Objective : Early progressive infarction (EPI) is frequently observed and related to poor functional outcome in patients with middle cerebral artery (MCA) infarction caused by MCA occlusion. We evaluated the perfusion parameters of magnetic resonance imaging (MRI) as a predictor of EPI. Methods : We...
Objective : Early progressive infarction (EPI) is frequently observed and related to poor functional outcome in patients with middle cerebral artery (MCA) infarction caused by MCA occlusion. We evaluated the perfusion parameters of magnetic resonance imaging (MRI) as a predictor of EPI. Methods : We retrospectively analyzed patients with acute MCA territory infarction caused by MCA occlusion. EPI was defined as a National Institutes of Health Stroke Scale increment ${\geq}2$ points during 24 hours despite receiving standard treatment. Regional parameter ratios, such as cerebral blood flow and volume (rCBV) ratio (ipsilateral value/contralateral value) on perfusion MRI were analyzed to investigate the association with EPI. Results : Sixty-four patients were enrolled in total. EPI was present in 18 (28%) subjects and all EPI occurred within 3 days after hospitalization. Diabetes mellitus, rCBV ratio and regional time to peak (rTTP) ratio showed statically significant differences in both groups. Multi-variate analysis indicated that history of diabetes mellitus [odds ratio (OR), 6.13; 95% confidence interval (CI), 1.55-24.24] and a low rCBV ratio (rCBV, <0.85; OR, 6.57; 95% CI, 1.4-30.27) was significantly correlated with EPI. Conclusion : The incidence of EPI is considerable in patients with acute MCA territory infarction caused by MCA occlusion. We suggest that rCBV ratio is a useful neuro-imaging parameter to predict EPI.
Objective : Early progressive infarction (EPI) is frequently observed and related to poor functional outcome in patients with middle cerebral artery (MCA) infarction caused by MCA occlusion. We evaluated the perfusion parameters of magnetic resonance imaging (MRI) as a predictor of EPI. Methods : We retrospectively analyzed patients with acute MCA territory infarction caused by MCA occlusion. EPI was defined as a National Institutes of Health Stroke Scale increment ${\geq}2$ points during 24 hours despite receiving standard treatment. Regional parameter ratios, such as cerebral blood flow and volume (rCBV) ratio (ipsilateral value/contralateral value) on perfusion MRI were analyzed to investigate the association with EPI. Results : Sixty-four patients were enrolled in total. EPI was present in 18 (28%) subjects and all EPI occurred within 3 days after hospitalization. Diabetes mellitus, rCBV ratio and regional time to peak (rTTP) ratio showed statically significant differences in both groups. Multi-variate analysis indicated that history of diabetes mellitus [odds ratio (OR), 6.13; 95% confidence interval (CI), 1.55-24.24] and a low rCBV ratio (rCBV, <0.85; OR, 6.57; 95% CI, 1.4-30.27) was significantly correlated with EPI. Conclusion : The incidence of EPI is considerable in patients with acute MCA territory infarction caused by MCA occlusion. We suggest that rCBV ratio is a useful neuro-imaging parameter to predict EPI.
* AI 자동 식별 결과로 적합하지 않은 문장이 있을 수 있으니, 이용에 유의하시기 바랍니다.
가설 설정
D : Fourteen hours after hospitalization, neurologic deterioration had occurred and follow-up MR image revealed extended infarction. E : We performed urgent superficial-middle cerebral artery bypass surgery and brain CT angiogram revealed transcranial passage of STA parietal branch (yellow arrow). F : Patients improved gradually and finally, the presence of neurological deficit was assessed using modified Rankin scale 2, three months later.
제안 방법
However, there are few report on the relationship between EPI and this perfusion MRI parameter in patients with occluded MCA ischemic stroke who have missed the therapeutic window for intravenous tissue plasminogen activator (t-PA) or intra-arterial thrombolysis. Therefore, in this study, we evaluated useful MRI perfusion parameters to identify the useful predictor of EPI in patients with mild neurologic symptoms but who subsequently developed an acute, large cerebral artery occlusion within a few days of admission.
CBF was obtained using the formula : CBF=CBV/ MTT. A TTP map was generated by calculating the difference of the arrival time of the contrast material, and the timing of the maximum contrast agent concentration following its injection. The regions of interest (ROI) were placed in the affected MCA distribution at the supraganglionic level.
Secondly, this study included a small number of patients at a single institution, the validity of our results cannot be absolutely confirmed. Nevertheless, the results of this study could raise the clinical attention to predict EPI using perfusion MRI. A multicenter study including multimodal radiologic imaging with a larger sample size is required to confirm our results.
Categorical variables were compared using the chi-squared test or Fisher’s exact probability test and the medians were compared using the Student’s t-test or the Wilcoxon rank sum test. Logistic regression was used to compute unadjusted and multivariable-adjusted odds ratios (OR) for the dichotomous outcomes of the EPI or non-EPI groups. ORs are presented with the 95% confidence intervals (CI).
대상 데이터
1. A 68 year-old female patient visited the emergency room, 8 hours after symptom onset. Initial NIHSS was 5.
데이터처리
Categorical variables were compared using the chi-squared test or Fisher’s exact probability test and the medians were compared using the Student’s t-test or the Wilcoxon rank sum test.
성능/효과
Furthermore, NIHSS scores at admission were not statistically significant (Table 1). With regard to radiological findings at the time of admission, occlusion of both MCA and ICA were more frequently observed in the EPI group compared to the non-EPI group, but the difference between the groups was not statistically significant (34% vs. 27%, p=0.154). The rCBF and rMTT ratio were lower in the EPI group but the difference was not statistically significant (rCBF : 0.
154). The rCBF and rMTT ratio were lower in the EPI group but the difference was not statistically significant (rCBF : 0.89 vs. 0.73, p=0.069 and rMTT : 1.32 vs. 1.22, p=0.075). In contrast, the EPI group displayed significantly decreasing rCBV and an increasing rTTP ratio (rCBV : 1.
From the multivariate analysis, two parameters were identified as valuable predictive factors for EPI : DM (OR, 6.1; 95% CI, 1.55–24.2; p=0.01) and rCBV <0.85 (OR, 6.6; 95% CI, 1.4–30.3; p=0.016) (Table 3).
Our study proved that the rCBV ratio assessed by perfusion MRI can be used to predict EPI in patients with acute ischemic stroke combined with MCA occlusion. It may useful for early prediction of EPI development as well as the ability to select patients in need of urgent EC-IC bypass surgery, such as STA-MCA.
In this series, TTP is also associated with EPI but this was not statistically significant (rTTP >0.15; OR, 1.96; 95% CI, 0.9–311.5; p=0.74).
참고문헌 (34)
1 Alawneh JA Moustafa RR Baron JC Hemodynamic factors and perfusion abnormalities in early neurological deterioration Stroke 2009 40 e443 e450 19390076
2 Birschel P Ellul J Barer D Progressing stroke : towards an internationally agreed definition Cerebrovasc Dis 2004 17 242 252 14718754
3 Campbell BC Christensen S Levi CR Desmond PM Donnan GA Davis SM Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core Stroke 2011 42 3435 3440 21980202
6 Desilles JP Meseguer E Labreuche J Lapergue B Sirimarco G Gonzalez-Valcarcel J Diabetes mellitus, admission glucose, and outcomes after stroke thrombolysis : a registry and systematic review Stroke 2013 44 1915 1923 23704108
8 Hjalmarsson C Manhem K Bokemark L Andersson B The role of prestroke glycemic control on severity and outcome of acute ischemic stroke Stroke Res Treat 2014 2014 694569 25295219
9 Horiuchi T Nitta J Ishizaka S Kanaya K Yanagawa T Hongo K Emergency EC-IC bypass for symptomatic atherosclerotic ischemic stroke Neurosurg Rev 2013 36 559 564 discussion 564-565 23821132
10 Hou Q Zuo Z Michel P Zhang Y Eskandari A Man F Influence of chronic hyperglycemia on cerebral microvascular remodeling : an in vivo study using perfusion computed tomography in acute ischemic stroke patients Stroke 2013 44 3557 3560 24029632
11 Jia Q Zhao X Wang C Wang Y Yan Y Li H Diabetes and poor outcomes within 6 months after acute ischemic stroke : the China National Stroke Registry Stroke 2011 42 2758 2762 21852614
12 Jørgensen HS Nakayama H Raaschou HO Olsen TS Effect of blood pressure and diabetes on stroke in progression Lancet 1994 344 156 159 7912765
13 Kawai N Keep RF Betz AL Hyperglycemia and the vascular effects of cerebral ischemia Acta Neurochir Suppl 1997 70 27 29 9416268
14 Khatri R Rodriguez GJ Suri MF Vazquez G Ezzeddine MA Lepto meningeal collateral response and computed tomographic perfusion mismatch in acute middle cerebral artery occlusion J Vasc Interv Neurol 2011 4 1 4 22518259
15 Kimura K Sakamoto Y Iguchi Y Shibazaki K Aoki J Sakai K Admission hyperglycemia and serial infarct volume after t-PA therapy in patients with and without early recanalization J Neurol Sci 2011 307 55 59 21624623
16 Kluytmans M van Everdingen KJ Kappelle LJ Ramos LM Viergever MA van der Prognostic value of perfusion- and diffusion-weighted MR imaging in first 3 days of stroke Eur Radiol 2000 10 1434 1441 10997432
17 Kwan J Hand P Early neurological deterioration in acute stroke : clinical characteristics and impact on outcome QJM 006 99 625 633 16905751
18 Lee SB Huh PW Kim DS Yoo DS Lee TG Cho KS Early superficial temporal artery to middle cerebral artery bypass in acute ischemic stroke Clin Neurol Neurosurg 2013 115 1238 1244 23266265
19 Lee SY Cha JK Kang MJ Regional cerebral blood volume ratio on perfusion MRI on the growth of infarct size in acute ischemic stroke Eur Neurol 2009 62 281 286 19690421
21 Liu Y Karonen JO Vanninen RL Nuutinen J Koskela A Soimakallio S Acute ischemic stroke : predictive value of 2D phase-contrast MR angiography--serial study with combined diffusion and perfusion MR imaging Radiology 2004 231 517 527 15044743
22 Neumann-Haefelin T Wittsack HJ Fink GR Wenserski F Li TQ Seitz RJ Diffusion- and perfusion-weighted MRI : influence of severe carotid artery stenosis on the DWI/PWI mismatch in acute stroke Stroke 2000 31 1311 1317 10835450
23 Nussbaum ES Janjua TM Defillo A Lowary JL Nussbaum LA Emergency extracranial-intracranial bypass surgery for acute ischemic stroke J Neurosurg 2010 112 666 673 19499983
24 Reeves MJ Vaidya RS Fonarow GC Liang L Smith EE Matulonis R Quality of care and outcomes in patients with diabetes hospitalized with ischemic stroke : findings from Get With the Guidelines-Stroke Stroke 2010 41 e409 e417 20224058
25 Schaefer PW Hunter GJ He J Hamberg LM Sorensen AG Schwamm LH Predicting cerebral ischemic infarct volume with diffusion and perfusion MR imaging AJNR Am J Neuroradiol 2002 23 1785 1794 12427640
26 Schaefer PW Souza L Kamalian S Hirsch JA Yoo AJ Kamalian S Limited reliability of computed tomographic perfusion acute infarct volume measurements compared with diffusion-weighted imaging in anterior circulation stroke Stroke 2015 46 419 424 25550366
27 Seners P Turc G Oppenheim C Baron JC Incidence, causes and predictors of neurological deterioration occurring within 24 h following acute ischaemic stroke : a systematic review with pathophysiological implications J Neurol Neurosurg Psychiatry 2015 86 87 94 24970907
28 Shimoyama T Shibazaki K Kimura K Uemura J Shiromoto T Watanabe M Admission hyperglycemia causes infarct volume expansion in patients with ICA or MCA occlusion : association of collateral grade on conventional angiography Eur J Neurol 2013 20 109 116 22747888
29 Srinivasan A Goyal M Al Azri F Lum C State-of-the-art imaging of acute stroke Radiographics 2006 26 Suppl 1 S75 S95 17050521
30 Toni D Fiorelli M Gentile M Bastianello S Sacchetti ML Argentino C Progressing neurological deficit secondary to acute ischemic stroke. A study on predictability, pathogenesis, and prognosis Arch Neurol 1995 52 670 675 7619022
31 Toyoda K Fujimoto S Kamouchi M Iida M Okada Y Acute blood pressure levels and neurological deterioration in different subtypes of ischemic stroke Stroke 2009 40 2585 2588 19407233
32 Vaidyula VR Rao AK Mozzoli M Homko C Cheung P Boden G Effects of hyperglycemia and hyperinsulinemia on circulating tissue factor procoagulant activity and platelet CD40 ligand Diabetes 2006 55 202 208 16380494
33 Wahlgren N Ahmed N Dávalos A Ford GA Grond M Hacke W Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) : an observational study Lancet 2007 369 275 282 17258667
34 Yamada K Wu O Gonzalez RG Bakker D Østergaard L Copen WA Magnetic resonance perfusion-weighted imaging of acute cerebral infarction : effect of the calculation methods and underlying vasculopathy Stroke 2002 33 87 94 11779894
※ AI-Helper는 부적절한 답변을 할 수 있습니다.