Perfusion computed tomography to assist decision making for stroke thrombolysis.
Perfusion computed tomography to assist decision making for stroke thrombolysis.
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DOI：
10.1093/brain/awv071
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发表时间：
2015-07
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影响因子：
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通讯作者：
Parsons M
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作者：
Bivard A;Levi C;Krishnamurthy V;McElduff P;Miteff F;Spratt NJ;Bateman G;Donnan G;Davis S;Parsons M
使用灌注成像来指导缺血性脑卒中患者选择溶栓治疗仍然存在争议。Bivard等人使用两个大型独立队列，证明灌注成像能够识别将从治疗中受益的患者，而这些患者不易通过临床评估识别。使用灌注成像来指导缺血性脑卒中患者选择溶栓治疗仍然存在争议。Bivard等人使用两个大型独立队列，证明灌注成像能够识别将从治疗中受益的患者，而这些患者不易通过临床评估识别。由于缺乏支持性的三期临床试验证据，使用灌注成像来指导卒中溶栓患者的选择仍然存在争议。我们的目的是测量在综合卒中护理机构接受静脉注射重组组织型纤溶酶原激活剂（rtPA）治疗的患者的结果，灌注计算机断层扫描通常用于溶栓资格决策辅助。我们的总体假设是灌注计算机断层扫描“目标”不匹配的患者在rtPA治疗后会有更好的结果。这是一项前瞻性队列研究，连续缺血性脑卒中患者符合静脉注射rtPA治疗的标准临床/非对比计算机断层扫描资格标准，但灌注计算机断层扫描用于指导最终治疗决策。“实时”灌注计算机断层扫描评估是定性的；大灌注计算机断层扫描缺血核心，或缺乏明显的灌注病变核心不匹配被认为是溶栓的相对排除标准。具体的容积灌注计算机断层扫描标准未用于治疗决策。初步分析比较了在“离线”（治疗后）定量容积灌注计算机断层扫描是否存在“目标”灌注病变-核心失配（失配比>1.8，体积>15 ml，核心<70 ml）后，治疗组和未治疗组患者3个月改良Rankin量表。在第二项分析中，我们比较了灌注计算机断层扫描选择的rtpa治疗患者与澳大利亚非对比计算机断层扫描选择的rtpa治疗患者的结果。在635例符合rtPA标准的急性缺血性卒中患者中，366例患者接受了溶栓治疗，269例患者根据视觉实时灌注计算机断层扫描评估被排除。离线定量灌注后计算机断层扫描分类：治疗组253例、未治疗组83例存在“靶”错配，治疗组56例、未治疗组31例存在较大的缺血核心，治疗组57例、未治疗组155例无靶错配。在初步分析中，rtpa治疗的患者只有在靶不匹配亚组中有明显更好的结局（3个月的优势比，修正Rankin量表0-2 = 13.8,P < 0.001）。灌注计算机断层扫描选择rtpa治疗的患者（n = 366）与临床/非对比计算机断层扫描选择rtpa治疗的患者（n = 396）相比，灌注计算机断层扫描选择组具有更高的调整后优转率（修正Rankin量表0-1优势比1.59,P = 0.009）和更低的死亡率（优势比0.56,P = 0.021）。虽然基于观察数据集，但我们的分析支持灌注计算机断层扫描提高了可能对溶栓有反应的患者的识别，以及那些自然病史可能难以通过治疗改变的患者的假设。
The use of perfusion imaging to guide selection of ischaemic stroke patients for thrombolytic therapy remains controversial. Using two large independent cohorts, Bivard et al. demonstrate that perfusion imaging is able to identify patients who will benefit from treatment and that these patients are not readily identifiable using clinical assessments. The use of perfusion imaging to guide selection of ischaemic stroke patients for thrombolytic therapy remains controversial. Using two large independent cohorts, Bivard et al. demonstrate that perfusion imaging is able to identify patients who will benefit from treatment and that these patients are not readily identifiable using clinical assessments. The use of perfusion imaging to guide selection of patients for stroke thrombolysis remains controversial because of lack of supportive phase three clinical trial evidence. We aimed to measure the outcomes for patients treated with intravenous recombinant tissue plasminogen activator (rtPA) at a comprehensive stroke care facility where perfusion computed tomography was routinely used for thrombolysis eligibility decision assistance. Our overall hypothesis was that patients with ‘target’ mismatch on perfusion computed tomography would have improved outcomes with rtPA. This was a prospective cohort study of consecutive ischaemic stroke patients who fulfilled standard clinical/non-contrast computed tomography eligibility criteria for treatment with intravenous rtPA, but for whom perfusion computed tomography was used to guide the final treatment decision. The ‘real-time’ perfusion computed tomography assessments were qualitative; a large perfusion computed tomography ischaemic core, or lack of significant perfusion lesion-core mismatch were considered relative exclusion criteria for thrombolysis. Specific volumetric perfusion computed tomography criteria were not used for the treatment decision. The primary analysis compared 3-month modified Rankin Scale in treated versus untreated patients after ‘off-line’ (post-treatment) quantitative volumetric perfusion computed tomography eligibility assessment based on presence or absence of ‘target’ perfusion lesion-core mismatch (mismatch ratio >1.8 and volume >15 ml, core <70 ml). In a second analysis, we compared outcomes of the perfusion computed tomography-selected rtPA-treated patients to an Australian historical cohort of non-contrast computed tomography-selected rtPA-treated patients. Of 635 patients with acute ischaemic stroke eligible for rtPA by standard criteria, thrombolysis was given to 366 patients, with 269 excluded based on visual real-time perfusion computed tomography assessment. After off-line quantitative perfusion computed tomography classification: 253 treated patients and 83 untreated patients had ‘target’ mismatch, 56 treated and 31 untreated patients had a large ischaemic core, and 57 treated and 155 untreated patients had no target mismatch. In the primary analysis, only in the target mismatch subgroup did rtPA-treated patients have significantly better outcomes (odds ratio for 3-month, modified Rankin Scale 0–2 = 13.8, P < 0.001). With respect to the perfusion computed tomography selected rtPA-treated patients (n = 366) versus the clinical/non-contrast computed tomography selected rtPA-treated patients (n = 396), the perfusion computed tomography selected group had higher adjusted odds of excellent outcome (modified Rankin Scale 0–1 odds ratio 1.59, P = 0.009) and lower mortality (odds ratio 0.56, P = 0.021). Although based on observational data sets, our analyses provide support for the hypothesis that perfusion computed tomography improves the identification of patients likely to respond to thrombolysis, and also those in whom natural history may be difficult to modify with treatment.