İskemik İnmede Penumbral Alanın Sonuç İnfarkt Hacmi ve Klinik Prognozu Üzerine Etkisi

Yıl 2020, Cilt: 30 Sayı: 1, 24 - 31, 01.03.2020

Hatice Şap Muazzez Betigül Yürüten Çorbacıoğlu Osman Serhat Tokgöz

Öz

Amaç: Klinik seyir üzerine yapılan çalışmalar inme progresyonunu takip etmede çok önemli bir yer tutar. Perfüzyon MR görüntülemelerinin akut iskemik inmede kullanıma girmesi penumbral alanın tespiti ve kurtarılması adına önemli bir köşe taşı olmuştur. Gereç ve Yöntem: İlk 24 saat içinde akut iskemik inme atağı geçiren hastaların geliş difüzyon ve perfüzyon ağırlıklı manyetik rezonans görüntülemeleri MRG tespit edildi. Perfüzyon-difüzyon uyumsuzluğu ciddi, orta-hafif ve olmama durumlarına göre 3 gruba ayrıldı. İyi klinik yanıt İKY gelişip gelişmediği başlangıç ve 15. gün klinik skorları The National Institute of Health Stroke Scale, European Stroke Scale and Modified Rankin Scale kullanılarak tespit edildi. Finalde lezyon hacim FLH büyümesi tespiti için 15. gün çekilen T2 ağırlıklı MRG ile başlangıç difüzyon ağırlıklı MRG hacim farkları alındı. Bulgular: Ciddi uyumsuzluğun olduğu grupta FLH de büyüme, hafif-orta uyumsuzluk olan gruba ve uyumsuzluğu olmayan gruba göre anlamlı derecede yüksek idi sırasıyla, median: 37 cm3, %95 CoI: 26.0-55.0; median: 10 cm3, %95CoI: 0-16.0; median: - 1.50 cm3, %95 CoI: -4.0 /8.0, χ2 = 8.294, p=0.017 . Uyumsuzluk ciddiyetinin İKY ile sonlanmaya etkisi ise istatistiksel olarak anlamlı değildi χ2:1.959, p:0,162 . İKY’nin elde edilme oranı FLH de büyüme olmayan grupta büyüme olan gruba göre istatistiksel olarak anlamlı düzeyde yüksek bulundu χ2:7,62, p:0,02 . Ancak ile İKY elde etme adına FLH hacim değişiminin bağımsız bir prediktör özelliği bulunmamıştır p:0.086, OR:0.972, %95CI:0.942-1.004 . Sonuç: Bu çalışmanın sonuçları şiddetli difüzyon-perfüzyon uyumsuzluğu olan akut iskemik inmeli hastaların radyolojik ve klinik gidişatları daha ciddi olabilir ve tedavide daha dikkatli olunmalıdır.

Anahtar Kelimeler

İskemik inme, difüzyon/perfüzyon uyumsuzluğu, sonuç infarktta büyüme, iyi klinik yanıt

Influence of penumbral area on final infarct volume and clinical outcome in ischemic stroke

Öz

Objective: Clinical outcome studies take an important place in following the progression of stroke. The use of perfusion weighted MR imaging in acute ischemic stroke has been an important cornerstone for the detection and treatment of the penumbral area. Material and Method: In the first 24 hours, diffusion and perfusion-weighted magnetic resonance imaging MRI were performed in patients with acute ischemic stroke. The perfusion-diffusion mismatch was divided into three groups as the patients with severe, with mild to moderate, and patients without mismatch. Clinical scores changes The National Institute of Health Stroke Scale, European Stroke Scale and Modified Rankin Scale at the admission and 15th day were examined to determine whether or not good clinical response GCR develops. Final lesion volume FLV was calculated as the difference of T2-weighted MRI taken on the 15th day from the initial diffusion-weighted MRI volume. Results: The increase in FLV was significantly higher in the group with severe mismatch than the group with mild to moderate mismatch and group without mismatch. respectively, median: 37 cm3, %95CoI: 26.0-55.0; median: 10 cm3, %95CoI: 0-16.0; median: - 1.50 cm3, %95CoI: -4.0 /8.0, χ2 = 8.294, p=0.017 . The effect of mismatch severity on GCR was not statistically significant χ2:1.959, p:0,162 . The rate of the GCR was found to be lower in the FLV growth group than the non-growth group with statistically significant difference x² = 7.62, p = 0.02 , but FLV change is not a independent predictor for GCR p:0.086, OR:0.972, %95CI:0.942-1.004 . Conclusion: Results of this study has suggested that among patients with acute stroke and severe mismatch, radiological and clinical outcomes can be more serious and treatment should be carefully considered.

Anahtar Kelimeler

Ischemic stroke, diffusion/perfusion mismatch, final lesion enlargement, favorable clinical response

Kaynakça

• Astrup J, Siesjo BK, Symon L. Thresholds in cerebral ische- mia the ischemic penumbra. Stroke 1981;12: 723-5.
• Neumann-Haefelin T, Wittsack HJ, Wenserski F, et al. Dif- fusion and Perfusion Weighted MRI The DWI/PWI Mis- match Region in Acute Stroke. Stroke 1999: 30; 1591-7.
• Dani KA, Thomas RG, Chappell FM, et al: Translational Medicine Research Collaboration Multicentre Acute Stroke Imaging Study. Ann Neurol 2011;70:384-401.
• Bandera Bandera E, Botteri M, Minelli C, et al. Cerebral blood flow threshold of ischemic penumbra and infarct core in acute ischemic stroke: a systematic review. Stroke 2006;37:1334-9.
• Campbell BC, Purushotham A, Christensen S, et al. The in- farct core is well represented by the acute diffusion lesion: sustained reversal is infrequent. J Cereb Blood Flow Metab 2012;32(1):50-6.
• Donnan GA, Baron JC, Ma H, et al. Penumbral selection of patients for trials of acute stroke therapy.The Lancet Neuro- logy 2009; 8: 261-9.
• Özeren A. Klinik yaklaşım ve sınıflama. In: Ed’s Kutluk K. Iskemik inme. Nobel Tıp Kitabevleri, 2004, pp: 70-1.
• Albers GW, Thijs VN, Wechsler L, et al. Magnetic resonan- ce imaging profiles predict clinical response to early reper- fusion: the diffusion and perfusion imaging evaluation for understanding stroke evolution (DEFUSE) study. Annals of Neurology 2006; 60: 508-7.
• Olivot JM, Mlynash M, Thijs VN, et al. Relationships betwe- en infarct growth, clinical outcome, and early recanalizati- on in diffusion and perfusion imaging for understanding stroke evolution (DEFUSE). Stroke 2008; 39: 2257-3.
• Luo S, Yang L, Wang L. Comparison of susceptibility-wei- ghted and perfusion-weighted magnetic resonance imaging in the detection of penumbra in acute ischemic stroke. J Neuroradiol 2015 Oct;42(5):255-60.
• Toth G, Albers GW. Use of MRI to estimate the therapeutic window in acute stroke: is perfusion-weighted imaging/dif- fusion-weighted imaging mismatch an EPITHET for salva- geable ischemic brain tissue? Stroke 2009; 40: 333-5.
• Baird AE, Benfield A, Schlaug G, et al. Enlargement of human cerebral ischemic lesion volumes measured by dif- fusion weighted magnetic resonance imaging. Annals of Neurology 1997; 41: 581-9.
• Hénon H, Godefroy O, Leys D, et al.Early predictors of de- ath and disability after acute cerebral ischemic event. Stroke 1995; 26: 392-8.
• Tong DC, Yenari MA, Albers GW, et al. Correlation of per- fusion- anddiffusion-weighted MRI with NIHSS score in acute (<6.5 hour) ischemicstroke. American Academy of Neurology 1998; 50: 864-70.
• Ay H, Dalkara T. İskemikpenumbra ve terapotik zaman aralığını etkileyen faktörler. Ed’s Balkan S. Serebrovasküler Hastalıklar. Güneş Tıp Kitabevi, 2005, pp: 29.
• Kutluk K. Hemodinami ve Otoregülasyon. Ed’s Kutluk K. İskemik İnme. Nobel Tıp Kitabevleri, 2004, pp: 9-17.
• Makris N, Chamard L, Mikkelsen IK, et al. Acute reperfu- sion without recanalization: Serial assessment of collaterals within 6 h of using perfusion-weighted magnetic resonan- cei maging. J Cereb Blood Flow Metab 2019;39:251-9.
• Warach S, Pettigrew LC, Dashe JF, et al. Effect of citicoli- ne on ischemic lesions as measured by diffusion-weighted magnetic resonance imaging. Citicoline 010 Investigators. Annals of Neurology 2000; 48: 713-22.
• Nuutinen J, Liu Y, Laakso MP, et al. Assessing the outcome of stroke: a comparison between MRI and clinical stroke scales. Acta Neurologica Scandinavia 2006;113: 100-7.
• Diner HC, Cunha L, Forbes C, et al. European Stroke Pre- vention Study 2. Dipyridamole and acetylsalicylicacid in the secondary prevention of stroke. Journal of the Neuro- logical Sciences 1996; 143: 1-13.
• European Stroke Organisation (ESO) Executive Commit- tee; ESO Writing Committee Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack. Ce- rebrovascular Diseases 2008; 25: 457-507.
• Chen C, Parsons MW, Clapham M, et al. Influence of pe- numbral reperfusion on clinical outcome depends on base- line ischemic core volume. Stroke 2017;48:2739-45.
• Heiss WD, Zaro-Weber O. Extension of therapeutic win- dow in ischemic stroke by selective mismatch imaging. Int J Stroke 2019;14:351-8.