探讨急性脑梗死不同治疗方法的TOAST分型及其影像学表现The TOAST classification and imaging characteristics in acute cerebral infarction with different treatment methods
任军;姜亮;殷信道;陈慧铀;彭明洋;陈松旺;毛存南;周俊山;张颖冬;
摘要(Abstract)：
目的应用多模磁共振扩散加权成像-灌注加权成像分析急性脑梗死不同治疗方法的影像学表现特征。材料与方法回顾性分析在我院神经内科住院治疗的急性脑梗死患者110例,所有患者均行多模磁共振检查,记录其影像学表现、临床资料和实验室常规检查,并根据结果行扩散加权成像(diffusion weighted imaging,DWI)分型及急性卒中治疗Org 10172试验(trial of org 10172 in acute stroke treatment,TOAST)分型,根据不同治疗方法分为静脉溶栓组(43例)、动脉取栓组(34例)及保守治疗组(33例),并对3组的影像学及临床资料进行统计学分析。结果 (1)动脉取栓组患者存在半暗带及血管高信号征的比率均高于静脉溶栓组及保守治疗组,差异均有统计学意义(F=13.713,P=0.001;F=8.108,P=0.017)。(2)在DWI分型构成比方面,静脉溶栓组以小穿支梗死及单侧前循环梗死所占比率较大(25.58%、23.26%),动脉取栓组和保守治疗组以单侧前循环及前-后循环所占比率较大(52.94%、21.43%;30.30%、30.30%)。(3)在TOAST分型构成比方面,静脉溶栓组以大动脉粥样硬化型(largeartery atherosclerosis,LAA)所占比率最高(39.53%),动脉取栓组以不明原因型(undetermined etiology,UND)所占比率最高(73.53%),保守治疗组以小动脉闭塞型(small artery occlusion,SAO)所占比率最高(48.48%)。(4)在磁共振血管造影(magnetic resonance angiography,MRA)影像学表现上,静脉溶栓组及保守治疗组MRA表现正常所占比率最高(72.09%、51.52%),而动脉取栓组MRA表现为大脑中动脉狭窄或闭塞所占比率最高(41.18%)。(5)3组间比较,动脉取栓组的出血转化率最高(26.47%),差异有统计学意义(F=6.462,P=0.040)。(6)入院美国国立卫生研究院卒中量表(National Institute of Health stroke scale,NIHSS)评分及高血脂症在3组间比较差异具有统计学意义(t=6.209,P=0.003;F=6.176,P=0.046)。(7)保守治疗组发病时间(6.55±4.70)长于静脉溶栓组(2.93±1.05)及动脉取栓组(3.07±2.51),3组间差异有统计学意义(t=16.246,P=0.000)。结论了解不同治疗方法患者的影像学表现特征,可帮助临床医生根据具体情况选择合理的治疗方案,实现个性化治疗。
关键词(KeyWords)： 脑梗死;磁共振成像;扩散加权成像;灌注加权成像;TOAST分型
基金项目(Foundation): 江苏省卫生计生委项目(编号:H201541);; 南京市科委项目(编号:201402046,201503021)~~
作者(Author): 任军;姜亮;殷信道;陈慧铀;彭明洋;陈松旺;毛存南;周俊山;张颖冬;
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参考文献(References)：
- [1]Neurology branch of Chinese Medical Association.Guidelines for diagnosis and treatment of acute ishemic stroke in china 2014.Chin J Neurol,2015,48(4):246-257.中华医学会神经病学分会.中国急性缺血性脑卒中诊治指南2014.中华神经科杂志,2015,48(4):246-257.
- [2]Wang X,Huang JX,Fan YH,et al.Relationship between etiology and diffusion weighted imaging patterns in acute stage of ischemic stroke.Chin J Neurol,2005,38(5):301-304.王新,黄家星,范玉华,等.急性缺血性卒中病因与早期弥散加权成像表现的关系.中华神经科杂志,2005,38(5):301-304.
- [3]Adams HP,Bendixen BH,Kappelle LJ,et al.Classification of subtype of acute ischemic stroke.Stroke,1993,24(1):35-41.
- [4]Kucinski T,Koch C,Eckert B,et al.Collateral circulation is an independent radiological predictor of outcome after thrombolysis in acute ischaemic stroke.Neuroradiology,2003,45(1):11-18.
- [5]Pang LH.Clinical treatment of acute cerebral infarction.Guide Chin Med,2012,10(16):12-14.庞利红.急性脑梗死患者的临床治疗方法比较.中国医药指南,2012,10(16):12-14.
- [6]Ebinger M,Kunz A,Wendt M.Effects of golden hour thrombolysis:a prehospital acute neurological treatment and optimization of medical care in stroke(PHANTOM-S)substudy.JAMA Neurol,2015,72(1):25-30.
- [7]Catanese L,Tarsia J,Fisher M.Acute ischemic stroke therapy overview.Circ Res,2017,120(3):541-558.
- [8]Fisher M.The ischemic penumbra:a new opportunity for neuroprotection.Cerebrovasc Dis,2006,21(2):64-70.
- [9]Ma H,Wright P,Allport L,et al.Salvage of the PWI/DWI mismatch up to 48 h from stroke onset leads to favorable clinical outcome.Int J Stroke,2015,10(4):565-570.
- [10]Liu ML,Cui SM,Zhang LL,et al.MRI study on graphic-penumbra of the hyperacute infarct with diffusion weighted imaging and perfusion imaging.Chin J Radiol,2002,36(12):1095-1100.刘梅丽,崔世民,张蕾莉,等.磁共振扩散加权和灌注成像对超急性期脑梗死影像半暗带的研究.中华放射学杂志,2002,36(12):1095-1100.
- [11]Sanossian N,Saver JL,Alger JR,et al.Angiography reveals that fluidattenuated inversion recovery vascular hyperintensities are due to slow flow,not thrombus.AJNR Am J Neuroradiol,2009,30(3):564-568.
- [12]Feng R,Shen LS,Liu ZS,et al.Formation mechanism of HVS based on magnetic resonance FLAIR sequence for acute cerebral infarction patients.Chin Heal standard management,2015,30(6):157-158.冯瑞,沈龙山,刘振生,等.急性脑梗死磁共振液体衰减反转恢复序列高信号血管征机制.中国卫生标准管理,2015,30(6):157-158.
- [13]Azizyan A,Sanossian N,Mogensen MA,et al.Fluid-attenuated inversion recovery vascular hyperintensities:an important imaging marker for cerebrovascular disease.AJNR Am J Neuroradiol,2011,32(10):1771-1775.
- [14]Kawashima M,Noguchi T,Yakushiji Y,et al.Leptomeningeal collateral and cerebral hemodynamics in patients with ICA and MCA steno-occlusion.Neurol Res,2011,33(3):307-313.