|
|
|
| Maximal infarct volume to benefit from intravenous thrombolysis and its relation with onset to treatment time |
| ZHANG Meixia, ZHOU Ying, ZHANG Ruiting, ZHANG Sheng, LOU Min |
| Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China |
|
|
|
Abstract Objective:To investigate the relationship between maximal infarct volume to benefit from intravenous thrombolysis (IVT) and onset to needle time (ONT). Methods:The clinical and image data of acute ischemic stroke patients who received IVT in the second Affiliated Hospital, Zhejiang University School of Medicine during May 2009 to June 2016 were retrospectively reviewed. Patients were classified into within-time-window group (ONT ≤ 4.5 h) and beyond-time-window group (ONT>4.5 h). Good and poor outcome were defined as modified Rankin scale (mRS) ≤ 2 or >2 at 3 months, respectively. The maximal infarct volume was analyzed by receiver operating characteristic (ROC) curve. Results:Among 587 patients (465 cases were within-time-window, 122 cases were beyond-time-window), baseline core volume was 15(2-46)mL,and 324 (55.2%) patients achieved good outcome. Compared with the good-outcome group, the baseline core volume was larger in the poor-outcome group (32 mL vs 5 mL,Z=-9.766,P<0.01). After adjusting age, ONT, baseline National Institutes of Health Stroke Scale (NIHSS) and atrial fibrillation, baseline infarct core volume independently predicted poor outcome (OR=1.014, 95% CI:1.008-1.020, P<0.01). The ROC curve analysis showed that the maximal infarct core volume for achieving good outcome in the within-time-window group and beyond-time-window group were 152 mL and 71mL, respectively. The maximal infarct volume to benefit from IVT diminished with the increasing delayed ONT of every 30 min (ρ=-0.691, P<0.05). Conclusion:The maximal infarct volume to benefit from thrombolysis is larger in patients treated within time window than those beyond the time window, and that volume diminishes with ONT delay.
|
|
Received: 10 February 2017
Published: 25 August 2017
|
|
|
静脉溶栓获益的最大梗死体积阈值与急性缺血性卒中患者发病时间的关系
目的：探究静脉溶栓治疗获益的最大梗死体积阈值及其与急性缺血性卒中患者发病时间的关系。方法：回顾性分析2009年5月至2016年6月发病9 h内在浙江大学医学院附属第二医院接受静脉溶栓治疗的急性缺血性卒中患者的临床及影像学资料。按起病至静脉溶栓时间（ONT）将患者分成时间窗内组（ONT ≤ 4.5 h）和超时间窗组（ONT>4.5 h），三个月临床预后采用改良Rankin评分（mRS）评估，mRS ≤ 2定义为预后良好，mRS>2定义为预后不良。利用受试者工作特征（ROC）曲线计算静脉溶栓治疗获益的最大梗死体积阈值。结果：共纳入587例急性缺血性卒中患者，时间窗内465例，超时间窗122例。相对于临床预后良好者，临床预后不良者基线梗死体积较大（Z=-9.766，P<0.01）。校正年龄、ONT、基线美国国立卫生研究院卒中量表（NIHSS）评分、心房颤动后，较大基线梗死体积是预后不良的独立影响因素（OR=1.014，95%CI：1.008~1.020，P<0.01）。根据ROC曲线，时间窗内患者和超时间窗患者静脉溶栓获益的最大梗死体积阈值分别为152 mL（曲线下面积为0.733，95%CI：0.686~0.779，P<0.01）和71 mL（曲线下面积为0.732，95%CI：0.644~0.820，P<0.01）。随着ONT延长，梗死体积阈值减小（ρ=-0.691，P<0.05）。结论：相对于超时间窗的缺血性卒中患者，时间窗内的患者从静脉溶栓中获益的梗死体积阈值更高，其阈值随时间延长而减小。
关键词：
急性病,
脑缺血/治疗,
卒中/治疗,
血栓溶解疗法/方法,
侧支循环,
预后,
治疗结果
|
|
| [1] SAVER J L. Time is brain-quantified[J]. Stroke,2006,37(1):263-266.
[2] LUBY M, WARACH S J, NADAREISHVILI Z, et al. Immediate changes in stroke lesion volumes post thrombolysis predict clinical outcome[J]. Stroke,2014,45(11):3275-3279.
[3] PICANCO M R, CHRISTENSEN S, CAMPBELL B C, et al. Reperfusion after 4.5 hours reduces infarct growth and improves clinical outcomes[J]. Int J Stroke,2014,9(3):266-269.
[4] CHO K H, KWON S U, LEE D H, et al. Early infarct growth predicts long-term clinical outcome after thrombolysis[J]. J Neurol Sci,2012,316(1-2):99-103.
[5] LEES K R, BLUHMKI E, VON KUMMER R, et al. Time to treatment with intravenous alteplase and outcome in stroke:an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials[J]. Lancet,2010,375(9727):1695-1703.
[6] NEUMANN-HAEFELIN T, WITTSACK H J, WENSERSKI F, et al. Diffusion-and perfusion-weighted MRI. The DWI/PWI mismatch region in acute stroke[J]. Stroke,1999,30(8):1591-1597.
[7] SCHAEFER P W, PULLI B, COPEN W A, et al. Combining MRI with NIHSS thresholds to predict outcome in acute ischemic stroke:value for patient selection[J]. AJNR Am J Neuroradiol,2015,36(2):259-264.
[8] YOO A J, BARAK E R, COPEN W A, et al. Combining acute diffusion-weighted imaging and mean transmit time lesion volumes with National Institutes of Health Stroke Scale Score improves the prediction of acute stroke outcome[J]. Stroke,2010,41(8):1728-1735.
[9] 中华医学会神经病学分会脑血管病学组急性缺血性脑卒中诊治指南撰写组.中国急性缺血性脑卒中诊治指南2014[J].中华神经科杂志,2014,48(4):246-257. Cerebrovascular Disease Study Group, Chinese Medical Association Branch of Neurology. Chinese guidelines for acute ischemic stroke treatment 2014[J]. Chinese Journal of Neurology,2014,48(4):246-257. (in Chinese)
[10] JAUCH E C, SAVER J L, ADAMS H P JR, et al. Guidelines for the early management of patients with acute ischemic stroke:a guideline for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke,2013,44(3):870-947.
[11] DEL ZOPPO G J, SAVER J L, JAUCH E C, et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator:a science advisory from the American Heart Association/American Stroke Association[J]. Stroke,2009,40(8):2945-2948.
[12] VOGT G, LAAGE R, SHUAIB A, et al. Initial lesion volume is an independent predictor of clinical stroke outcome at day 90:an analysis of the Virtual International Stroke Trials Archive (VISTA) database[J]. Stroke,2012,43(5):1266-1272.
[13] PARSONS M W, CHRISTENSEN S, MCELDUFF P, et al. Pretreatment diffusion-and perfusion-MR lesion volumes have a crucial influence on clinical response to stroke thrombolysis[J]. J Cereb Blood Flow Metab,2010,30(6):1214-1225.
[14] WIJDICKS E F, SHETH K N, CARTER B S, et al. Recommendations for the management of cerebral and cerebellar infarction with swelling:a statement for healthcare professionals from the American Heart Association/American Stroke Association[J]. Stroke,2014,45(4):1222-1238.
[15] HACKE W, SCHWAB S, HORN M, et al. ‘Malignant’ middle cerebral artery territory infarction:clinical course and prognostic signs[J]. Arch Neurol,1996,53(4):309-315.
[16] MINNERUP J, WERSCHING H, RINGELSTEIN E B, et al. Prediction of malignant middle cerebral artery infarction using computed tomography-based intracranial volume reserve measurements[J]. Stroke,2011,42(12):3403-3409.
[17] MA H, PARSONS M W, CHRISTENSEN S, et al. A multicentre, randomized, double-blinded, placebo-controlled Phase Ⅲ study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits (EXTEND)[J]. Int J Stroke,2012,7(1):74-80.
[18] THOMALLA G, FIEBACH J B, ØSTERGAARD L, et al. A multicenter, randomized, double-blind, placebo-controlled trial to test efficacy and safety of magnetic resonance imaging-based thrombolysis in wake-up stroke (WAKE-UP)[J]. Int J Stroke,2014,9(6):829-836. |
|
Viewed |
|
|
|
Full text
|
|
|
|
|
Abstract
|
|
|
|
|
Cited |
|
|
|
|
| |
Shared |
|
|
|
|
| |
Discussed |
|
|
|
|
