단일 피질하 경색의 분류와 위치에 따른 치료적 혈압 상승 요법의 효과 비교

Abstract

Background and Objective: Early neurological deterioration (END) is associated with poor outcome in single subcortical infarction (SSI). Induced hypertension therapy (IHT) demonstrated efficacy in treating END in the non-cardioembolic stroke. Considering the diverse pathomechanisms within the SSI group, this study aimed to investigate the effectiveness of IHT in treating END specifically in SSI cases. We hypothesized that the response to IHT may vary depending on the underlying mechanism of SSI. Methods: We conducted a study involving patients with SSI who experienced END and received IHT. SSI was classified as proximal (pSSI; infarction extended to the basis of basal ganglia or basis pontis), distal (dSSI) and SSI with parental artery disease (SSIPAD; with stenosis at parental artery disease < 50%). END was defined as worsening of National Institution of Health Stroke Scale (NIHSS) score more than 2 points, 1 point in motor score or the emergence of any new neurological symptoms as indicated by the NIHSS score. IHT was performed via intravenous phenylephrine infusion targeting 10-20% elevation of baseline systolic blood pressure. The response to IHT was defined as reduction of more than 2 points in the total NIHSS score, any observed decrease in the motor score or complete disappearance of newly developed neurological symptoms documented during the episode of END. Characteristic were compared between responder and non-responder. Factors associated with response of induced hypertension were investigated. Results: among 1224 cases with SSI, 96 patients (49 responder and 47 non responder) were enrolled. There were no significant differences between responders and non-responders except, Hba1c level (responder: 6.2 [5.5-7.25] vs. non-responder: 6.1 [5.4-7.6]; p-value < 0.001) and BP variability (responder: 12.09 [8.71-16.28] vs. non-responder: 13.03 [9.51-15.69]; p-value < 0.001). In the imaging data, the only notable difference between responders and non-responders was the type of SSI. Among responders, pSSI was the most common type (61.2%) whereas, among non-responder, SSIPAD was most common (42.6%). Multivariable analysis revealed that pSSI (reference = dSSI; adjusted Odds Ratio = 24.7; 95% confidence interval 4.84 - 126.7; p-value < 0.001), Fazekas scale of deep white matter (reference = Fazekas scale 0; Fazekas scale 2 adjusted Odds Ratio = 0.15; 95% confidence interval 0.03.- 0.69; p-value = 0.021) and blood urea nitrogen (adjusted Odds Ratio = 1.11; 95% confidence interval 1.02 - 1.22; p-value = 0.019) were significantly associated with the response to IHT. Conclusion: Our analysis revealed that among patients with SSI and END, the response to IHT varied depending on the type of SSI. Particularly, our findings indicated that patients with pSSI demonstrated a better response to IHT compared to those with dSSI.