Relationship Between Clinical-diffusion Mismatch And Outcomes And TCM Syndromes In Patients With Acute Ischemic Stroke

Background Stroke trials have failed to show a significant benefit of intravenous tissue plasminogen activator(tPA) when administered beyond time window. More importantly, most patients do not have a chance to get thrombolytic therapy. However, there is evidence that even at later treatment times, carefully selected patients may benefit from reperfusion. Currently, Perfusion-weighted MRI (PWI) and diffusion-weighted MRI(DWI)mismatch is used for selecting patients with a penumbra to take thrombolytic therapy, which is widely used in clinical trials. A limitation of this model is the comparatively high requirement, which have limited its routine clinical use. Mismatch between stroke severity, assessed with the national institutes of health stroke scale(NIHSS), and the volume of the DWI lesion(clinical diffusion mismatch, CDM) has been suggested as a most promising select tool for identifying patients with penumbral tissue, replacing PWI-DWI mismatch.Purpose The aim of this study is to evaluate the law of CDM within1week of symptom onset and analysis the relationship between CDM and outcomes and TCM Syndromes in Patients with Acute Ischemic Stroke. Consequently, we pursue to provide evidence for clinical management strategies for different patients.Methods We conducted a prospective study. Fifty-six patients with middle cerebral artery (MCA) were admitted to hospital within72hours and imaged within168hours of symptom onset. DWI volumes were measured with using semi-automated thresholding technique. We performed clinical assessment including NIHSSS, mRS, TCM syndromes in admission time points,7days,15days and30days after symptom onset, respectively. CDM was defined as NIHSS>8and DWI<25mL. favorable clinical outcome was defined as an improvement on the NIHSS at least8points between baseline and30days or NIHSS<1at30days or mRS<2at30days.Results1. A total of16of56(28.6%) patients fulfilled the proposed definition of CDM. favorable clinical outcome and death cases were not significantly different between with CDM and without CDM (p=0.091,1.000, respectively). And then, the CDM group and without CDM group have4of16and14of40cases got neurologic deterioration, but not significant (p=0.473).2. The changes of NIHSS between the two groups were significantly different. From the baseline to day7, the NIHSS of with CDM group declined2.7while this figure in the without CDM group is0.4(p=0.026). At day15, the changes of with CDM and without CDM group were-2.3and-0.7respectively (p=0.022). At the endpoint of our observation (day30), the changes of NIHSS for the two groups were-2.5and-1.7, respectively (p=0.04).3. There was a highly significant positive correlation between NIHSS and DWI volume(rs=0.721, p=0.009), but the data in without CDM group(rs=0.847, P=0.000) is better correlated with NIHSS than that of with CDM group (rs=0.610, P=0.012).4. With the extension of onset time, the ratio of CDM declined gradually.12of33(36.3%) patients who were performed with MRI examinations within72hours after onset while the figure in the others who took MRl examinations beyond72hours was4of23(17.4%).5. The wind syndrome and blood stasis syndrome got the highest score (median of both=6.0). At day7, phegmdampness syndrome was comparatively severity (median=7.0). Firehot and blood stasis syndrome remained stable(median=:3.0and6.0,respectively). However, Qi deficiency syndrome became more serious(median=6.0).at day15,both wind syndrome and phegmdampness experienced an consistent decline(median=2.0and6.0,respectively). firehot did not show a significant fluctuation(median=3.5). at the same time, qi deficiency showed an increasing trends(median=7.5). After that, the wind syndrome showed little change. The phegmdampbess syndrome and blood stasis syndrome descend, qi deficiency also released at some extent.6. From baseline to day30, The two groups were significantly different in the scores change of Blood stasis (median-1.0vs-5.5, p=0.040) and Qi deficiency (median=-0.5vs3.0, p=0.004). The change of the rest TCM syndromes were not significantly.7. There was a highly significant negative correlation between promoting blood circulation for removing blood stasis and mRS (rs=-0.331, p=0.013). precisely, in the patients with CDM, inhibition of platelet aggregation also showed a negative correlation with the transformation of mRS (rs=-0.504, p=0.047). for the other group, Inhibition of platelet aggregation did not show a significantly correlation with the fluctuation of mRS (rs=-0.204, p=0.206); promoting blood circulation for removing blood stasis was not significantly correlated with the change of mRS (rs=-0.385, p=0.141),on the other hand, it was significantly correlated with mRS change(rs=-0.377, p=0.016).Conclusion Potential salvageable tissue may still exist in patients with acute ischemic stroke within1week, in the daily clinical routines, there are no significantly difference in clinical outcomes between patients with CDM and without CDM. however, the improvement of NIHSS for with CDM group was more obvious than that of without CDM group, and the neurological outcome of CDM group was better than the other group.The evolutions of TCM syndromes in the two groups are vary from each other, which was shown in the change of Blood stasis and Qi deficiency. Also, the clinical responses of them are different. We should develop different clinical management strategies for the two types of patients.