DEFUSE3研究中中风发作后24小时内持续性靶点失配情况

DEFUSE3研究中中风发作后24小时内持续性靶点失配情况

瑟伦·克里斯滕森1号、迈克尔·姆林纳什1号、斯蒂芬妮·肯普1号、阿玛纳特·延努1号、杰里米·J·海特2号、迈克尔·P·马克2号、马丁·G·兰斯堡1号、格雷戈里·W·阿尔伯斯1号

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PMID:30735466 DOI:10.1161/STROKEAHA.118.023392

摘要

背景和目的-血管内血栓切除术的有效性已被证实，在脑卒中发病后24小时内，患者选择灌注成像。我们假设一些患者在发病后24小时内存在持续良好的灌注曲线，并且可以通过较低的基线低灌注强度比来预测，这表明侧支循环良好。方法：我们从DEFUSE 3试验（缺血性卒中影像学评价后的血管内治疗）中确定对照组患者，随机分组后24小时进行弥散加权成像和灌注磁共振成像，并比较持续失配患者的影像学和临床变量与随机化后24小时不再出现不匹配的患者相比。结果-18%的对照组患者在最后一次已知的健康时间后>38小时有持续良好的外形。这些患者的基线弥散加权成像和Tmax>6秒容积与最初良好灌注曲线变得不利的患者相似（弥散加权成像病灶7 vs 17 mL；P=0.17，Tmax>6秒98 vs 100 mL；P=0.48），但梗死生长较少（15 vs 59 mL；P<0.001），随机分组后24小时梗死体积缩小3倍（15对59 mL；P<0.001）。持续良好灌注的患者在基线成像时低灌注强度比率显著降低（0.2比0.4；P<0.01）。只有10%的持续失配患者在90天时出现了良好的临床结果。结论：约20%的大脑中动脉或颈内动脉闭塞患者在延长的时间窗内出现，且未接受血栓切除术治疗，其持续失配至少持续24小时。这些患者在出现时具有良好的低灌注强度比，可能出现延迟性梗死扩大，临床预后较差。需要进行临床试验，以确定灌注情况良好的患者是否能从24小时后的再灌注中获益。临床试验注册-网址：https://www.clinicaltrials.gov。唯一标识符：NCT02586415。Stroke

. 2019 Mar;50(3):754-757.

 doi: 10.1161/STROKEAHA.118.023392.

Persistent Target Mismatch Profile >24 Hours After Stroke Onset in DEFUSE 3

Søren Christensen 1, Michael Mlynash 1, Stephanie Kemp 1, Amarnath Yennu 1, Jeremy J Heit 2, Michael P Marks 2, Maarten G Lansberg 1, Gregory W Albers 1

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• PMID: 30735466

•  

• DOI: 10.1161/STROKEAHA.118.023392

Abstract

Background and Purpose- Efficacy of endovascular thrombectomy has been demonstrated up to 24 hours after stroke onset in patients selected with perfusion imaging. We hypothesized that a persistent favorable perfusion profile exists in some patients beyond 24 hours from the onset and can be predicted by a lower baseline hypoperfusion intensity ratio, which indicates favorable collaterals. Methods- We identified control arm patients from the DEFUSE 3 trial (The Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) with a diffusion weighted imaging and perfusion magnetic resonance imaging performed 24 hours following randomization and compared imaging and clinical variables between patients with persistent mismatch versus patients who no longer had a mismatch 24 hours after randomization. Results- Eighteen percent of the control arm patients had a persistent favorable profile >38 hours after last known well time. These patients had similar baseline diffusion weighted imaging and Tmax >6 seconds volumes as patients whose initially favorable perfusion profile became unfavorable (diffusion weighted imaging lesion 7 versus 17 mL; P=0.17, Tmax >6 seconds 98 versus 100 mL; P=0.48) yet experienced less infarct growth (15 versus 59 mL; P<0.001) and had 3-fold smaller infarct volumes (15 versus 59 mL; P<0.001) 24 hours after randomization. Patients with a persistent favorable perfusion profile had a significantly lower hypoperfusion intensity ratio on baseline imaging (0.2 versus 0.4; P<0.01). Favorable clinical outcome at 90 days occurred in only 10% of the persistent mismatch patients. Conclusions- About 20% of patients with a middle cerebral artery or internal carotid artery occlusion who present in an extended time window and are not treated with thrombectomy have a persistent mismatch for at least an additional 24 hours. These patients have a favorable hypoperfusion intensity ratio at presentation, may experience delayed infarct expansion, and have poor clinical outcomes. Clinical trials are needed to determine if patients with a favorable perfusion profile benefit from reperfusion beyond 24 hours. Clinical Trial Registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02586415.