【作者】 张晓程；

【导师】 楼敏；

【作者基本信息】 浙江大学 ， 临床医学（专业学位）， 2017， 硕士

【摘要】 背景与目的脑内深部静脉对急性缺血性卒中(acute ischemic stroke,AIS)患者静脉溶栓后神经功能结局的影响目前尚不明确。本研究旨在观察AIS磁敏感影像(Susceptibility-weighted imaging,SWI)上的静脉表现,并探讨其与静脉溶栓后远期功能结局的关系。材料与方法我们回顾2011年9月至2015年7月期间发病6小时内在浙江大学附属第二医院神经内科接受静脉阿替普酶(recombinant tissue plasminogen activator,rt-PA)溶栓治疗的AIS且溶栓前行多模式磁共振检查的患者。利用SWI重建影像评估静脉,测定双侧丘纹静脉(thalamostriate vein,TSV),隔静脉(septal vein,SV),大脑内静脉(internal cerebral vein,ICV)的信号密度值,计算双侧静脉的相对信号差率(signal difference ratio,SDR)。溶栓后24小时灌注恢复≥70%定义为成功再灌。3 月改良 Rankin 评分(3 month-modified Rankin Scale,3m-mRS)>2 分定义为预后不良,分析TSV,SV,ICV的SDR与静脉溶栓后远期预后的关系。研究结果共109例患者纳入分析,只有TSV的SDR与静脉溶栓后远期预后不良(3m-mRS>2)(ρ= 0.25,p = 0.008)显着相关,其预测预后不良的最佳阈值为SDR>4.8%(敏感性为 53.7%,特异性为 80.9%)。而 SV(ρ=0.04,p = 0.73)或 ICV(ρ=0.07,p = 0.47)的SDR与预后无相关性。我们定义TSV的SDR≥5%为"患侧丘纹静脉明显(ipsilateral prominent TSV,IPTSV)"。共 35 例(32.1%)存在 IPTSV。与无IPTSV征象的患者相比,具有IPTSV征象的患者获得成功再灌的比例更低(37.5%vs 60.0%,OR = 0.35,95%CI 0.13-0.92,p = 0.03),且更可能远期预后不良(62.9%vs 25.7%,OR = 3.66,95%CI 1.25-10.68,p = 0.02)。在具有 IPTSV 征象的患者中,未达到成功再灌者更易远期预后不良(80.0%vs44.4%,p = 0.04)。研究结论基线IPTSV征象提示静脉溶栓后成功再灌率较低,且具有该征象的患者更易远期预后不良。对于此类患者,可能需要进一步的再灌注治疗。更多还原

【Abstract】 Background and purposeThe impact of deep cerebral veins on neurological outcome after intravenous thrombolysis(IVT)in patients with acute ischemic stroke(AIS)is unclear.We investigated the relationship between the appearance of deep cerebral veins on susceptibility-weighted imaging(SWI)and neurological outcome in patients who underwent thrombolysis.Materials and methodsWe retrospectively reviewed our prospectively collected database for AIS patients who were admitted to our center between June 2011 and July 2015.Consecutive acute ischemic stroke patients who who had pretreatment SWI and receivedintravenous thrombolysis(IVT)within 6 hours were retrospectively studied.We evaluated thalamostriate vein(TSV),septal vein(SV)and internal cerebral vein(ICV)on the reconstructed SWIand calculated the signal difference ratio(defined as the relative difference in signal intensity between the ipsilateral and contralateral vein).Successful reperfusion was defined as>70%reduction in hypoperfusion volume between pretreatment and 24-hour perfusion imaging.Patients were dichotomized into good(modified Rankin Scale,mRS<2)versus poor outcome(mRS>2)at 90 days.ResultOnly signal difference ratio of the TSV was significantly associated with poor outcome(3-month modified Rankin scale score>2)(p= 0.25,p=0.008).The optimal threshold was relative hypointensity of the ipsilateral vein>4.8%(sensitivity of 53.7%and specificity of 80.9%).We defined a signal difference ratio of the TSV>5%as"ipsilateral prominent TSV(IPTSV)".IPTSV was seen in 35 patients(32.1%).Patients with IPTSV were more likely to have poor outcome(62.9%vs 25.7%,OR=3.66 95%CI 1.25-10.68,p=0.02),and lower rate of successful reperfusion(reperfusion rate>70%)(37.5%vs 60.0%,OR=0.35 95%CI 0.13-0.92,p=0.03),compared with those without ipsilateral prominent TSV.However,patients with ipsilateral prominent TSV,were still less likely to experience poor outcome when reperfusion was achieved compared to when reperfusion did not occur(80.0%vs 44.4%,p=0.04).ConclusionPretreatment ipsilateral prominent TSV was associated with reduced reperfusion after thrombolysis and poor outcome.More intensive reperfusion approaches may be required for patients with ipsilateral prominent TSV.更多还原