The thesis describes clinical features, subclinical and imaging quality in patients with cerebral infarction was re-released in the first 6 hours. Analysis of the relationship between clinical features and reconstituted cerebral infarction images in the first 6 hours on multi-sequence computerized tomography.
MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE VIETNAM MILITARY MEDICAL ACADEMY NGUYEN QUAN AN STUDY ON CLINICAL AND SUBCLINICAL CHARACTERISTICS, COMPUTED TOMOGRAPHY IMAGING OF ACUTE ISCHEMIC STROKE AFTER REVASCULARIZATION WITHIN FIRST HOURS Specialized: Neurology Code: 9720159 THE SUMMARY OF MEDICAL PHYLOSOPHIC THESIS Hanoi - 2020 THIS STUDY HAD BEEN COMPLETED IN VIETNAM MILITARY MEDICAL ACADEMY Supervisor: PROF PhD NGUYỄN MINH HIỆN Reviewer No 1: PROF PhD Tran Van Tuan Reviewer No 2: PROF PhD Tran Cong Hoan Reviewer No 3: PROF PhD Nguyen Van Thong The thesis was defended in the Committee Council of Vietnam Military Medical Academy at …………… The PhD thesis can be found at: National Library Library of Vietnam Military Medical Academy INTRODUCTION According to the World Health Organization (WHO), stroke is the third leading cause of death and leading cause of disability in adults, in which ischemic stroke accounts for about 80-85% of stroke patients The incidence of stroke ranges from 600-1430/100,000 people depending on the country The current guideline for stroke treatment is to treat early, positively, comprehensively and prevent recurrence based on the degree of damage of brain parenchyma, collateral circulation, risk factors for each patients The brain is a high level nerve center, accounting for only 2% of the weight but requires a mass of blood to 20% of the body's blood The vascular system of the brain is very rich and, when forming the clots it caused cerebral infarction, which is the cause of various neurological deficiencies If the cerebral blood flow (CBF) is 22ml/100g/minute, there will be a slight deficiency and complete paralysis when CBF is 8ml/100g/minute On electroencephalography, the automatic reflex of the cortical cells will completely lose at about 18ml/100g/minute The life time of a nerve cell can be extended when CBF from 17-20ml/100g brain/minute, if CBF is 12ml/100g/minute, the life time of brain cells can last for about 2-3 hours, then progress to true lesions, when CBF ≤ 11ml/100g/min, brain cells die and not recover These characteristics depend on the time from the onset to the time of treatment, which is the basis for the golden-time emergency treatments of "time is brain" treatment techniques Over the past decade, in parallel with comprehensive treatment, the use of thrombolytic agents, intervention to remove thrombosis, has brought many positive results in reducing mortality and disability for stroke patients Acute cerebral infarction The patients with cerebral infarction who had a resuscitation in the first hours had risk factors (age, blood pressure, cardiovascular history), clinical, subclinical features, brain imaging, bladder circulation ? What is the relationship between these factors? In fact, in hospital settings in Vietnam, during a stroke emergency, during the first hours, emergency crews often focus on techniques to re-open circuits or ensure survival indicators without full attention to the above factors so the treatment results are limited and vary In order to comprehensively assess risk factors, clinical and subclinical characteristics, brain CT images of patients with cerebral infarction were re-opened in the first hours to improve the effectiveness of treatment at hospitals To collect and treat strokes, we conduct research on the topic "Study of clinical features, subclinical and computerized tomography images of patients with cerebral infarction in the first hours" to target: Description of clinical, subclinical characteristics and images of ARVs in patients with cerebral infarction are re-activated in the first hours Analysis of the relationship between clinical features and images of cerebral infarction re-released in the first hours on CT scan images The structure of the thesis The thesis consits of 120 pages, including: introduction pages, the overview 32 pages, objects and methos 13 pages, results 24 pages, discussion 34 pages, conclusion pages, recommendation page There are 32 tables, 01 grapth, 144 reference in which 23 Vietnamese and 121 English articles CHAPTER 1: OVERVIEW 1.1 Definition and classification of ischemic stroke subtypes 1.1.1 Definition Definition of ischemic stroke by World Health Organization 1989 1.1.2 Classification of ischemic subtypes Classification of ischemic subtypes based on OCSPC 1991 Sort NMN based on TOAST 1.2 Blood supply to the brain 1.2.1 Arteries perfuse blood to the brain 1.2.1.1 Internal carotid arteries 1.2.1.2 Vertebrobasilar arteries 1.2.2 Brain blood flow 1.2.3 Factors affecting brain blood flow Hypertension, Alteration of structures and function of brain arteries, brain arteries with a suitable structure 1.2.4 Circulatory connection of cerebral arteries 1.2.4.1 Circulatory connection of internal carotid arteries and external carotid arteries The connection of internal carotid arteries and the external carotid arteries via circulatory connection of the central retina artery, maxillary artery Connection of the vertebral artery and external carotid artery via the occipital artery Connection of the internal carotid artery and basilar artery, which allows transverse perfusion to the brain hemisphere, the flow within Willis can supply blood to the blocked arteries 1.2.4.2 The circulatory connection on the surface of the brain; Between anterior cerebral artery - mid cerebral artery – posterior cerebral artery, between posterior cerebral artery and cerebellum 1.2.5 Levels of circulatory connection - Characteristics of collateral circulation when cerebral embolism happens: The further the occlusion is from the brain (near the aortic knuckle), the greater the ability to perfuse the brain The slower the embolism happens, the more effective the collateral circulation works 1.3 Mechanism of brain anemia and progress over time 1.3.1 Blood flow and normal metabolism Brain cells mainly depend on oxygen and glucose The brain uses glucose as the only substance for energy generation, and glucose is oxidized into carbon dioxide (CO2) and water The metabolism of glucose results in adenosine diphosphate (ADP) and then adenosine triphosphate (ATP) The presence of oxygen increases the brain's efficiency in generating ATP 1.3.2 Factors affecting the viability of brain cells 1.3.2.1 The impact of collateral circulation 1.3.2.2 Blood transport nutrient 1.3.2.3 Changes inside lesions of blocked blood vessel 1.3.2.4 Internal resistance of the peripheral vascular network 1.3.3 Penumbra Some parts of the brain parenchyma are rapidly destroyed and unable to recover from ischemia, the enclosed brain area is still able to survive for a few hours (the Penumbra area) The progression of mild neurological deficiency when the cerebral blood flow (CBF) is 22ml/100g/minute and complete paralysis when CBF is 8ml/100g /minute or under 1.4 Clinical characteristics of stroke patients The clinical characteristics of ischemic stroke patients depend on the location of the affected brain part 1.4.1 Cerebral artery thrombosis 1.4.1.1 Common clinical characteristics - Most patients have symptoms before the onset of ischemic stroke, this stage is very important for proper diagnosis of cerebral artery thrombosis The sign is warning TIA attacks Depending on the location of the thrombosis, TIA can cause different clinical symptoms - Stroke onset context: Stroke usually occurs at night or early in the morning - Stroke onset: Most patients start with common symptoms of brain lesions (fatigue, dizziness, numbness in the limbs, etc) before the stroke onset from a few hours to a few days - Process pattern: patients often describe gradually or rapidly progressive clinical symptoms - Common neurological symptoms: headache, vomiting, convulsions, mild conciousness disorders, possible sphincter disorders, frequent urinary retention or urinary incontinence - Localized neurological symptoms: Depending on the artery lesion, there are corresponding clinical symptoms: Speech disorders, seventh cranial nerve paralysis and hemiplegia on the side of the body opposite to the area of cerebral damage, cerebral palsy, brain stem and/or medulla damage (HC Weber, Benedickt, Foville, Milard - Gubler) 1.4.2 The cerebral artery syndrome - Internal carotid artery occlusion syndrome - Mid cerebral artery syndrome - Vertebrobasilar Insufficiency syndrome 1.5 Visual characteristics of cranial CT Scan in stroke patients within hours after stroke onset 1.5.1 Computed tomography without contrast 1.5.1.1 Signs for early diagnosis of ischemic stroke Cranial CT scan allows early diagnosis of ischemic stroke, but does not give an accurate measurement of the volume of anemia, does not assess the vascular condition, does not assess the survival possibility of brain parenchyma, especially in the early stage Five basic signs to early diagnose ischemic stroke on CT scan without contrast: hyperdensity of artery, hypodensity of brain parenchyma, hypodensity of lentiform nucleus, loss of insular ribbon, losing the distinction between gray matter and white matter, and unclear brain grooves 1.5.1.2 ASPECT scale ASPECT scale has been widely used since 2000 in clinical practice to assess the degree of early ischemic changes on brain imaging The ASPECT scale is a 10-point scoring system that is equivalent to 10 anatomical regions according to the blood supply region from the mid cerebral artery 1.5.2 Computed tomography with contrast 1.5.2.1 Position the blocked artery 1.5.2.2 Assess brain parenchyma from scanned image 1.5.2.3 Assess the degree of collateral circulation 1.6 Thrombectomy and thrombolysis treatment in ischemic stroke patients 1.6.1 Thrombolysis 1.6.2 Thrombectomy CHAPTER OBJECTS AND METHODS OF THE STUDY 2.1 Studied objects 2.1.1 Object, time, and place of study From June 2016 to July 2017, we conducted a study of 114 patients with acute cerebral ischemic stroke at Stroke Center, 108 Military Central Hospital These patients were selected under the selection and exclusion criteria 2.1.2 Selection criteria - The patient is diagnosed with acute ischemic stroke within the first hours after the stroke onset to admission at 108 Military Central Hospital; Based on Guidelines for the Early Management of Patients With Acute Ischemic Stroke in 2015 by American Heart Association/American Stroke Association (AHA / ASA) + Clinical symptoms: face dropping, sudden weakness of the body, sudden trouble speaking, turning head and eyes towards the intact side + Patient have: - CT scan without contrast to exclude hemorrhagic stroke - CT scan with contrast to identify damaged brain artery Classify subtypes of stroke: blocked large arteries or small artery (lacunar infarct) Identify the infarction happens on the anterior cerebral circulation or the posterior cerebral circulation + If the patient has a history of brain stroke, mRS score exclude from to score + ≥ 18 years of age + Less than hours after the stroke onset + patient or his/her legal protector approved to participate in the study + Patients have been under treatment: thrombolysis, thrombonectomy or a combination of the two above treatments 2.1.3 Exclusion criteria - Hemorrhagic stroke - Ichemic stroke patients with a history of traumatic brain injury, encephalitis, and/or brain tumor 2.2 Research Methods 2.2.1 Study design A prospective descriptive and cross-section study 2.2.2 Clinical study 2.2.2.1 Questionaire * Create a unified registration form based on such criteria as: Age, gender, time of onset, nature of the onset, place of the onset, time of admission to Emergency Department * Identify stroke signs of the patient: Sudden face dropping, numbness or weakness of one arm and/or one leg on one side of the body, difficulty speaking or communicating, sudden loss of vision in one or both two eyes, dizziness, loss of balance or movement coordination disorders * Identify the time of stroke onset * Collect patient's medical history and information 2.2.2.2 Clinical examination - Access neurological symptoms (hemiplegia, cranial nerve palsy, sensory disorders, speech and language disorders, etc.), consciousness disorders, vital signs such as pulse, blood pressure, heart rate, breathing, SpO2, temperature - Access patients’ situation based on: Glasgow, limb muscle strength MRC, NIHSS 2.2.3 Subclinical study - Blood count, blood biochemistry, immunity, ECG, cardiac ultrasound - CT scan of cranial brain imaging, Computed tomography angiography (CTA), right at the Emergency Department - Digital Subtraction Angiography (DSA) to prepare for cerebral intervention - Evaluate ASPECT scores, consider early signs on cranial CT, collateral circulation scale, occlusion location 2.3 Study content 2.3.1 Describe the clinical features, CT images of brain in patients with ischemic stroke and recirculation done in hours 2.3.1.1 Common characteristicsof the studied objects - Identify age, gender, risk factors, time of stroke onset 2.3.1.2 Clinical and subclinical characteristics - Stroke onset symptoms, physical signs upon admission, blood count, biochemistry, echocardiogram, Electrocardiography - ECG, cranial CT scan, assess patients with ASPECT, pc-ASPECT score on cranial CT film + Identify brain lesions on CT angiogram: lesion area, damaged artery location, assess the degree of collateral circulation 2.3.2 Evaluate the relationship of clinical signs with CT images in ischemic patients who had recirculation in the first hours - Assess the relationship between early signs on cranial CT scan according to time: less than hours, to 4,5 hours and from 4.5 to hours - Assess the relationship between clinical characteristics of patients with hypodensity of brain parenchyma and patients without hypodensity of brain parenchyma on CT scan film - Assess the relationship between clinical features of patients with cerebral infarction due to damages on the anterior cerebral circulation and damages on the posterior cerebral circulation - Assess the relationship between clinical characteristics of patients with ischemic stroke to ASPECT score - Assess the relationship between the NIHSS score and the ASPECT score - Assess the relationship between the limb muscle strength and the ASPECT score - Assess the relationship between the NIHSS score and the collateral circulatory system score of the anterior cerebral circulation system - Assess the relationship between Glasgow point and the collateral circulatory system score of the anterior cerebral circulation system - Assess the relationship between the limb muscle strength and the collateral circulatory system score of the anterior cerebral circulation system 2.4 Data processing methods - Data collection and data input using SPSS 22.0 software 2.5 Research ethics - Ensuring medical ethics during the study CHAPTER : RESULTS 3.2 Clinical features and CT scan images of acute ischemic stroke in the first hours 3.2.1 Characteristics of clinical symptoms of patients at hospitalized time Table 3.4 Clinical signs at hospitalized time No Onset symptoms Language disorder Hemiplegia Face dropping Headache Sensation disorders on one side of the body Dizziness Vomitting Convulsion Number of patients (n=114) 104 110 105 31 20 15 10 Ratio (%) 91,2 96,5 92,1 27,2 17,5 13,2 8,8 0,9 Table 3.5 Glasgow at hospitalized time Number of patients (n = 114) Ratio (%) 15 29 25,4 9-14 71 62,3 6-8 12 10,5 3-5 1,8 Group Glasgow Scale Average Glasgow Scale: 11,98 ± 2,65 - Average Glasgow Scale of Stroke Patients was 11,98 ± 2,65 Table 3.6 Classification of muscle scaleat hospitalized time Group Upper limb muscle Lower limb muscle strength strength Muscle Scale- MRC n = 114 (%) n = 114 (%) 66 (57,9) 61 (53,5) 16 (14,0) 19 (16,7) (7,0) 10 (8,8) 20 (17,5) 19 (16,7) (1,8) (2,6) (1,8) (1,8) Table 3.7 NIHSS scoreat hospitalized time Number of patients Ratio (n = 114) (%) ≤5 7,9 – 15 38 33,3 16 – 20 30 26,3 21 – 42 37 32,5 NIHSS score group NIHSS group Average 16,897,14 The average NIHSS score of patients in this study was 16.897.14 scores, the highest was 42 scores, the lowest was scores Table 3.8 Characteristics of blood pressure at hospitalized time Group Number of patients (n = 114) Blood pressure Systole (mmHg) Diastole (mmHg) Systolic HA group (mmHg) Average 140,61 25,58 Lowest 85 Highest 217 Average 81,80 14,10 Lowest 48 Highest 140 < 90 (0,9) 90 – 139 59 (51,8) 140 – 184 49 (43,0) ≥ 185 (4,4) 3.2.2 Hematological, biochemical, ultrasound and ECG characteristics of hospitalized patients Table 3.9 The composition of complete blood count General Group (n = 114) Complete blood Counts Red blood cell (T/l) 4,57 ± 0,55 Hematocrit (l/l) 0,41 ± 0,04 Platelets (G/l) 242,79 ± 76,73 Table 3.10 The basic coagulation components No Coagulation components Test result Prothrombin time (s) (n = 102) 11,98 ± 3,73 INR (n = 54) 1,11 ± 0,31 Fibrinogen concentration (g/l) (n = 93) 4,00 ± 1,25 Table 3.11 The basic biochemical components No Biochemical components Test result Cholesterol (mmol/L) (n=86) 4,93 ± 1,20 Triglycerid (mmol/L) (n=86) 2,05 ± 1,60 Blood Glucose (mmol/L) (n=110) 8,03 ± 3,02 Table 3.12 ECG characteristics No Characteristics Atrial Fibrillation No atrial fibrillation Number of patients (n=99) 40 Ratio (%) 35,1 59 51,8 Table 3.13 Doppler echocardiogram results No Echocardiogramcharacteristics Number of patients (n=83) Ratio (%) Normal 45 54,2 Heart failure 7,2 Mitral stenosis 18 21,7 Leaky heart valve 14 16,9 3.2.3 CT scan images features at hospitalized time Table 3.14 Features of early brain damage on CT scan of the anteriorcerebral circulation Group Anteriorcerebral circulation Signs n = 104 (%) Hypodensity ofthe cortex 57 (54,8) Unclear brain grooves 35 (33,7) Loss of insular ribbon 36 (34,6) Unclear lentiform nucleus 21 (20,2) Area of hypodensity >1/3 (8,7) Signs of “Hyperdensity of artery” 12(11,5) Most stroke patients come early with images of hypodensity ofthe cortex (54.8%) Early signs of damage were noted as unclear brain grooves (33.7%) Table 3.15 Characteristics of artery lesion sites Characteristics of injury Number of patient Ratio (n=114) (%) Internal carotid artery 40 35,1 Middle cerebral artery 61 53,5 Anterior cerebral artery 0,9 Vertebral artery 3,5 Basilar artery 5,3 Small cerebral artery 1,8 Table 3.16 ASPECT score for the blood supply area of the middle cerebral artery Number of patients (n=61) Ratio (%) ≤5 3,3 6–7 14 23,0 ≥8 45 73,8 ASPECT score ASPECT group Average: 8,30 ± 1,52 Table 3.17 Collateral circulation score of the anteriorcerebral circulation Level of Number collateral Ratio (%) (n=102) circulation Good 24 23,5 Average 48 47,0 Bad 30 29,5 3.3 Relationship betweencranial CT scan and clinical features of patients with acute ischemic strokein the first hours 3.3.1 Relationship with onset time Table 3.21 Relationship with onset time of stroke < hours n (%) - 4,5 hours n (%) >4,5 - hours n (%) p 24 (54,5) 21 (48,8) 10 (37,0) >0,05 20 (45,5) 22 (51,2) 17 (63,0) >0,05 44 (100) 43 (100) 27 (100) - ( X SD) (n = 61) 25 (8,68 1,31) 26 (8,12 1,37) 10 (7,80 2,20) < 0,05 Anterior cerebral circulation (n=104) 39 (88,6) 41 (95,3) 24 (88,9) Posteriorcerebral circulation (n=10) (11,4) (4,7) (11,1) CT scan images No hypodensity (n=55) Hypodensity (n = 59) Total (n=114) ASPECT score >0,05 >0,05 The ASPECT score of patients with ischemic stroke had a tendency to decrease over time from the stroke onset to admission time, the difference was statistically significant Table 3.22 Relationship between early signs on cranial CT scan and time of stroke onset 14 (32,6) >4,5 – hours n = 27 (%) 12 (44,4) >0,05 (18,2) 18 (41,9) 10 (37,0) 0,05 Signs of “Hyperdensity of artery” (n=12) (11,4) (11,6) (7,4) >0,05 The image of cranial CT scan < hours n =44(%) - 4,5 hours n = 43 (%) Unclearbrain grooves (n=36) 10 (22,7) Loss of insular ribbon(n=36) p The image of loss of insular ribbon and unclear lentiform nucleushas a significant relationship with the time from the onset of brain stroke 3.3.2 Relationship withhypodensity of brain parenchyma Table 3.23 The relationship between clinical symptoms and the density of brain parenchyma Group n = 59 (%) No hypodensity n = 55 (%) p 31 (27,2) 15 (25,4) 16 (29,1) > 0,05 10 (8,8) (5,1) (12,7) > 0,05 Dizziness 15 (13,2) (8,5) 10 (18,2) > 0,05 Turning of head and eyes towards the intact side 11 (9,6) (15,3) (3,6) < 0,05 Sensation disorders on one side of the body 20 (17,5) (11,9) 13 (23,6) > 0,05 Hemiplegia 110 (96,5) 58 (98,3) 52 (94,5) > 0,05 Central seventh nerve palsy 105 (92,1) 56 (94,9) 49 (89,1) > 0,05 Language disorders 104 (91,2) 56 (94,9) 48 (87,3) > 0,05 Sensory disorders 85 (74,6) 47 (79,7) 38 (69,1) >0,05 General n = 114 (%) Hypodensity Headache Vomitting Signs 3.3.3 Relationship with ASPECT score Table 3.24 The relationship between clinical symptoms and ASPECT score ASPECT score ≤5 n = (%) 6-7 n = 14 (%) ≥8 n = 45 (%) p Headache (50,0) (14,3) 14 (31,1) > 0,05 Vomitting (0) (7,1) (15,6) > 0,05 Dizziness (0) (7,1) (15,6) > 0,05 Turning of head and eyes towards the intact side (50,0) (14,3) (6,7) > 0,05 Sensation disorders on one side of the body (0) (14,3) 13 (28,9) > 0,05 Hemiplegia (100) 14 (100) 45 (100) < 0,01 Central seventh nerve palsy (50,0) 14 (100) 43 (95,6) < 0,05 Language disorders (100) 14 (100) 40 (88,9) > 0,05 Sensory disorders (100) 12 (85,7) 30 (66,7) >0,05 Signs Table 3.25 The relationship between NIHSS score and ASPECT score (n=61) ASPECT ≤5 n = (%) 6-7 n = 14 (%) ≥8 n = 45 (%) ≤ (n=2) (0) (7,1) (2,2) – 15(n=28) (0) (14,3) 26 (57,8) 16 – 20(n=14) (0) (42,9) (17,8) 21 – 42(n=17) (100) (35,7) 10 (22,2) 22,0 1,41 18,93 6,25 15,07 5,82 score p NIHSSscore NIHSS Group