急性缺血性卒中不同时间窗影像学评价及应用进展

doi:10.3969/j.issn.1673-5765.2024.09.015

摘要/Abstract

摘要： 急性缺血性卒中（acute ischemic stroke，AIS）具有高致残率和高致死率特征，早期识别AIS和准确评估AIS的时间窗，对提高治疗效果具有重要意义。近年来，多模态影像技术指导的治疗时间窗评估在AIS的个体化精细管理中越来越被重视。明确AIS不同发病时间的影像特征，对早期识别AIS、评估AIS患者发病时间、判断病情动态变化以及指导再灌注治疗有重要意义。目前单一成像模式已经无法满足AIS精细化管理的临床需求，通过合理的多模态影像联合应用，能够更好地实现AIS的早期诊断、发病时间评估和预后评价。本文分别对AIS不同发病时间CT、MRI的影像学特征，多模态影像技术的应用价值和进展，以及机器学习和人工智能技术在AIS诊断和治疗中的潜在价值进行综述。

文章导读： 本文综述了影像学技术指导的治疗时间窗评估在急性缺血性卒中个体化精细管理中的应用及前景，特别是多模态影像和人工智能的发展，有望更好地实现AIS的早期诊断、发病时间评估和预后评价，为扩展急性缺血性卒中治疗的时间窗提供支持。

关键词: 急性缺血性卒中; 影像技术; 多模态; 发病至成像时间; 人工智能

Abstract: Acute ischemic stroke (AIS) is characterized by high rates of disability and mortality. Early identification of AIS and accurate assessment of the time window for AIS are of great significance for improving the outcome. In recent years, the evaluation of the treatment time window guided by multimodal imaging technology has been increasingly concerned in the individualized and precise management of AIS. Clarifying the imaging characteristics of AIS at various onset time is crucial for early identification of AIS, accurate assessment of its onset time, evaluation of dynamic changes of the disease, and the effective guidance of reperfusion therapy. At present, a single imaging mode can no longer meet the clinical needs of precise management of AIS. Reasonable combined application of multimodal imaging can better achieve early diagnosis, onset time assessment, and prognosis evaluation of AIS. This paper reviewed the CT and MRI imaging characteristics of AIS at different onset time, the application value and progress of multimodal imaging technology, as well as the potential value of machine learning and artificial intelligence in the diagnosis and treatment of AIS.

Key words: Acute ischemic stroke; Imaging technology; Multimodality; Onset-to-imaging time; Artificial intelligence

中图分类号:

吴春艳, 尹雅诗, 王广志, 岳奎涛. 急性缺血性卒中不同时间窗影像学评价及应用进展[J]. 中国卒中杂志, 2024, 19(9): 1094-1101.

WU Chunyan, YIN Yashi, WANG Guangzhi, YUE Kuitao. Evaluation and Application of Medical Imaging for Acute Ischemic Stroke at Different Time Windows: A Review[J]. Chinese Journal of Stroke, 2024, 19(9): 1094-1101.

参考文献

[1] ESTRADA U M L，MEEKS G，SALAZAR-MARIONI S，et al. Quantification of infarct core signal using CT imaging in acute ischemic stroke[J/OL]. Neuroimage Clin，2022，34：102998[2024-02-18]. https://doi.org/10.1016/j.nicl.2022.102998.

[2] VIRANI S S，ALONSO A，BENJAMIN E J，et al. Heart disease and stroke statistics—2020 update：a report from the American Heart Association[J/OL]. Circulation，2020，141（9）：e139-e596[2024-02-18]. https://doi.org/10.1161/CIR.0000000000000757.

[3] MENDELSON S J，PRABHAKARAN S. Diagnosis and management of transient ischemic attack and acute ischemic stroke：a review[J]. JAMA，2021，325（11）：1088-1098.

[4] GOLDSTEIN L B. IV tPA for acute ischemic stroke：times are changing[J]. Neurology，2016，87（21）：2178-2179.

[5] VAN POPPEL L M，MAJOIE C B L M，MARQUERING H A，et al. Associations between early ischemic signs on non-contrast CT and time since acute ischemic stroke onset：a scoping review[J/OL]. Eur J Radiol，2022，155：110455[2024-02-18]. https://doi.org/10.1016/j.ejrad.2022.110455.

[6] RENNERT R C，WALI A R，STEINBERG J A，et al. Epidemiology，natural history，and clinical presentation of large vessel ischemic stroke[J/OL]. Neurosurgery，2019，85（suppl_1）：S4-S8[2024-02-18]. https://doi.org/10.1093/neuros/nyz042.

[7] 浦溦. 基于深度学习的急性缺血性脑卒中CTP图像分割研究[D]. 重庆：重庆理工大学，2023.

PU W. Research on CTP image segmentation of acute ischemic stroke based on deep learning[D]. Chongqing：Chongqing University of Technology，2023.

[8] 国家卫生健康委员会脑卒中防治工程委员会神经影像专业委员会，中华医学会放射学分会神经学组. 脑血管病影像规范化应用中国指南[J]. 中华放射学杂志，2019，53（11）：916-940.

National Health Commission Stroke Prevention Expert Commission Neuroimaging Committee，Chinese Medical Association Radiology Society Neuroimaging Group. Chinese guideline for standard utilization of imaging for cerebrovascular diseases[J]. Chin J Radiol，2019，53（11）：916-940.

[9] 陈晓宇，王希明. 人工智能在急性缺血性脑卒中成像中的应用进展[J]. 国际医学放射学杂志，2022，45（4）：444-448.

CHEN X Y，WANG X M. The progress of artificial intelligence in acute ischemic stroke imaging[J]. International Journal of Medical Radiology，2022，45（4）：444-448.

[10] 王华明，凌倪云，鲁彩云. 急性缺血性脑卒中多模态影像学诊断效能与血管内介入治疗效果的应用研究[J]. 现代医用影像学，2023，32（2）：391-393，396.

WANG H M，LING N Y，LU C Y. Research on the application of multimodal imaging diagnostic efficacy and endovascular intervention therapeutic effects in acute ischemic stroke[J]. Modern Medical Imageology，2023，32（2）：391-393，396.

[11] 高天理. 不同时间窗急性缺血性脑卒中患者及不同药物在静脉溶栓治疗中的临床应用推荐：2021版《欧洲卒中组织急性缺血性脑卒中静脉溶栓指南》解读[J]. 实用心脑肺血管病杂志，2021，29（7）：1-8.

GAO T L. Recommendations for the clinical application of patients with acute ischemic stroke in different time windows and different drugs in intravenous thrombolysis：interpretation of 2021 European Stroke Organization（ESO）Guidelines on Intravenous Thrombolysis for Acute Ischemic Stroke[J]. Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease，2021，29（7）：1-8.

[12] 中华医学会神经病学分会，中华医学会神经病学分会脑血管病学组. 中国急性缺血性卒中诊治指南2023[J]. 中华神经科杂志，2024，57（6）：523-559.

Chinese Society of Neurology，Chinese Stroke Society. Chinese guidelines for diagnosis and treatment of acute ischemic stroke 2023[J]. Chin J Neurol，2024，57（6）：523-559.

[13] 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[2024-02-18]. https://doi.org/10.1161/STR.0000000000000211.

[14] SARIKAYA B，PROVENZALE J. Frequency of various brain parenchymal findings of early cerebral ischemia on unenhanced CT scans[J]. Emerg Radiol，2010，17（5）：381-390.

[15] GARCíA-BERMEJO P，CALLEJA A I，PéREZ-FERNáNDEZ S，et al. Perfusion computed tomography-guided intravenous thrombolysis for acute ischemic stroke beyond 4.5 hours：a case-control study[J]. Cerebrovasc Dis，2012，34（1）：31-37.

[16] BATHLA G，AJMERA P，MEHTA P M，et al. Advances in acute ischemic stroke treatment：current status and future directions[J]. AJNR Am J Neuroradiol，2023，44（7）：750-758.

[17] MA H，CAMPBELL B C V，PARSONS M W，et al. Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke[J]. N Engl J Med，2019，380（19）：1795-1803.

[18] 方琪，王希明，李子惠. 急性缺血性脑卒中缺血半暗带影像评估研究进展[J]. 第二军医大学学报，2018，39（9）：954-958.

FANG Q，WANG X M，LI Z H. Progress in imaging evaluation of ischemic penumbra in acute ischemic stroke[J]. Acad J Sec Mil Med Univ，2018，39（9）：954-958.

[19] DHILLON P S，BUTT W，PODLASEK A，et al. Perfusion imaging for endovascular thrombectomy in acute ischemic stroke is associated with improved functional outcomes in the early and late time windows[J]. Stroke，2022，53（9）：2770-2778.

[20] 中国医师协会神经外科学分会神经重症专家委员会，上海卒中学会，重庆市卒中学会. 脑卒中病情监测中国多学科专家共识[J]. 中华医学杂志，2021，101（5）：317-326.

Neurocritical Care Expert Committee of Branch of Neurosurgery of Chinese Medical Doctor Association，Shanghai Stroke Association，Chongqing Stroke Association. Chinese multidisciplinary expert consensus on stroke condition monitoring[J]. Natl Med J China，2021，101（5）：317-326.

[21] 王丹，王秀玲，汪轩. 弥散加权成像（DWI）和灌注加权成像（PWI）在超急性和急性缺血性脑卒中的应用价值[J]. 影像研究与医学应用，2022，6（15）：86-88.

WANG D，WANG X L，WANG X. Application value of diffusion weighted imaging（DWI）and perfusion weighted imaging（PWI）in hyperacute and acute ischemic stroke[J]. Journal of Imaging Research and Medical Applications，2022，6（15）：86-88.

[22] BRUNSER A M，HOPPE A，ILLANES S，et al. Accuracy of diffusion-weighted imaging in the diagnosis of stroke in patients with suspected cerebral infarct[J]. Stroke，2013，44（4）：1169-1171.

[23] 卢明聪，符大勇，孟云，等. 表观弥散系数及脑血流量值在急性大面积缺血性脑卒中出血转化预测中的应用价值[J]. 中国实用神经疾病杂志，2018，21（20）：2205-2211.

LU M C，FU D Y，MENG Y，et al. Value of apparent diffusion coefficient and cerebral blood flow in predicting hemorrhagic transformation in acute massive ischemic stroke[J]. Chinese Journal of Practical Nervous Diseases，2018，21（20）：2205-2211.

[24] GERALDO A F，BERNER L P，HAESEBAERT J，et al. Does b1000-b0 mismatch challenge diffusion-weighted imaging-fluid attenuated inversion recovery mismatch in stroke？[J]. Stroke，2016，47（3）：877-881.

[25] 陈鹏，李瑞雄，卢伟娟，等. 参数优化MRI作为急性缺血性脑卒中患者首选影像检查的可行性研究[J]. 中华急诊医学杂志，2019，28（9）：1118-1122.

CHEN P，LI R X，LU W J，et al. A feasibility study of parameter-optimized MRI as the first choice for imaging examination in patients with acute ischemic stroke[J]. Chin J Emerg Med，2019，28（9）：1118-1122.

[26] 吴迎春，王俊梅. DWI/Flair不匹配在醒后卒中和不明发病时间卒中患者再灌注治疗中应用研究[J]. 医学综述，2018，24（19）：3824-3828.

WU Y C，WANG J M. Reperfusion therapy for wake-up stroke and unknown-onset stroke based on DWI/Flair mismatch[J]. Medical Recapitulate，2018，24（19）：3824-3828.

[27] THOMALLA G，CHENG B，EBINGER M，et al. DWI-FLAIR mismatch for the identification of patients with acute ischaemic stroke within 4.5 h of symptom onset（PRE-FLAIR）：a multicentre observational study[J]. Lancet Neurol，2011，10（11）：978-986.

[28] LU P，CUI L Y，ZHAO X Q. The prognostic impact of susceptibility-weighted imaging prominent veins in acute ischemic stroke：a systematic review and meta-analysis[J/OL]. Neuropsychiatr Dis Treat，2021，17：3069-3079[2024-02-18]. https://doi.org/10.2147/NDT.S331874.

[29] ZHOU Z，MALAVERA A，YOSHIMURA S，et al. Clinical prognosis of FLAIR hyperintense arteries in ischaemic stroke patients：a systematic review and meta-analysis[J]. J Neurol Neurosurg Psychiatry，2020，91（5）：475-482.

[30] 陈妙玲，梁满球，邹玉坚，等. 急性缺血性脑卒中FLAIR高信号血管征与SWI突出血管征的影响因素及其相关性研究[J]. 中国中西医结合影像学杂志，2023，21（1）：21-26.

CHEN M L，LIANG M Q，ZOU Y J，et al. Influence factors an correlation of hyperintense vessel sign on FLAIR and prominent vessel sign on SWI in patients with acute ischemic stroke[J]. Chinese Imaging Journal of Integrated Traditional and Western Medicine，2023，21（1）：21-26.

[31] 陈妙玲，梁满球，邹玉坚，等. 改良SWI-ASPECTS预测急性缺血性脑卒中早期神经功能恶化的可行性[J]. 放射学实践，2023，38（5）：547-552.

CHEN M L，LIANG M Q，ZOU Y J，et al. Feasibility of modified SWI-ASPECTS in predicting early neurological deterioration in patients with acute ischemic stroke[J]. Radiol Practice，2023，38（5）：547-552.

[32] 周杰，王开乐，张欣. 多模态MRI评估急性缺血性脑梗死侧支循环的临床分析[J]. 中国CT和MRI杂志，2022，20（5）：26-29.

ZHOU J，WANG K L，ZHANG X. Clinical analysis of multimodal MRI in the evaluation of collateral circulation in acute ischemic stroke[J]. Chinese Journal of CT and MRI，2022，20（5）：26-29.

[33] AOKI J，KIMURA K，IGUCHI Y，et al. FLAIR can estimate the onset time in acute ischemic stroke patients[J]. J Neurol Sci，2010，293（1/2）：39-44.

[34] 耿文，姜亮，陈慧铀，等. DWI/FLAIR失匹配预测急性缺血性脑卒中发作时间的应用价值[J]. 临床放射学杂志，2019，38（5）：773-777.

GENG W，JIANG L，CHEN H Y，et al. To explore the application value of DWI/FLAIR mismatch in predicting the onset time of acute ischemic stroke[J]. Journal of Clinical Radiology，2019，38（5）：773-777.

[35] WEI J Y，SONG X Y，WEI X E，et al. Knowledge-augmented deep learning for segmenting and detecting cerebral aneurysms with CT angiography：a multicenter study[J/OL]. Radiology，2024，312（2）：e233197[2024-09-06]. https://doi.org/10.1148/radiol.233197.

[36] KUANG H，NAJM M，CHAKRABORTY D，et al. Automated ASPECTS on noncontrast CT scans in patients with acute ischemic stroke using machine learning[J]. AJNR Am J Neuroradiol，2019，40（1）：33-38.

[37] MAEGERLEIN C，FISCHER J，MÖNCH S，et al. Automated calculation of the Alberta stroke program early CT score：feasibility and reliability[J]. Radiology，2019，291（1）：141-148.

[38] SOUN J E，CHOW D S，NAGAMINE M，et al. Artificial intelligence and acute stroke imaging[J]. AJNR Am J Neuroradiol，2021，42（1）：2-11.

[39] SHETH S A，GIANCARDO L，COLASURDO M，et al. Machine learning and acute stroke imaging[J]. J Neurointerv Surg，2023，15（2）：195-199.

[40] 张月，谢刚，李康. 人工智能预测急性缺血性脑卒中后出血转化的研究进展[J]. 国际医学放射学杂志，2024，47（2）：160-164.

ZHANG Y，XIE G，LI K. Research progress of artificial intelligence in predicting hemorrhagic transformation after acute ischemic stroke[J]. In J Med Radiol，2024，47（2）：160-164.

[41] GUBERINA N，DIETRICH U，RADBRUCH A，et al. Detection of early infarction signs with machine learning-based diagnosis by means of the Alberta stroke program early CT score（ASPECTS）in the clinical routine[J]. Neuroradiology，2018，60（9）：889-901.

[42] ABEDI V，GOYAL N，TSIVGOULIS G，et al. Novel screening tool for stroke using artificial neural network[J]. Stroke，2017，48（6）：1678-1681.

[43] WANG J J，TAN D，LIU J Y，et al. Merging multiphase CTA images and training them simultaneously with a deep learning algorithm could improve the efficacy of AI models for lateral circulation assessment in ischemic stroke[J/OL]. Diagnostics（Basel），2022，12（7）：1562[2024-02-18]. https://doi.org/10.3390/diagnostics12071562.

[44] HAMON G，LEGRAND L，HMEYDIA G，et al. Multicenter validation of synthetic FLAIR as a substitute for FLAIR sequence in acute ischemic stroke[J/OL]. Eur Stroke J，2024：23969873241263418[2024-09-06]. https://doi.org/10.1177/23969873241263418.

[45] 王燕玲，王超，赵刚. 基于DWI+FLAIR图像的急性缺血性卒中患者发病时间预测[J]. 生命科学仪器，2022，20（4）：65-70.

WANG Y L，WANG C，ZHAO G. Prediction of onset time of acute ischemic stroke patients based on DWI+FLAIR images[J]. Life Science Instruments，2022，20（4）：65-70.

[46] TAVAKKOL E，KIHIRA S，MCARTHUR M，et al. Automated assessment of the DWI-FLAIR mismatch in patients with acute ischemic stroke：added value to routine clinical practice[J]. AJNR Am J Neuroradiol，2024，45（5）：562-567.

[47] LEE H，LEE E J，HAM S，et al. Machine learning approach to identify stroke within 4.5 hours[J]. Stroke，2020，51（3）：860-866.

[48] JIANG L，WANG S Y，AI Z P，et al. Development and external validation of a stability machine learning model to identify wake-up stroke onset time from MRI[J]. Eur Radiol，2022，32（6）：3661-3669.

[49] CAI H，FAN S Y，BIAN Y Y，et al. Two-way comparison of brain perfusion image processing software for patients with acute ischemic strokes in real-world[J]. Neuroradiology，2022，64（1）：161-169.