自动化头颅计算机断层扫描灌注成像在脑急性大血管闭塞血管内治疗中的应用研究进展

doi:10.3969/j.issn.1673-5765.2021.11.002

摘要/Abstract

摘要： 自动化CTP是通过自动化灌注处理软件处理CTP原始数据的一种灌注成像方式，能快速、精准地定量预测急性缺血性卒中核心梗死和缺血半暗带体积，评估侧支循环代偿情况及识别闭塞血管类型，帮助临床医师更精准地选择能从血管内治疗中获益的急性脑大血管闭塞患者。本文就自动化CTP参数的具体意义和临床应用的最新进展进行综述，并评价自动化CTP的局限性及未来发展方向。

文章导读： 自动化CTP是在血管内治疗前评估急性脑大血管闭塞患者能否从中获益的重要影像方式。未来还需不断优化自动化CTP处理软件的算法，积极应用其作为后循环大血管闭塞的术前评估工具，使更多患者获益。

关键词: 计算机断层扫描灌注成像; 急性大血管闭塞; 血管内治疗; 核心梗死; 缺血半暗带; 缺血性卒中

Abstract: Automated CTP imaging is an kind of perfusion image method using automated perfusion processing software to interpret perfusion raw data. It can quickly, accurately and quantitatively evaluate the volume of core infarction and ischemic penumbra, evaluate collateral circulation and identify the type of occlusion vessels, and help doctors to select eligible patients with acute large vessel occlusion who can benefit from endovascular treatment. This article reviewed the specific significance of CTP parameters, and the progress of clinical application, the limitations and future development directions of automated CTP.

Key words: Computed tomography perfusion imaging; Acute large vessel occlusion; Endovascular treatment; Core infarction; Ischemic penumbra; Ischemic stroke

孙大鹏, 霍晓川, 马高亭, 佟旭, 张雪蕾, 缪中荣. 自动化头颅计算机断层扫描灌注成像在脑急性大血管闭塞血管内治疗中的应用研究进展[J]. 中国卒中杂志, 2021, 16(11): 1092-1098.

SUN Da-Peng, HUO Xiao-Chuan, MA Gao-Ting, TONG Xu, ZHANG Xue-Lei, MIAO Zhong-Rong. vProgress of Automated Computed Tomography Perfusion in Endovascular Treatment for Acute Large Vessel Occlusion[J]. Chinese Journal of Stroke, 2021, 16(11): 1092-1098.

参考文献

[1] WU S M，WU B，LIU M，et al. Stroke in China：
advances and challenges in epidemiology，prevention，
and management[J]. Lancet Neurol，2019，18（4）：
394-405.
[2] KHANDELWAL P，YAVAGAL D R，SACCO R L.
Acute ischemic stroke intervention[J]. J Am Coll
Cardiol，2016，67（22）：2631-2644.
[3] OSPEL J M，HOLODINSKY J K，GOYAL M.
Management of acute ischemic stroke due to largevessel
occlusion：JACC focus seminar[J]. J Am Coll
Cardiol，2020，75（15）：1832-1843.
[4] GOYAL M，MENON B K，VAN ZWAM W H，et
al. Endovascular thrombectomy after large-vessel
ischaemic stroke：a meta-analysis of individual
patient data from five randomised trials[J]. Lancet，
2016，387（10029）：1723-1731.
[5] NOGUEIRA R G，JADHAV A P，HAUSSEN D C，
et al. Thrombectomy 6 to 24 hours after stroke with
a mismatch between deficit and infarct[J]. N Engl J
Med，2018，378（1）：11-21.
[6] ALBERS G W，MARKS M P，KEMP S，et al.
Thrombectomy for stroke at 6 to 16 hours with
selection by perfusion imaging[J]. N Engl J Med，
2018，378（8）：708-718.
[7] CAMPBELL B C V，LANSBERG M G，
BRODERICK J P，et al. Acute stroke imaging
research roadmap IV：imaging selection and
outcomes in acute stroke clinical trials and
practice[J]. Stroke，2021，52（8）：2723-2733.
[8] POWERS W J，RABINSTEIN A A，ACKERSON
T，et al. Guidelines for the early management of
patients with acute ischemic stroke：2019 update
to the 2018 guidelines for the early management of
acute ischemic stroke：a guideline for healthcare
professionals from the American Heart Association/
American Stroke Association[J/OL]. Stroke，2019，
50（12）：e344-e418[2021-08-10]. https：//doi.
org/10.1161/STR.0000000000000211.

[9] SOTOUDEH H，BAG A K，BROOKS M D. "Code-

Stroke" CT perfusion; challenges and pitfalls[J].
Acad Radiol，2019，26（11）：1565-1579.
[10] WINTERMARK M，SINCIC R，SRIDHAR D，et
al. Cerebral perfusion CT：technique and clinical
applications[J]. J Neuroradiol，2008，35（5）：253-
260.
[11] WHEELER H M，MLYNASH M，INOUE M，et
al. Early diffusion-weighted imaging and perfusionweighted
imaging lesion volumes forecast final
infarct size in DEFUSE 2[J]. Stroke，2013，44（3）：
681-685.
[12] BARBER P A，DEMCHUK A M，ZHANG
J，et al. Validity and reliability of a quantitative
computed tomography score in predicting outcome
of hyperacute stroke before thrombolytic therapy.
ASPECTS study group. Alberta stroke programme
early CT score[J]. Lancet，2000，355（9216）：1670-
1674.
[13] ALBERS G W. Use of imaging to select patients for
late window endovascular therapy[J]. Stroke，2018，
49（9）：2256-2260.
[14] DEMEESTERE J，WOUTERS A，CHRISTENSEN
S，et al. Review of perfusion imaging in acute
ischemic stroke：from time to tissue[J]. Stroke，2020，
51（3）：1017-1024.
[15] CAMPBELL B C V，CHRISTENSEN S，LEVI C R，
et al. Cerebral blood flow is the optimal CT perfusion
parameter for assessing infarct core[J]. Stroke，2011，
42（12）：3435-3440.
[16] CEREDA C W，CHRISTENSEN S，CAMPBELL B
C V，et al. A benchmarking tool to evaluate computer
tomography perfusion infarct core predictions
against a DWI standard[J]. J Cereb Blood Flow
Metab，2016，36（10）：1780-1789.
[17] ALBERS G W，GOYAL M，JAHAN R，et al.
Ischemic core and hypoperfusion volumes predict
infarct size in SWIFT PRIME[J]. Ann Neurol，2016，
79（1）：76-89.
[18] AMUKOTUWA S，STRAKA M，AKSOY D，et
al. Cerebral blood flow predicts the infarct core：
new insights from contemporaneous diffusion and
perfusion imaging[J]. Stroke，2019，50（10）：2783-
2789.
[19] YANG S H，LIU R. Four decades of ischemic
penumbra and its implication for ischemic stroke[J].
Transl Stroke Res，2021，12（6）：937-945.
[20] OLIVOT J M，MLYNASH M，THIJS V N，et al.
Optimal Tmax threshold for predicting penumbral
tissue in acute stroke[J]. Stroke，2009，40（2）：469-
475.
[21] ZARO-WEBER O，MOELLER-HARTMANN
W，HEISS W D，et al. Maps of time to maximum
and time to peak for mismatch definition in clinical
stroke studies validated with positron emission
tomography[J]. Stroke，2010，41（12）：2817-2821.
[22] BERETTA S，CUCCIONE E，VERSACE A，et
al. Cerebral collateral flow defines topography and
evolution of molecular penumbra in experimental
ischemic stroke[J/OL]. Neurobiol Dis，2015，74：
305-313[2021-08-10]. https：//doi.org/10.1016/
j.nbd.2014.11.019.
[23] BAL S，BHATIA R，MENON B K，et al. Time
dependence of reliability of noncontrast computed
tomography in comparison to computed tomography
angiography source image in acute ischemic
stroke[J]. Int J Stroke，2015，10（1）：55-60.
[24] KASCHKA I N，KLOSKA S P，STRUFFERT T，et
al. Clot burden and collaterals in anterior circulation
stroke：differences between single-phase CTA and
multi-phase 4D-CTA[J]. Clin Neuroradiol，2016，26
（3）：309-315.
[25] OLIVOT J M，MLYNASH M，INOUE M G，et
al. Hypoperfusion intensity ratio predicts infarct
progression and functional outcome in the DEFUSE
2 cohort[J]. Stroke，2014，45（4）：1018-1023.
[26] GUENEGO A，MLYNASH M，CHRISTENSEN
S，et al. Hypoperfusion ratio predicts infarct growth
during transfer for thrombectomy[J]. Ann Neurol，
2018，84（4）：616-620.
[27] GUENEGO A，FAHED R，ALBERS G W，et
al. Hypoperfusion intensity ratio correlates with
angiographic collaterals in acute ischaemic stroke
with M1 occlusion[J]. Eur J Neurol，2020，27（5）：
864-870.
[28] ARENILLAS J F，CORTIJO E，GARCÍABERMEJO
P，et al. Relative cerebral blood volume
is associated with collateral status and infarct growth
in stroke patients in SWIFT PRIME[J]. J Cereb
Blood Flow Metab，2018，38（10）：1839-1847.
[29] BECKS M J，MANNIESING R，VISTER J，et
al. Brain CT perfusion improves intracranial
vessel occlusion detection on CT angiography[J]. J
Neuroradiol，2019，46（2）：124-129.
[30] FASEN B A C M，HEIJBOER R J J，HULSMANS
F H，et al. CT angiography in evaluating large-vessel
occlusion in acute anterior circulation ischemic
stroke：factors associated with diagnostic error in
clinical practice[J]. AJNR Am J Neuroradiol，2020，
41（4）：607-611.
[31] AMUKOTUWA S A，WU A，ZHOU K，et al. Distal
medium vessel occlusions can be accurately and
rapidly detected using Tmax maps[J]. Stroke，2021，52
（10）：3308-3317.
[32] CAMPBELL B C，MITCHELL P J，KLEINIG T J，
et al. Endovascular therapy for ischemic stroke with
perfusion-imaging selection[J]. N Engl J Med，2015，
372（11）：1009-1018.
[33] SAVER J L，GOYAL M，BONAFE A，et al. Stentretriever
thrombectomy after intravenous t-PA vs .
t-PA alone in stroke[J]. N Engl J Med，2015，372
（24）：2285-2295.
[34] SARRAJ A，HASSAN A E，GROTTA J，et al. Early
infarct growth rate correlation with endovascular
thrombectomy clinical outcomes：analysis from the
SELECT study[J]. Stroke，2021，52（1）：57-69.
[35] CAMPBELL B C V，MAJOIE C，ALBERS G W，et
al. Penumbral imaging and functional outcome in
patients with anterior circulation ischaemic stroke
treated with endovascular thrombectomy versus
medical therapy：a meta-analysis of individual
patient-level data[J]. Lancet Neurol，2019，18（1）：
46-55.
[36] SARRAJ A，HASSAN A E，SAVITZ S，et al.
Outcomes of endovascular thrombectomy vs medical
management alone in patients with large ischemic
cores：a secondary analysis of the optimizing
patient's selection for endovascular treatment in
acute ischemic stroke（SELECT）study[J]. JAMA
Neurol，2019，76（10）：1147-1156.
[37] SENERS P，OPPENHEIM C，TURC G，et al.
Perfusion imaging and clinical outcome in acute
ischemic stroke with large core[J]. Ann Neurol，2021，
90（3）：417-427.
[38] YOSHIMOTO T，INOUE M，TANAKA K，et
al. Identifying large ischemic core volume
ranges in acute stroke that can benefit from
mechanical thrombectomy[J/OL]. J Neurointerv
Surg，2020[2021-08-10]. https：//doi.org/10.1136/
neurintsurg-2020-016934.
[39] REN Z G，HUO X C，MA G T，et al. Selection
criteria for large core trials：rationale for the
ANGEL-ASPECT study design[J/OL]. J Neurointerv
Surg，2021，neurintsurg-2021-017798[2021-08-10].
https：//doi.org/10.1136/neurintsurg-2021-017798.
[40] KASASBEH A S，CHRISTENSEN S，STRAKA
M，et al. Optimal computed tomographic perfusion
scan duration for assessment of acute stroke lesion
volumes[J]. Stroke，2016，47（12）：2966-2971.
[41] NAJM M，AL-AJLAN F S，BOESEN M E，et al.
Defining CT perfusion thresholds for infarction in
the golden hour and with ultra-early reperfusion[J].
Can J Neurol Sci，2018，45（3）：339-342.
[42] BIVARD A，KLEINIG T，MITEFF F，et al.
Ischemic core thresholds change with time to
reperfusion：a case control study[J]. Ann Neurol，
2017，82（6）：995-1003.