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浙江大学学报（医学版）
浙江大学学报（医学版）  2015, Vol. 44 Issue (6): 611-617    DOI: 10.3785/j.issn.1008-9292.2015.11.03
专题报道     
利用CT灌注评估大脑中动脉闭塞患者血栓长度并预测血管再通
陈清梦1, 许绿依2, 严慎强1, 张晓程1, 张圣1, 楼敏1
1. 浙江大学医学院附属第二医院神经内科, 浙江 杭州 310009;
2. 杭州市下城区中医院全科, 浙江 杭州 310004
Thrombus length evaluated by CT perfusion imaging and its value in prediction of recanalization after intravenous thrombolysis therapy
CHEN Qing-meng1, XU Lyu-yi2, YAN Shen-qiang1, ZHANG Xiao-cheng1, ZHANG Sheng1, LOU Min1
1. Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China;
2. Department of Geriatrics, Traditional Chinese Medicine Hospital of Xiacheng District, Hangzhou 310004, China
全文: PDF(895 KB)  
摘要: 

目的:本研究旨在利用CT灌注图像对大脑中动脉闭塞患者的血栓长度进行评估,并探讨其对静脉溶栓治疗后血管再通和神经功能结局的预测能力。方法:连续收集2009年6月至2015年5月期间在浙江大学医学院附属第二医院神经内科接受重组组织型纤溶酶原激活剂静脉溶栓治疗的急性缺血性卒中患者,纳入溶栓前行CT灌注检查提示急性大脑中动脉近端(M1)闭塞的患者,收集其临床及实验室检查资料;通过CT灌注动态血管图像测量血栓近端与远端,定义为血栓长度,利用动脉闭塞病灶(AOL)量表评估溶栓后血管再通情况,随访3个月改良Rankin评分。采用二元logistic回归分析患者血栓长度与静脉溶栓后大脑中动脉再通及3个月不良神经功能结局的相关性,并利用ROC曲线寻找血栓长度的最佳切点。结果:患者纳入分析56例,平均年龄(68.8±11.7)岁,男性、女性均28例(50.0%),发病至溶栓时间为(214.3±82.0) min,神经功能缺损评分中位数为13(四分位距为8~17)。静脉溶栓24 h后血管再通患者共42例(75%),血栓平均长度为(9.0±4.7) mm;血管未再通患者共14例(25%),血栓平均长度为(10.0±5.4) mm。二元logistic回归分析提示,血栓长度能独立预测静脉溶栓24 h后大脑中动脉再通(OR=0.869;95% CI:0.764~0.987;P=0.031),且血栓长度11.3 mm是提示静脉溶栓后血管未再通的最佳切点(AUC=0.697,敏感度71.4%,特异度76.2%)。同时,血栓长度亦是静脉溶栓后3个月不良神经功能结局的独立危险因素(OR=1.180;95%CI:1.023~1.362;P=0.023),且血栓长度9.9 mm是提示静脉溶栓后不良神经功能结局的最佳切点(AUC=0.689,敏感度64.7%,特异度71.4%)。结论:CT灌注可以额外获得大脑中动脉闭塞患者血栓长度的信息,并且该血栓长度能有效预测静脉溶栓24 h后血管再通及3个月神经功能结局。
关键词 ： 梗死,大脑中动脉/药物疗法,  卒中/药物疗法,  急性病,  脑缺血/药物疗法,  组织型纤溶酶原激活物/治疗应用,  血栓溶解疗法,  体层摄影术, X线计算机,  血栓形成    
Abstract：

Objective: To evaluate the thrombus length on CT perfusion imaging and to assess its predictive value for recanalization and clinical outcome after intravenous thrombolysis therapy (IVT). Methods: Fifty-six consecutive acute ischemic stroke patients with proximal middle cerebral artery (M1 segment) occlusion underwent CT perfusion imaging examination before IVT between June 2009 and May 2015. The onset-to needle time was (214.3±82.0) min, and the pretreatment NIHSS score of patients was 13 (IQR 8-17). The thrombus length was determined as the distance between the proximal and distal thrombus end delineated on dynamic angiography, which was reconstructed from CT perfusion source images. Recanalization was evaluated according to Arterial Occlusive Lesion (AOL) scale, and functional outcome was based on modified Rankin scale (mRS) 3 months after IVT. Logistic regression model was used to investigate the relationship between thrombus length and recanalization, and the optimal cut-off points were determined by receiver operating characteristic curve (ROC). Results: Among 56 patients, 42 (75%) achieved recanalization 24 h after IVT with mean thrombus length of (9.0±4.7) mm; and 14 (25%) patients remained occlusion with mean thrombus length of (10.0±5.4) mm. Logistic regression analysis demonstrated that thrombus length was an independent predictor for both recanalization (OR=0.869; 95%CI:0.764-0.987; P=0.031) and unfavorable outcome (OR=1.180;95%CI:1.023-1.362; P=0.023). Thrombus length of 11.3 mm was identified as the optimal cut-off value for recanalization (AUC=0.697, sensitivity 71.4%, specificity 76.2%), while thrombus length of 9.9 mm was the optimal cut-off value for unfavorable functional outcome (AUC=0.689, sensitivity 64.7%, specificity 71.4%). Conclusion: The thrombus length evaluated on CT perfusion imaging is an effective predictor for recanalization and unfavorable outcome after IVT in acute ischemic stroke patients with middle cerebral artery occlusion.
Key words： Infarction, middle cerebral artery/drug therapy    Stroke/drug therapy    Acute disease    Brain ischemia/drug therapy    Tissue plasminogen activator/therapeutic use    Thrombolytic therapy    Tomography, X-ray computed    Thrombosis
出版日期: 2015-12-12
CLC:  R743  
基金资助:

浙江省重大科技专项计划(2013C03043-3);国家自然科学基金(81171095,81471170)
通讯作者: 楼敏(1976-),女,博士,教授,主任医师,博士生导师,从事神经病学研究;E-mail:loumingxc@vip.sina.com;http://orcid.org/0000-0002-6627-064X     E-mail: loumingxc@vip.sina.com
作者简介: 陈清梦(1992-),女,硕士研究生,从事神经病学研究,E-mail:sakumotoiris@icloud.com;http://orcid.org/0000-0002-5702-0331;许绿依(1974-),女,学士,主治医师,从事老年医学研究;E-mail:23144732@qq.com;http://orcid.org/0000-0002-3197-2887
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引用本文:

陈清梦等. 利用CT灌注评估大脑中动脉闭塞患者血栓长度并预测血管再通[J]. 浙江大学学报（医学版）, 2015, 44(6): 611-617.
CHEN Qing-meng, XU Lyu-yi, YAN Shen-qiang, ZHANG Xiao-cheng, ZHANG Sheng, LOU Min. Thrombus length evaluated by CT perfusion imaging and its value in prediction of recanalization after intravenous thrombolysis therapy. Journal of ZheJiang University(Medical Science), 2015, 44(6): 611-617.

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http://www.zjujournals.com/xueshu/med/CN/10.3785/j.issn.1008-9292.2015.11.03      或      http://www.zjujournals.com/xueshu/med/CN/Y2015/V44/I6/611

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