卒中后出血转化的影像学评估

doi:10.3969/j.issn.1673-5765.2019.08.013

摘要/Abstract

摘要：

出血转化是缺血性卒中患者静脉溶栓及血管内治疗最严重的并发症之一，对于缺血性卒中患者，在考虑卒中急性期血流再灌注、避免血管再闭塞的同时，关注出血转化高风险人群的筛查是提高卒中治疗质量的关键之一。颅脑CT、CTA、MRI、DWI、SWI及灌注成像等多种神经影像学诊断技术可快速获取有关卒中性质、核心梗死灶体积、病灶及周围血流灌注状态、血管病变程度及病变血管管壁通透性等相关信息，以预测患者的出血转化风险，指导临床医师治疗措施的选择，从而改善患者预后。

文章导读： 本文对传统和新发展的影像学技术在预测急性缺血性卒中溶栓和血管内治疗后出血转化风险方面的研究进展进行了概述。

关键词: 缺血性卒中; 出血转化; 神经影像学技术

Abstract:

Hemorrhagic transformation (HT) is one of the most severe complications after endovascular revascularization or intravenous thrombolysis in patients with acute ischemic stroke. Identifying ischemic stroke patients who are at high risk of HT is crucial for guiding therapeutic strategies. Currently, there are a variety of neuroimaging techniques such as brain CT, CTA, MRI, DWI, SWI and perfusion imaging and etc. The information of stroke category, core infarct volume, vascular lesions, the perfusion state of ischemic lesion and perilesional area, the permeability of culprit vessel wall and so on can be rapidly obtained by the above imaging examination, which can be used to assess the risk of HT. In a word, the evaluation of HT risk is very helpful for clinicians to make optimal therapeutic strategy for stroke patients, to improve the prognosis of patients.

Key words: Ischemic stroke; Hemorrhagic transformation; Neuroimaging technique

李文君，刘俊艳. 卒中后出血转化的影像学评估[J]. 中国卒中杂志, 2019, 14(08): 803-808.

LI Wen-Jun, LIU Jun-Yan. Imaging Evaluation of Post-stroke Hemorrhagic Transformation[J]. Chinese Journal of Stroke, 2019, 14(08): 803-808.

参考文献

[1] National Institute of Neurological Disorders

and Stroke rt-PA Stroke Study Group. Tissue

plasminogen activator for acute ischemic stroke[J].

N Engl J Med，1995，333（24）：1581-1587.

[2] HACKE W，KASTE M，BLUHMKI E，et al.

Thrombolysis with alteplase 3 to 4.5 hours after

acute ischemic stroke[J]. N Engl J Med，2008，359

（13）：1317-1329.

[3] The NINDS t-PA Stroke Study Group. Intracerebral

hemorrhage after intravenous t-PA therapy for

ischemic stroke[J]. Stroke，1997，28（11）：2109-2118.

[4] MAZYA M，EGIDO J A，FORD G A，et al. Predicting the risk of symptomatic intracerebral

hemorrhage in ischemic stroke treated with

intravenous alteplase：Safe Implementation

of Treatments in Stroke（SITS）symptomatic

intracerebral hemorrhage risk score[J]. Stroke，2012，

43（6）：1524-1531.

[5] CAMM A J，KIRCHHOF P，LIP G Y，et al.

Guidelines for the management of atrial fibrillation：

the Task Force for the Management of Atrial

Fibrillation of the European Society of Cardiology

（ESC）[J]. Eur Heart J，2010，31（19）：2369-2429.

[6] BARBER P A，DEMCHUK A M，ZHANG J. 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.

[7] CAMPBELL B C，CHRISTENSEN S，BUTCHER

K S，et al. Regional very low cerebral blood volume

predicts hemorrhagic transformation better than

diffusion-weighted imaging volume and thresholded

apparent diffusion coefficient in acute ischemic

stroke[J]. Stroke，2010，41（1）：82-88.

[8] 王崇，董瑞国. Alberta卒中项目早期CT评分系统及其

应用[J]. 国际脑血管病杂志，2010，18（11）：854-859.

[9] 齐洁，高红梅，龙涛，等. 急性脑梗死合并脑心综合征

患者血糖水平对预后的影响[J]. 中华危重病急救医学，

2016，28（7）：646-647.

[10] 罗轩文，罗伟良. 合并非瓣膜性房颤急性脑梗死2周内

脑出血转化的危险因素[J]. 中国神经精神疾病杂志，

2019，45（3）：139-143.

[11] KIM S K，BAEK B H，LEE Y Y，et al. Clinical

implications of CT hyperdense artery sign in patients

with acute middle cerebral artery occlusion in the era

of modern mechanical thrombectomy[J]. J Neurol，

2017，264（12）：2450-2456.

[12] 郭毅佳，朱加应，洪烨，等. 大脑中动脉高密度征对

急性缺血性卒中的临床预测价值：一项基于多模态

CT的队列研究[J]. 四川大学学报（医学版），2018，48

（5）：743-748.

[13] ZOU M，CHURILOV L，HE A，et al. Hyperdense

middle cerebral artery sign is associated with

increased risk of hemorrhagic transformation after

intravenous thrombolysis for patients with acute

ischaemic stroke[J]. J Clin Neurosci，2013，20（7）：

984-987.

[14] 彭琳，郭岩，王玉，等. 伴有大脑中动脉高密度征的急

性脑梗死静脉溶栓疗效分析[J]. 中华医学杂志，2017，

97（3）：193-197.

[15] GEORGIADIS D，WIRZ F，VON BÜDINGEN H

C，et al. Intravenous thrombolysis in stroke patients

with hyperdense middle cerebral artery sign[J]. Eur J

Neurol，2009，16（2）：162-167.

[16] 邢鹏飞，沈红健，李子付，等. 机械取栓术中平板CT高

密度征出血转化及预后的影响因素分析[J]. 中国脑血

管病杂志，2019，16（2）：57-65.

[17] ROUCHAUD A，PISTOCCHI S，BLANC R，et al.

Predictive value of flat-panel CT for haemorrhagic

transformations in patients with acute stroke treated

with thrombectomy[J]. J Neurointerv Surg，2014，6

（2）：139-143.

[18] KIM J M，PARK K Y，LEE W J，et al. The cortical

contrast accumulation from brain computed

tomography after endovascular treatment predicts

symptomatic hemorrhage[J]. Eur J Neurol，2015，22

（11）：1453-1458.

[19] 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.

[20] MADELUNG C F，OVESEN C，TRAMPEDACH

C，et al. Leptomeningeal collateral status predicts

outcome after middle cerebral artery occlusion[J].

Acta Neurol Scand，2018，137（1）：125-132.

[21] FANOU E M，KNIGHT J，AVIV R I，et al. Effect of

collaterals on clinical presentation，baseline imaging，

complications，and outcome in acute stroke[J]. AJNR

Am J Neuroradiol，2015，36（12）：2285-2291.

[22] SCHWAMM L H，ROSENTHAL E S，SWAP C

J，et al. Hypoattenuation on CT angiographic source

images predicts risk of intracerebral hemorrhage and

outcome after intra-arterial reperfusion therapy[J].

AJNR Am J Neuroradiol，2005，26（7）：1798-1803.

[23] LIN K，ZINK W E，TSIOURIS A J，et al. Risk

assessment of hemorrhagic transformation of acute

middle cerebral artery stroke using multimodal CT[J].

J Neuroimaging，2012，22（2）：160-166.

[24] JAIN A R，JAIN M，KANTHALA A R，et

al. Association of CT perfusion parameters with

hemorrhagic transformation in acute ischemic

stroke[J]. AJNR Am J Neuroradiol，2013，34（10）：

1895-1900.

[25] LIU L，WU B，ZHAO J，et al. Computed tomography

perfusion alberta stroke program early computed

tomography score is associated with hemorrhagic

transformation after acute cardioembolic stroke[J/OL].

Front Neurol，2017，8：591. https：//doi.org/10.3389/

fneur.2017.00591.

[26] SOUZA L C，PAYABVASH S，WANG Y，et al.

Admission CT perfusion is an independent predictor

of hemorrhagic transformation in acute stroke with

similar accuracy to DWI[J]. Cerebrovasc Dis，2012，

33（1）：8-15. [27] MOKIN M，MORR S，FANOUS A A，et al.

Correlation between cerebral blood volume values

and outcomes in endovascular therapy for acute

ischemic stroke[J]. J Neurointerv Surg，2015，7（10）：

705-708.

[28] SHINOYAMA M，NAKAGAWARA J，YONEDA

H，et al. Initial 'TTP Map-Defect' of computed

tomography perfusion as a predictor of hemorrhagic

transformation of acute ischemic stroke[J].

Cerebrovasc Dis Extra，2013，3（1）：14-25.

[29] YU S，LIEBESKIND D S，DUA S，et al.

Postischemic hyperperfusion on arterial spin

labeled perfusion MRI is linked to hemorrhagic

transformation in stroke[J]. J Cereb Blood Flow

Metab，2015，35（4）：630-637.

[30] CHEN H，LIU N，LI Y，et al. Mismatch of

low perfusion and high permeability predicts

hemorrhagic transformation region in acute

ischemic stroke patients treated with intra-arterial

thrombolysis[J/OL]. Sci Rep，2016，6：27950. https：

//doi.org/10.1038/srep27950.

[31] YEN P，COBB A，SHANKAR J J. Does computed

tomography permeability predict hemorrhagic

transformation after ischemic stroke?[J]. World J

Radiol，2016，8（6）：594-599.

[32] HOM J，DANKBAAR J W，SOARES B P，et

al. Blood-brain barrier permeability assessed by

perfusion CT predicts symptomatic hemorrhagic

transformation and malignant edema in acute

ischemic stroke[J]. AJNR Am J Neuroradiol，2011，

32（1）：41-48.

[33] KUFNER A，GALINOVIC I，BRUNECKER P，et

al. Early infarct FLAIR hyperintensity is associated

with increased hemorrhagic transformation after

thrombolysis[J]. Eur J Neurol，2013，20（2）：281-

285.

[34] AHN S H，KIM B J，KIM Y J，et al. Fluidattenuated

inversion recovery hyperintensity is

associated with hemorrhagic transformation

following reperfusion therapy[J]. J Stroke

Cerebrovasc Dis，2017，26（2）：327-333.

[35] WEI C C，ZHANG S T，WANG Y H，et al.

Association between leukoaraiosis and hemorrhagic

transformation after cardioembolic stroke due to

atrial fibrillation and/or rheumatic heart disease[J/

OL]. J Neurol Sci，2017，378：94-99. https：//doi.org/

10.1016/j.jns.2017.05.001.

[36] 刘艳艳，张敏，恽文伟，等. 中重度脑白质疏松对急

性脑梗死静脉溶栓患者出血转化及预后的影响[J].

中华神经科杂志，2017，50（12）：885-891.

[37] 刘艳艳，张敏，高萍，等. 伴有中重度脑白质疏松的

急性脑梗死患者静脉溶栓疗效分析[J]. 中华医学杂

志，2018，98（13）：998-1002.

[38] GUO G，YANG Y，YANG W. Validation of

hyperintense middle cerebral artery sign in acute

ischemic stroke：comparison between magnetic

resonance imaging and angiography[J]. Neural

Regen Res，2012，7（3）：229-234.

[39] MORIYA Y，TAKAHASHI W，KIJIMA C，et al.

Predictors for hemorrhagic transformation with

intravenous tissue plasminogen activator in acute

ischemic stroke[J]. Tokai J Exp Clin Med，2013，38

（1）：24-27.

[40] TAKAHASHI W，MORIYA Y，MIZUMA A，et al.

Cerebral microbleeds on T2

*-weighted images and

hemorrhagic transformation after antithrombotic

therapies for ischemic stroke[J/OL]. J Stroke

Cerebrovasc Dis，2013，22（8）：e528-e532. https：//

doi.org/10.1016/j.jstrokecerebrovasdis.2013.05.037.

[41] LI-PENG CHEN，XIN-QING JIANG，ZHAO

ZHAO，et al. Apparent diffusion coeffcient value for

prediction of hemorrhagic transformation in acute

ischemic infarction[J]. Int J Clin Exp Med，2018，11

（1）：109-117.

[42] SHINODA N，HORI S，MIKAMI K，et al. Utility

of relative ADC ratio in patient selection for

endovascular revascularization of large vessel

occlusion[J]. J Neuroradiol，2017，44（3）：185-191.

[43] SHINODA N，HORI S，MIKAMI K，et al.

Prediction of hemorrhagic transformation after

acute thrombolysis following major artery occlusion

using relative ADC ratio：a retrospective study[J]. J

Neuroradiol，2017，44（6）：361-366.

[44] NAGARAJA N，TASNEEM N，SHABAN A，et al.

Cerebral microbleeds are an independent predictor of

hemorrhagic transformation following intravenous

alteplase administration in acute ischemic stroke[J].

J Stroke Cerebrovasc Dis，2018，27（5）：1403-1411.

[45] TSIVGOULIS G，ZAND R，KATSANOS A H，et

al. Risk of symptomatic intracerebral hemorrhage

after intravenous thrombolysis in patients with acute

ischemic stroke and high cerebral microbleed burden：

a Meta-analysis[J]. JAMA Neurol，2016，73（6）：

675-683.