评分对患者预后的预测能力更好31，本研究未进行单独研究；卒中门诊仅一名专科医师对患者进行接诊救治，在紧急情况下不能排除医师临床经验的不同对患者NIHSS评分存在主观性判断而导致评分结果有一定的偏差。本研究的局限性如下：本研究为单中心回顾性研究，数据容易受到回顾性收集及抽样的偏差，并且结果不具有普遍的推广性，未来需要进行多中心的前瞻性随机对照试验进一步证明结论；本研究未对患者EVT后的不良事件进行分析，从而进一步分析患者预后的影响因素；本研究排除了图像不清楚和图像中质量不合格的患者，造成一定的选择偏倚；本研究纳入患者的基线核心梗死范围较大，可对不同梗死体积患者进一步进行亚组分析，排除或减少其他混杂因素的影响。综上所述，LVO-AIS患者在EVT前进行CT灌注成像，并通过Rapid软件自动分析灌注图像得到的参数HIR和VCBF30%是影响患者90 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