CT平扫联合脑CT灌注成像在前循环颅内大血管闭塞血管内治疗预后评价中的应用

目的 探讨CT平扫联合脑CT灌注成像在前循环颅内大血管闭塞血管内治疗预后评价中的应用。方法 回顾性分析2016年5月—2020年5月在青海省人民医院行血管内治疗的151例急性前循环颅内大血管闭塞患者的临床资料，根据改良Rankin量表（mRS）评分将患者分为预后良好组（mRS评分0～2分）75例和预后不良组（mRS评分3～6分）76例。所有患者入院后行头颅CT平扫联合脑CT灌注成像，记录影像学特征［CT平扫大脑中动脉高密度征（HMCAS）及CT灌注成像参数脑血流量（CBF）、脑血容量（CBV）、平均通过时间（MTT）、达峰时间（TTP）］，记录两组患者入院美国国立卫生研究院卒中量表（NIHSS）评分、Alberta卒中项目早期CT评分（ASPECTS）、急性卒中Org 10 172治疗试验（TOAST）分型、侧支血流分级情况、术后即刻脑梗死溶栓（TICI）分级、术中及术后症状性颅内出血发生率等。采用多因素Logistic回归分析急性前循环颅内大血管闭塞患者血管内治疗临床预后的独立影响因素，评价头颅CT平扫中HMCAS和CT灌注成像参数在患者血管内治疗预后评价中的应用价值。结果 预后良好组年龄、冠状动脉粥样硬化性心脏病病史、心房颤动、入院时NIHSS评分、MTT-ASPECTS评分、侧支循环分级0～2级比例、术后TICI分级< 2b级比例、发病至血管再通时间、取栓次数、收缩压、HMCAS比例、MTT、TTP低于预后不良组（P <0.05）；CBV-ASPECTS评分、CBF、CBV高于预后不良组（P <0.05）。两组性别、吸烟史、高血压、糖尿病、高脂血症、闭塞部位、TOAST卒中分型、桥接治疗、空腹血糖、舒张压、肌酐、白细胞计数比较，差异无统计学意义（P >0.05）。多因素Logistic回归分析显示，入院时NIHSS评分［O^R=1.160（95% CI：1.019，1.321）］、CBV-ASPECTS评分［O^R=1.789（95% CI：1.276，2.500）］、MTT-ASPECTS评分［O^R=2.463（95% CI：1.431，4.239）］、侧支循环分级［O^R=5.712（95% CI：1.669，19.549）］、发病至血管再通时间［O^R=1.007（95% CI：1.002，1.012）］、收缩压［O^R=1.032（95% CI：1.009，1.056）］、HMCAS［O^R=1.326（95% CI：1.055，1.667）］、CBF［O^R=0.975（95% CI：0.962，0.988）］、CBV［O^R=1.462（95% CI：1.094，1.954）］、MTT［O^R=1.314（95% CI：1.076，1.605）］和TTP［O^R=4.460（95% CI：1.120，17.760）］是急性前循环颅内大血管闭塞患者血管内治疗临床预后的危险因素（P <0.05）。结论 除入院时NIHSS评分、CBV-ASPECTS评分、MTT-ASPECTS评分、侧支循环分级、发病至血管再通时间、收缩压外，CT平扫中HMCAS及CT灌注成像参数CBF、CBV、MTT、TTP也是急性前循环颅内大血管闭塞患者血管内治疗临床预后的独立影响因素，临床应引起足够重视。

The value of combined non-contrast CT scan and cerebral CT perfusion imaging in prognosis evaluation of endovascular treatment for large vessel occlusion of anterior circulation

Objective To explore the value of combined non-contrast computed tomography (CT) scan and cerebral CT perfusion imaging in the prognosis evaluation of endovascular treatment for large vessel occlusion of anterior circulation.Methods The clinical data of 151 patients with acute large vessel occlusion of anterior circulation who received endovascular treatment in Qinghai Provincial People''s Hospital from May 2016 to May 2020 were retrospectively analyzed. According to the modified Rankin Scale (MRS) score, the patients were divided into the good prognosis group (MRS score: 0 to 2) of 75 cases and the poor prognosis group (MRS score: 3 to 6) of 76 cases. After admission, all patients received non-contrast CT scan combined with CT perfusion imaging, and the imaging parameters including hyperdense middle cerebral artery sign (HMCAS) in the non-contrast CT scan and cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) in the cerebral CT perfusion imaging were recorded. The National Institutes of Health Stroke Scale (NIHSS) score at admission, Alberta Stroke Program Early CT Score (ASPECTS), Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification, collateral blood flow classification, immediate postoperative thrombolysis in cerebral infarction (TICI) classification, and intraoperative and postoperative incidence of symptomatic intracranial hemorrhage were detected. Multivariate Logistic regression was used to analyze the independent influencing factors for the clinical outcome after the endovascular treatment in patients with acute large vessel occlusion of anterior circulation. The application values of HMCAS in the non-contrast CT scan and the aforementioned CT perfusion imaging parameters in the prognosis evaluation of endovascular treatment for large vessel occlusion of anterior circulation were determined.Results The age, the proportion of patients with a history of coronary heart disease and atrial fibrillation, NIHSS score at admission, MTT-ASPECTS score, the proportion of grade 0 to 2 collateral blood flow, the proportion of postoperative TICI less than grade 2b, the number of thrombectomy attempts, systolic blood pressure, and the incidence of HMCAS were lower, and onset-to-reperfusion time, MTT and TTP were shorter in the good prognosis group relative to those in the poor prognosis group, while the CBV-ASPECTS score, CBF and CBV were higher in the good prognosis group than those in the poor prognosis group (P < 0.05). There were no significant differences in gender composition, history of smoking, history of hypertension, history of diabetes mellitus, history of hyperlipidemia, sites of occlusion, TOAST classification, bridging therapy, fasting blood glucose, diastolic blood pressure, creatinine and white blood cell count between the two groups (P > 0.05). Multivariate Logistic regression analysis showed that NIHSS score at admission O^R = 1.160 (95% CI: 1.019, 1.321)], CBV-ASPECTS score O^R = 1.789 (95% CI: 1.276, 2.500)], MTT- ASPECTS score O^R = 2.463 (95% CI: 1.431, 4.239)], collateral blood flow classification O^R = 5.712 (95% CI: 1.669, 19.549)], onset-to-reperfusion time O^R= 1.007 (95% CI: 1.002, 1.012)], systolic blood pressure O^R = 1.032 (95% CI: 1.009, 1.056)], HMCAS O^R = 1.326 (95% CI: 1.055, 1.667)], CBF O^R = 0.975 (95% CI: 0.962, 0.988)], CBV O^R = 1.462 (95% CI: 1.094, 1.954)], MTT O^R = 1.314 (95% CI: 1.076, 1.605)] and TTP O^R = 4.460 (95% CI: 1.120, 17.760)] were factors affecting the clinical prognosis after endovascular treatment in patients with acute large vessel occlusion of anterior circulation (P < 0.05).Conclusions In addition to NIHSS score at admission, CBV-ASPECTS score, MTT-ASPECTS score, collateral blood flow classification, onset-to-reperfusion time, and systolic blood pressure, HMCAS in the non-contrast CT scan and CT perfusion imaging parameters including CBF, CBV, MTT and TTP, are also independent influencing factors for the clinical prognosis of patients with acute large vessel occlusion of anterior circulation after endovascular treatment, which should be paid enough attention in clinical practice.