CT/MRI 第 42 回日本脳卒中学会講演シンポジウム 総説 はじめに. MRI magnetic resonance imaging DWI diffusion-weighted. DWI/CBF malignant profile

Transcription

1 第 42 回日本脳卒中学会講演シンポジウム 総説 CT/MRI 1 要旨 rt-pa MRI magnetic resonance imaging DWI diffusion-weighted image Tmax time-to-maximum DWI/PWI perfusion image mismatch CT computed tomography CBF cerebral blood flow <30 Tmax CBF/PWI mismatch DWI/CBF malignant profile Key words: magnetic resonance imaging, perfusion imaging, reperfusion therapy, mismatch software はじめに doi: /jstroke iv rt-pa recombinant tissue plasminogen activator 2010 endovascular therapy: EVT 2015 EVT EVT iv rt-pa EVT iv rt-pa EVT 2 MRI magnetic resonance imaging DWI diffusion-weighted image PWI perfusion image 1 Perfusion imaging PWI DSC dynamic susceptibility contrast DCE dynamic contrast enhanced DSC T2 T2 DCE T1 DSC ml 3 4 ml/ 3 4 ml/ T2 T2 R2 ΔR2 ΔR2 time-concentration curve TCC AIF arterial in- 1

2 Fig. 1 MRI DWI Tmax 6> put function deconvolution 1 CBF cerebral blood flow CBV cerebral blood volume mean transit time MTT time-to-maximum Tmax CT computed tomography perfusion MR perfusion Tmax 2 4 PET positron emission tomography Xenon CT Tmax 5, 6 Tmax PET Tmax>5.5 7 PWI Tmax Tmax 6 PWI Tmax>6 tissue at risk DWI-PWI mismatch assessment Fig. 1 2 PWI ASSIST-JAPAN PMA perfusion mismatch analyzer umin.jp/ RAPID 8 RAPID RAPID RApid processing of PerfusIon and Diffusion C ++ DWI CTP-CBF PWI CBF CBV MTT Tmax>4 Tmax>6 Tmax>8 Tmax>10 6 CT/MRI RAPID motion correction AIF VOF venous output function deconvolution CBF CBV MTT Tmax ADC< mm 2 / DWI Tmax>6 Tmax>6 /DWI 2

3 Fig. 2 Target mismatch DWI-PWI RAPID target mismatch 1 74 DWI 12 ml Tmax>6 116 ml 9.5 target mismatch Fig. 2 target mismatch profile EXTEND-IA 9 SWIFT-PRIME 10 RAPID perfusion malignant profile perfusion imaging Malignant profile MR perfusion 11 DWI >70 ml Tmax>8 >85 ml Tmax>10 >100 ml CT perfusion CBF CBF>53 ml malignant profile 12 3 modified Rankin Scale mrs 5 6 CT iv rt-pa perfusion imaging malignant profile 13 CTP Tmax>10 malignant profile iv rt-pa 3 perfusion imaging EVT tissue time tube TICI thrombolysis in cerebral infarction 14 2b/3 2b 3 5 RCT 15, 16 CT DSA digital subtraction angiography MR CLEAN 66.6 CT perfu- 3

4 sion ESCAPE 43.8 REVS- CAT 31.1 THERAPY 37.0 perfusion imaging 17 EX- TEND-IA SWIFT-PRIME CT perfusion 12 RAPID 6 3 1/ DWI FLAIR fluid attenuated inversion recovery DWI-FLAIR DWI 1 FLAIR rt-pa WAKE-UP 22 THAWS 23 EVT DAWN 24 DEFUSE 3 25 clinical-dwi core DWI-PWI DAWN NIHSS RAPID 30 ml 80 NIHSS ml EVT EVT 26 DEFUSE 3 MRA magnetic resonance angiography / CTA CT angiography MCA middle cerebral artery ICA internal carotid artery target mismatch profile DWI CBF core/pwi ml 15 ml DAWN DEFUSE 3 おわりに time is brain 27, time is penumbra 29 PWI tissue time tube tissue DAWN DEFUSE 3 3 T tissue time tube perfusion imaging perfusion imaging COI COI 参考文献 1 Ostergaard L, Sorensen AG, Kwong KK, et al: High resolution measurement of cerebral blood flow using intravascular tracer bolus passages. Part II: Experimental comparison and preliminary results. Magn Reson Med 36: , Shih LC, Saver JL, Alger JR, et al: Perfusion-weighted magnetic resonance imaging thresholds identifying core, irreversibly infarcted tissue. Stroke 34: , Østergaard L: Principles of cerebral perfusion imaging by bolus tracking. J Magn Reson Imaging 22: , Kudo K, Sasaki M, Østergaard L, et al: Susceptibility of Tmax to tracer delay on perfusion analysis: quantitative evaluation of various deconvolution algorithms using digital phantoms. J Cereb Blood Flow Metab 31: , Olivot JM, Mlynash M, Zaharchuk G, et al: Perfusion MRI (Tmax and MTT) correlation with xenon CT cerebral blood flow in stroke patients. Neurology 72: , Zaro-Weber O, Moeller-Hartmann W, Heiss WD, et al: Maps of time to maximum and time to peak for mismatch definition in clinical stroke studies validated with positron emission tomography. Stroke 41: , Zaro-Weber O, Moeller-Hartmann W, Heiss WD, et al: MRI perfusion maps in acute stroke validated with 15O-water positron emission tomography. Stroke 41: , Straka M, Albers GW, Bammer R: Real-time diffusion-perfu- 4

5 sion mismatch analysis in acute stroke. J Magn Reson Imaging 32: , Campbell BC, Mitchell PJ; EXTEND-IA Investigators: Endovascular therapy for ischemic stroke. N Engl J Med 372: , Saver JL, Goyal M, Bonafe A, et al: Stent-retriever thrombectomy after intravenous t-pa vs. t-pa alone in stroke. N Engl J Med 372: , Mlynash M, Lansberg MG, De Silva DA, et al: Refining the definition of the malignant profile: insights from the DEFUSE- EPITHET pooled data set. Stroke 42: , Inoue M, Mlynash M, Straka M, et al: Patients with the malignant profile within 3 hours of symptom onset have very poor outcomes after intravenous tissue-type plasminogen activator therapy. Stroke 43: , Nogueira RG, Haussen DC, Dehkharghani S, et al: Large volumes of critically hypoperfused penumbral tissue do not preclude good outcomes after complete endovascular reperfusion: redefining malignant profile. Stroke 47: 94 98, Higashida RT, Furlan AJ, Roberts H, et al: Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 34: e , Saver JL, Goyal M, van der Lugt A, et al: Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA 316: , Goyal M, Menon BK, van Zwam WH, et al: Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials. Lancet 387: , Warach SJ, Luby M, Albers GW, et al: Acute stroke imaging research roadmap III imaging selection and outcomes in acute stroke reperfusion clinical trials: consensus recommendations and further research priorities. Stroke 47: , Serena J, Dávalos A, Segura T, et al: Stroke on awakening: looking for a more rational management. Cerebrovasc Dis 16: , Kang DW, Sohn SI, Hong KS, et al: Reperfusion therapy in unclear-onset stroke based on MRI evaluation (RESTORE): a prospective multicenter study. Stroke 43: , Koton S, Tanne D, Bornstein NM; NASIS Investigators: Ischemic stroke on awakening: patients characteristics outcomes and potential for reperfusion therapy. Neuroepidemiology 39: , Thomalla G, Rossbach P, Rosenkranz M, et al: Negative fluidattenuated inversion recovery imaging identifies acute ischemic stroke at 3 hours or less. Ann Neurol 65: , Thomalla G, Fiebach JB, Østergaard L, et al: A multicenter, randomized, double-blind, placebo-controlled trial to test efficacy and safety of magnetic resonance imaging-based thrombolysis in wake-up stroke (WAKE-UP). Int J Stroke 9: , Koga M, Toyoda K, Kimura K, et al: THrombolysis for acute wake-up and unclear-onset strokes with alteplase at 0 6 mg/kg (THAWS) trial. Int J Stroke 9: , Jovin TG, Saver JL, Ribo M, et al: Diffusion-weighted imaging or computerized tomography perfusion assessment with clinical mismatch in the triage of wake up and late presenting strokes undergoing neurointervention with Trevo (DAWN) trial methods. Int J Stroke 12: , Albers GW, Lansberg MG, Kemp S, et al: A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3). Int J Stroke 12: , Nogueira RG, Jadhav AP, Haussen DC, et al: Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 378: 11 21, Gomez CR: Editorial: Time is brain! J Stroke Cerebrovasc Dis 3: 1 2, Saver JL: Time is brain--quantified. Stroke 37: , Davis S, Donnan GA: Time is Penumbra: imaging, selection and outcome. The Johann jacob wepfer award Cerebrovasc Dis 38: 59 72,

6 Abstract Acute CT/MRI perfusion imaging in reperfusion therapy Manabu Inoue, M.D., Ph.D. 1) 1) Department of Endovascular Surgery, National Cerebral and Cardiovascular Center Evolution of reperfusion therapy in acute stroke has been accelerated after the evolution of the efficacy of endovascular therapy after/without recombinant tissue plasminogen activator (iv rt-pa). Reperfusion therapy has moved into a new era, although certain imaging criteria should have some favorable outcome which has not yet been established. Penumbral imaging has the potential to solve this issue both by CT and MRI scanning. Optimal mismatch ratio between MRI diffusion-weighted image/cerebral blood volume (DWI/CBF) (<30% of the contralateral hemisphere) and perfusion image (PWI) Tmax > 6 s area may predict the favorable outcome. On the other hand, certain large core threshold called malignant profile lead to poor outcomes despite any reperfusion therapies. Several criteria have been discussed but not met the consensus for optimal mismatch ratio and hazardous volume thresholds. Key words: magnetic resonance imaging, perfusion imaging, reperfusion therapy, mismatch software 6