血栓切除术院间转移前血脑屏障破坏和临床结果

摘要(中文译文)

在伴大血管闭塞的急性缺血性卒中（AIS-LVO）中，为接受血管内治疗（EVT）而进行的院际转运提供了一个理想的时间窗，在此期间可对神经保护策略进行评估，从而在再灌注前获得充分的暴露。我们旨在确定院际转运接受EVT前评估的血脑屏障（BBB）破坏是否与24小时出血转化（HT）及3个月功能结局相关。在这项多中心回顾性研究中，我们纳入了从前4家法国初级卒中中心（PSC）转运至综合卒中中心进行EVT评估的前循环AIS-LVO患者，这些患者在转运前于PSC接受了基线MR灌注成像。BBB破坏通过灌注源图像上钆对比剂渗漏所致的信号变化百分比进行量化。平均通透性异常（MPD）定义为缺血核心区内所有通透性值高于预设阈值的体素的平均值。主要结局为24小时随访影像上的任何脑实质内HT。采用多变量混合二元logistic回归分析研究MPD与HT之间的关联。共纳入289例患者：中位年龄为74岁（四分位距63-81），49%为女性，中位NIHSS评分为13（7-19），中位最后正常至PSC成像时间为2.5小时（1.7-4.7），中位核心体积为17 mL（0-40）。71%的患者在转运前接受了静脉溶栓，最终71%接受了EVT。从PSC成像至综合卒中中心到达的中位时间为3.3小时（2.6-3.8）。129例患者（45%）在24小时发生任何HT。在多变量分析中，校正核心体积、血糖水平、闭塞部位、发病至成像时间以及是否实施EVT后，MPD ≥3%与任何HT独立相关（OR 6.58；95% CI 2.84-15.22；< 0.001）。脑实质血肿（校正OR 3.31；95% CI 1.48-7.41；= 0.004）和3个月功能结局不良（改良Rankin量表评分3-6，校正OR 3.13；95% CI 1.38-7.09；= 0.006）也观察到类似关联。转运前灌注MRI上的BBB破坏与AIS-LVO患者的24小时HT及3个月功能结局不良相关。这些发现凸显了其在早期风险分层中的潜在价值，并为在院际转运接受EVT期间开展BBB靶向策略的前瞻性评估提供了依据。

Abstract

In acute ischemic stroke with large vessel occlusion (AIS-LVO), interhospital transfer for endovascular therapy (EVT) provides an ideal therapeutic window during which neuroprotective strategies could be evaluated, allowing sufficient exposure before reperfusion. We aimed to determine whether blood-brain barrier (BBB) disruption assessed before interhospital transfer for EVT is associated with 24-hour hemorrhagic transformation (HT) and 3-month functional outcome. In this multicenter retrospective study, we included patients with anterior circulation AIS-LVO transferred from 4 French primary stroke centers (PSCs) to comprehensive stroke centers for EVT assessment, with baseline MR perfusion imaging performed at the PSC before transfer. BBB disruption was quantified as the percentage signal change due to gadolinium leakage on perfusion source images. Mean permeability derangement (MPD) was defined as the average of all voxels within the ischemic core exhibiting permeability values greater than a prespecified threshold. The primary outcome was any intraparenchymal HT on 24-hour follow-up imaging. The association between MPD and HT was studied in multivariable mixed binary logistic regression analyses. A total of 289 patients were included: the median age was 74 years (interquartile range 63-81), 49% were female, the median NIHSS score was 13 (7-19), the median last-seen-well-to-PSC imaging time was 2.5 hours (1.7-4.7), and the median core volume was 17 mL (0-40). Intravenous thrombolysis was administered before transfer in 71% of patients, and EVT was eventually performed in 71%. The median time from PSC imaging to comprehensive stroke center arrival was 3.3 hours (2.6-3.8). Any HT at 24 hours occurred in 129 patients (45%). In multivariable analysis, MPD ≥3% was independently associated with any HT (OR 6.58; 95% CI 2.84-15.22; < 0.001) after adjustment for core volume, glucose level, occlusion site, onset-to-imaging time, and whether EVT was performed. Similar associations were observed for parenchymal hematoma (adjusted OR 3.31; 95% CI 1.48-7.41; = 0.004) and poor 3-month functional outcome (modified Rankin Scale score 3-6, adjusted OR 3.13; 95% CI 1.38-7.09; = 0.006). BBB disruption on pretransfer perfusion MRI is associated with 24-hour HT and poor 3-month functional outcome in patients with AIS-LVO. These findings highlight its potential value for early risk stratification and justify prospective evaluation of BBB-targeted strategies during interhospital transfer for EVT.

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