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首页> 外文期刊>Journal of stroke and cerebrovascular diseases: The official journal of National Stroke Association >The Effect of Clot Volume and Permeability on Response to Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke
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The Effect of Clot Volume and Permeability on Response to Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke

机译：凝块体积和渗透性对急性缺血性卒中中静脉内组织纤溶酶原激活剂的影响

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Background and Aims: The characteristics of clot causing acute ischemic stroke, such as size, content, and location, are among the main determinants of response to intravenous tissue plasminogen activator [IV tPA]. Clot heterogeneity and permeability are under-recognized features that might provide additional information in predicting the efficacy of IV tPA. Methods and Patients: Patients with proximal middle cerebral artery occlusion treated with "IV tPA alone" were included. The mean Hounsfield's unit (HU) value, as objective measure of clot attenuation, and its standard deviation (SD), as proposed measure of clot heterogeneity, were obtained. The difference in HU values between CT Angiography and CT was defined as "clot permeability", or "perviousness'. The size (length and volume-mm3) of pre-clot pouch and occluding clot along with ASPECT score and Maas' silvian and leptomeningeal collateral score were measured. Results: The study included 84 cases (44 women, age: 68 +/- 14 years, pretPA NIHSS: 16 +/- 5). Patients with excellent response to tPA (31%) had lower thrombus volume (37.54 +/- 32.37 versus 63.49 +/- 37.36, P = .009) and heterogeneity (4.05 +/- 1.49 versus 5.35 +/- 2.34, P = .011), along with higher clot permeability (48 +/- 35.48 to 31.32 +/- 18.62, P = .006). However, significance of permeability did not survived in the regression analysis with adjustment for NIHSS (beta:-.296, P = .003); clot volume (beta:-.240, P = .014) and collateral status (beta:.346, P < .001). In patients with good prognosis, clot volume was significantly lower (37.76 +/- 30.08 versus 67.57 +/- 37.83, P < .001), whereas permeability was significantly higher (43.97 +/- 32.33 versus 31.13 +/- 19.01, P = .026). However, this effect did not persist in the regression analysis after adjustment for NIHSS (beta:-.399, P < .001), collateral status (beta:.343, P < .001) and clot volume beta:-.297, P = .001). Clot permeability was significantly higher (45.78 +/- 36.34 versus 33 +/- 20.2, P = .045) and heterogeneity was lower (4.1 +/- 1.55 to 5.27 +/- 2.32, P = .028) in patients with dramatic response to tPA (27%). In patients responding positively to IV tPA (48%), clot permeability was numerically higher (39.85 +/- 31.79 to 33.47 +/- 19.28, P = .268), while clot volume (48.15 +/- 34.5 to 62.07 +/- 39.62, P = .093) was lower. Clot volume, permeability and heterogeneity did not show a significant difference in any (38.1%) or symptomatic (8.3%) bleeders after IV tPA. The chance of IV tPA to be beneficial increased in patients with clot volume lower than 45 mm(3), with an increased likelihood of this benefit to be observed within the first day after IV tPA. Our detailed explorative ROC analysis was not able to detect a volume threshold above which the positive effect of IV tPA disappeared. Conclusion: Clot volume is critical for the effectiveness of IV tPA in acute ischemic stroke. Clot permeability and heterogeneity may modify its effect. CT technologies, which are readily available when evaluating a stroke patient in an emergency setting, provide us with useful parameters regarding the size, permeability and heterogeneity of the clot.
机译：背景和目的：引起急性缺血性中风的血栓的特征，如大小、含量和位置，是静脉注射组织型纤溶酶原激活剂[IV-tPA]反应的主要决定因素之一。血栓异质性和通透性是未被认识到的特征，可能为预测静脉注射tPA的疗效提供额外信息。方法和患者：包括接受“单独静脉注射tPA”治疗的大脑中动脉近端闭塞患者。获得了平均Hounsfield单位（HU）值，作为血栓衰减的客观度量，以及其标准偏差（SD），作为血栓异质性的拟议度量。CT血管造影和CT之间HU值的差异被定义为“血栓通透性”，结果：该研究包括84例患者（44名女性，年龄68+/-14岁，pretPA NIHSS:16+/-5）。对tPA有良好反应的患者（31%）血栓体积较低（37.54+/-32.37对63.49+/-37.36，P=.009）异质性（4.05+/-1.49对5.35+/-2.34，P=0.011），以及较高的血栓通透性（48+/-35.48对31.32+/-18.62，P=0.006）。然而，在对NIHSS进行调整后的回归分析中，渗透率的显著性没有保留下来（β：-.296，P=.003）；血栓体积（β：-240，P=0.014）和侧支循环状态（β：-346，P<0.001）。在预后良好的患者中，血栓体积显著降低（37.76+/-30.08对67.57+/-37.83，P<0.001），而通透性显著升高（43.97+/-32.33对31.13+/-19.01，P=0.026）。然而，在对NIHSS（β-0.399，P<0.001）、侧支循环状态（β-0.343，P<0.001）和血栓体积β-0.297，P=0.001）进行调整后，这种影响在回归分析中并未持续。在对tPA（27%）有显著反应的患者中，血栓通透性显著升高（45.78+/-36.34对33+/-20.2，P=0.045），异质性降低（4.1+/-1.55对5.27+/-2.32，P=0.028）。在对静脉tPA有积极反应的患者中（48%），血栓通透性数值较高（39.85+/-31.79至33.47+/-19.28，P=0.268），而血栓体积较低（48.15+/-34.5至62.07+/-39.62，P=0.093）。静脉注射tPA后，血栓体积、通透性和异质性在任何（38.1%）或症状性（8.3%）出血患者中均未显示出显著差异。对于血栓体积小于45mm（3）的患者，静脉注射tPA有益的几率增加，在静脉注射tPA后的第一天内观察到这种益处的可能性增加。我们详细的探索性ROC分析未能检测到体积阈值，超过该阈值时，IV-tPA的积极作用消失。结论：血栓容量对静脉注射tPA治疗急性缺血性卒中的有效性至关重要。血栓通透性和异质性可能会改变其效果。CT技术在紧急情况下评估中风患者时很容易获得，它为我们提供了有关血栓大小、通透性和异质性的有用参数。

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