2012国际卒中大会：卒中血管内治疗转归与ASPECTS相关
2012-02-17 MedSci MedSci原创
2012国际卒中大会公布的START研究初步结果显示，CTA原始图像所示的治疗前艾伯塔卒中方案早期CT评分（ASPECTS）较高与血管内治疗后转归较好相关。NCCT与ASPECTS对比研究为确定其转归预测相对准确性所必需。 目前尚无用于选择患者行血管内卒中治疗（EVT）的标准成像方法。CT依然是应用最为广泛的卒中评价方法，并且ASPECTS定量的非强化CT缺血改变（NCCT
2012国际卒中大会公布的START研究初步结果显示，CTA原始图像所示的治疗前艾伯塔卒中方案早期CT评分（ASPECTS）较高与血管内治疗后转归较好相关。NCCT与ASPECTS对比研究为确定其转归预测相对准确性所必需。
目前尚无用于选择患者行血管内卒中治疗（EVT）的标准成像方法。CT依然是应用最为广泛的卒中评价方法，并且ASPECTS定量的非强化CT缺血改变（NCCT）可预测EVT的临床反应。
START为一项前瞻性多中心研究，在接受EVT的患者中评估了治疗前核心卒中面积的临床影响。成像方法依据各患者实际情况而定，其中包括NCCT、CTA原始图像（CTA-SI）、CT灌注或MRI弥散成像。以盲法对ASPECTS进行分期，并依据既往分类方法（0-4，5-7，8-10）加以分析。临床转归被二分位90天改良Rankin量表评分为0-2和3-6。利用单变量和多变量分析确定转归预测因素。
结果显示，在纳入的145例患者中，56例符合初步分析标准。平均年龄为（65.5±14.2）岁，中位NIHSS（美国国立卫生研究院卒中量表）为19.5。女性为30例（53.6%），靶血管阻塞为颈内动脉（ICA，14例）和大脑中动脉（MCA）M1段和M2段（41例）。CTA-SI所示的中位治疗前ASPECTS为6。评分为0-4、5-7和8-10的患者分别14（25%）、34（60.7%）和8例（14.3%）。TIMI 2-3血运重建率为87.3%。腹股沟穿刺至阿司匹林停药中位时间73.5分钟。
27例（48.2%）患者实现良好90天转归；15例（26.8%）死亡。仅有1例（1.8%）患者出现症状性出血。CTA-SI所示治疗前ASPECTS较高与良好转归相关（P<0.05）。ASPECTS 0-4、5-7和8-10的良好转归（mRS 0-2）比率分别为21.4%、55.9%和62.5%（P=0.08）。对年龄和NIHSS校正之后，治疗前ASPECTS为良好转归的独立预测因子。在ROC分析中，治疗前ASPECTS>4为确认良好转归的最佳阈值（敏感性89%，特异性38%）。良好转归的其他单变量预测因素为低龄、低NIHSS、更远端阻塞以及腹股沟穿刺至阿司匹林停用时间较短。
相关链接：
International Stroke Conference
Late-Breaking Science Poster Abstracts：LB P3
Publishing Title:The Penumbra START Trial: Preliminary Results on the Clinical Impact of Pre-treatment CTA Source Image ASPECTS in Endovascularly-Treated Stroke Patients
Abstract :
Background: There is no standard imaging approach to select patients for endovascular stroke therapy (EVT). CT remains the most widely used modality for stroke evaluation, and ischemic change on noncontrast CT (NCCT) quantified using ASPECTS has been demonstrated to predict the clinical response to EVT. To date, there have been no good studies evaluating the influence of CTA source image (CTA-SI) pre-treatment ASPECTS (pre-ASPECTS) on outcomes following EVT.
Methods: START was a prospective multicenter study to evaluate the clinical impact of pre-treatment core infarct size in patients undergoing EVT using the Penumbra System. The imaging approach was left to each center‟s discretion, and included NCCT, CTA-SI, CT perfusion or MRI diffusion imaging. This study focused on the preliminary CTA-SI results. ASPECTS was graded in a blinded fashion and analyzed according to the a priori classification scheme (0-4, 5-7, 8-10), as well as using the entire scale. Clinical outcomes were dichotomized as 90-day modified Rankin Scale scores (mRS) of 0-2 (good) vs. 3-6. Univariate and multivariate analyses were performed to determine predictors of outcome.
Results: Of the 145 patients enrolled, 56 met study criteria for this preliminary analysis. The mean age was 65.5 ± 14.2 years; median NIHSS was 19.5 (14-24). There were 30 (53.6%) females, and target vessel occlusions were in the ICA (n=14), MCA M1 & M2 segments (n=41). The median pre-ASPECTS on CTA-SI was 6 (4.5-7). There were 14 (25%) patients with scores of 0-4, 34 (60.7%) with 5-7, 8 (14.3%) with 8-10. The rate of TIMI 2-3 revascularization was 87.3% (48/55). The median time from groin puncture to discontinuation of aspiration was 73.5 (40-108) minutes. Twenty-seven (48.2%) patients achieved a good 90-day outcome. Fifteen (26.8%) died. Only one (1.8%) patient suffered a symptomatic hemorrhage. Higher pre-ASPECTS on CTA-SI was significantly associated with good outcomes (median 6 [IQR 5-7] vs. 5 [IQR 3-7], p<0.05). The rate of good outcomes (mRS 0-2) was 21.4% for ASPECTS 0-4, 55.9% for 5-7, and 62.5% for 8-10 (p=0.08). Adjusting for age and NIHSS, pre-ASPECTS was an independent predictor of good outcome (OR 1.5, p<0.04). In ROC analysis, ASPECTS >4 was the optimal threshold for identifying good outcomes (89% sensitivity, 38% specificity). Other univariate predictors of good outcome were lower age (p=0.02), lower NIHSS (p=0.02), more distal occlusion (p<0.05) and shorter time from groin puncture to stopping aspiration (p=0.02).
Conclusions: These preliminary results show that higher pre-treatment ASPECTS on CTA source images is associated with better outcomes following endovascular therapy. Comparative studies versus NCCT ASPECTS are necessary to determine their relative accuracy for outcome prediction.
Methods: START was a prospective multicenter study to evaluate the clinical impact of pre-treatment core infarct size in patients undergoing EVT using the Penumbra System. The imaging approach was left to each center‟s discretion, and included NCCT, CTA-SI, CT perfusion or MRI diffusion imaging. This study focused on the preliminary CTA-SI results. ASPECTS was graded in a blinded fashion and analyzed according to the a priori classification scheme (0-4, 5-7, 8-10), as well as using the entire scale. Clinical outcomes were dichotomized as 90-day modified Rankin Scale scores (mRS) of 0-2 (good) vs. 3-6. Univariate and multivariate analyses were performed to determine predictors of outcome.
Results: Of the 145 patients enrolled, 56 met study criteria for this preliminary analysis. The mean age was 65.5 ± 14.2 years; median NIHSS was 19.5 (14-24). There were 30 (53.6%) females, and target vessel occlusions were in the ICA (n=14), MCA M1 & M2 segments (n=41). The median pre-ASPECTS on CTA-SI was 6 (4.5-7). There were 14 (25%) patients with scores of 0-4, 34 (60.7%) with 5-7, 8 (14.3%) with 8-10. The rate of TIMI 2-3 revascularization was 87.3% (48/55). The median time from groin puncture to discontinuation of aspiration was 73.5 (40-108) minutes. Twenty-seven (48.2%) patients achieved a good 90-day outcome. Fifteen (26.8%) died. Only one (1.8%) patient suffered a symptomatic hemorrhage. Higher pre-ASPECTS on CTA-SI was significantly associated with good outcomes (median 6 [IQR 5-7] vs. 5 [IQR 3-7], p<0.05). The rate of good outcomes (mRS 0-2) was 21.4% for ASPECTS 0-4, 55.9% for 5-7, and 62.5% for 8-10 (p=0.08). Adjusting for age and NIHSS, pre-ASPECTS was an independent predictor of good outcome (OR 1.5, p<0.04). In ROC analysis, ASPECTS >4 was the optimal threshold for identifying good outcomes (89% sensitivity, 38% specificity). Other univariate predictors of good outcome were lower age (p=0.02), lower NIHSS (p=0.02), more distal occlusion (p<0.05) and shorter time from groin puncture to stopping aspiration (p=0.02).
Conclusions: These preliminary results show that higher pre-treatment ASPECTS on CTA source images is associated with better outcomes following endovascular therapy. Comparative studies versus NCCT ASPECTS are necessary to determine their relative accuracy for outcome prediction.
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#ASPECTS#
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#PE#
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#CTS#
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