Multimodal Nuclear Magnetic Imaging Prediction of Early Neurological Deterioration in Patients with Acute Stroke Using Intravenous Thrombolysis

Multimodal Nuclear Magnetic Imaging Prediction of Early Neurological Deterioration in Patients with Acute Stroke Using Intravenous Thrombolysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Multimodal Nuclear Magnetic Imaging Prediction of Early Neurological Deterioration in Patients with Acute Stroke Using Intravenous Thrombolysis Xiaoyue Long, Peiren Zhang, Bin Luo, Xiao Yang, Yuxuan Du, Xiaoqing Yu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4945314/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: To explore the relationship between Signal intensity ratio (SIR) levels, a cerebral hemodynamic index, and early neurological function deterioration in patients with acute cerebral infarction under the guidance of multimodal nuclear magnetic resonance imaging (NMRI) with intravenous thrombolysis. Methods: 157 patients with acute cerebral infarction who received intravenous thrombolysis within 4.5 hours of stroke were obtained from Tianjin Huanhu Hospital between January 2022 and February 2024. early neurological deterioration (END) was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) score of ≥4 points from baseline at 24 hours after intravenous thrombolysis or death. The patients were divided into 36 cases in the END group and 121 cases in the non-END group. Baseline, clinical, and imaging data were collected from patients. Patients who received treatment were followed for 3 months. Magnetic resonance angiography (MRA) was used to determine SIR levels before and after thrombolysis and to analyze the correlation between SIR levels and END. Results: Patients in the END group had higher baseline systolic blood pressure, diastolic blood pressure, post-thrombolysis hemorrhage conversion, baseline NIHSS score, discharge NIHSS score, and modified Rankin Scale (mRS) score than those in the no-END group, whereas pre- and post-thrombolysis SIR levels were lower than those in the no-END group (P<0.05). Multifactorial logistic regression analysis showed that baseline NIHSS score, post-thrombolytic hemorrhagic conversion, and pre-thrombolytic SIR were independent risk factors for the development of END in patients with acute cerebral infarction treated with intravenous thrombolysis. Receiver operating curve (ROC) analysis showed that the area under the curve (AUC) of END detected by the combination of baseline NIHSS score and pre-thrombolysis SIR level was 0.791 (95% CI: 0.712-0.870), with sensitivity and specificity of 60% and 88.9%, respectively, and P<0.001 (Figure 1), which was higher than that of END detected by the two measures alone (baseline NIHSS score: AUC 0.770, 95% CI: 0.691-0.849, p=0.000; pre-thrombolytic SIR: AUC 0.654, 95% CI: 0.556-0.752, p=0.005). Spearman's correlation analysis showed that pre-thrombolysis SIR level was negatively correlated with the level of mRS score and post-thrombolysis hemorrhagic conversion (r=-0.218, p=0.000; r=-0.166, p=0.038), whereas it was positively correlated with post-thrombolysis SIR level (r=0.408, p=0.000). Conclusions: SIR levels can be used as a simple, non-invasive and highly reproducible method in combination with baseline NIHSS scores to determine the occurrence of END after intravenous thrombolysis, providing a method for early screening of individuals at risk for END. acute cerebral infarction hemodynamics intravenous thrombolysis multimodal imaging neurological function Figures Figure 1 Figure 2 Figure 3 Introduction Acute cerebral infarction (ACI) is a neurological disease associated with high morbidity, disability, and mortality worldwide. According to previous studies, the global incidence of stroke has increased by 70%, the prevalence by 75% and the mortality rate by 43% [ 1 ] . Acute cerebrovascular infarction (ACI) is a class of diseases in which ischemia and hypoxia of brain cells occur due to insufficient blood supply to brain tissues, eventually leading to neurological impairment mainly [ 2 ] , among which large artery atherosclerotic cerebral infarction (LAA) is more common, accounting for about 25% [ 3 ] . In previous studies, it was reported that in cases of ACI treated with rt-PA intravenous thrombolysis, the risk of death in patients with early neurological deterioration appeared to be 5.28 times higher than that of patients without END, and the prognosis was relatively poor, which is a difficult point of clinical management [ 4 ] . At present, according to the clinical consensus of ACI intravenous thrombolytic therapy, the time window within 4.5 hours by rt-PA intravenous thrombolytic therapy is still the preferred method. However, early neurological deterioration (END) has been reported to occur in approximately one third of patients treated with intravenous thrombolysis for ACI [ 5 ] . There is still a lack of understanding of the pathogenesis of END after intravenous thrombolytic therapy for ACI. Studies have reported that systolic blood pressure, atrial fibrillation, and baseline NIHSS score are risk factors for END in ischemic stroke patients [ 6 ] . Currently, the NIHSS score is used to assess the severity of acute ischemic stroke patients in terms of 15 aspects such as level of consciousness, speech, and visual field defects. And no single factor leads to END after intravenous thrombolytic therapy for ACI, so screening for early predictive markers that can help predict intravenous thrombolytic therapy for ACI will help clinical diagnosis and treatment. Cerebral hemodynamics is the mechanics of cerebral blood flow through the cerebral arterial system [ 7 ] . Altered cerebral hemodynamics is a pathophysiological factor in LAA type acute cerebral infarction. When the cerebral blood flow fluctuates greatly or when the cerebral arteries are narrowed, hemodynamic changes in the brain are caused. Especially at the branching or turning point of the vasculature, due to the decrease of cerebral perfusion, the deposition of lipids and other substances occurs, leading to the occurrence of vascular atherosclerosis, endothelial cell damage, platelet aggregation, and so on, causing the reduction of blood supply and leading to the occurrence of acute cerebral infarction [ 8 ] . LAA more likely to develop END [ 9 ] . Time-of-flight magnetic resonance angiography (TOF-MRA) on the basis of the ratio of distal to proximal signal intensity at the stenosis of the middle cerebral artery for blood flow signal intensity (signal intensity ratio, SIR) has been reported to evaluate the degree of cerebral blood perfusion, which is noninvasive, simple, reproducible, and independent of contrast media [ 10 ] . One study reported using SIR to predict the risk of recurrent ischaemic stroke and found that the risk of recurrent stroke was 5.2 times higher in the SIR 0.9 group.. Furthermore, the degree of stenosis does not reflect the hemodynamic changes, so it is not the only factor used to determine whether or not END occurs [ 11 ] . It is concluded that SIR levels for hemodynamic evaluation are clinically useful in predicting the effectiveness and prognosis of patients undergoing intravenous thrombolytic therapy for acute stroke. Previous studies in patients with symptomatic anterior circulation intracranial atherosclerosis found a significant negative linear correlation between SIR levels and stroke infarct volume (P < 0.05) [ 12 ] . Additionally, SIR levels were found to be significantly lower in the under-perfused group than in the normal-perfused group in a study of the relationship between unilateral MCA stenosis and cerebral perfusion [ 13 ] . The measurement of SIR levels by MRA as a non-invasive and easy to perform method has been validated in the previous studies mentioned above. The aim of this study is to investigate the clinical value of monitoring cerebral haemodynamics (SIR level), NHISS and post-thrombolytic haemorrhagic transformation using magnetic resonance imaging (MRI)-based MRA technology, to comprehensively and systematically analyse the clinical value of prognostic assessment of patients with acute cerebral infarction treated with intravenous thrombolysis, and to provide basic scientific support for the therapeutic prognosis of acute cerebral infarction. Materials and Methods 1.1 Subjects of the research A total of 157 patients with acute cerebral infarction who were admitted to the Department of Neurology, Tianjin Huanhu Hospital from January 2022 to February 2024 were enrolled, including 110 men and 47 women, aged 22-87 (62.59±10.69) years. Grouping was based on an increase of ≥4 points in the baseline NIHSS score at 24 hours after intravenous thrombolysis or death defined as END.Patients were divided into 36 cases in the END group and 121 cases in the non-END group. Inclusion criteria:(1) All patients underwent head MRI+MRA before and after thrombolysis and met the ESO guidelines for intravenous thrombolysis in acute ischemic stroke for screening and treatment [16] ; (2) unilateral or bilateral stenosis of the M1 segment of the middle cerebral artery ranging from 50% to 99%, with the severe side predominating in cases where both sides were stenotic; (3) age ≥18 years; (4) received intravenous thrombolysis within 4. 5 hours of onset; (5) have well-established clinical and imaging data; (6) good compliance. Exclusion criteria: (1) Patients with TIA; (2) Patients with stroke mimics; (3) those who received intravenous thrombolysis and then underwent bridging therapy or neurosurgery; (4) stenosis located at the bifurcation of the vessel or at the orifice of the perforating artery; (5) comorbidities with other diseases, such as inflammation, tumors, hepatic and renal insufficiency, and severe neurological deficits, etc. (6) Incomplete data, such as clinical and imaging data; (7) Poor compliance to participate in the study or refusal to participate in this study. The study was approved by the Ethics Committee of Tianjin Huanhu Hospital (Approval number:2022-047; Data:2022.5.10), and patients signed the corresponding informed consent form. 1.2 Methods 1.2.1 Collection of General Information Baseline clinical data of the enrolled patients were collected and recorded, including age, sex, BMI, smoking, alcohol consumption, and medical history (hypertension, diabetes mellitus, coronary artery disease, atrial fibrillation, previous cerebral infarction). Before thrombolysis, venous blood was collected from the enrolled subjects for blood cytology, coagulation profile and blood glucose; 24 hours after thrombolysis, fasting venous blood was collected in the morning for routine blood count, coagulation profile, blood lipids (LDL, HDL, TC, TG), fasting blood glucose, homocysteine, liver and kidney function and CRP. 1.2.2 Intravenous Thrombolysis Data Collection ESSEN score before thrombolysis; NIHSS score before thrombolysis, 1 hour, 24 hours and 7 days after thrombolysis; mRS score 3 months after hospital discharge; examination results before and after thrombolysis (including head MRI+MRA, head CT, routine electrocardiogram, etc.). 1.2.3 Methods to Assess Neurological Function and Prognosis END was defined as an increase of ≥4 points in the total NIHSS score from the admission NIHSS score within 24 hours of intravenous thrombolysis or death [14]. Patients were followed up at 3 months, and an mRS score of 0-2 points at 3 months after treatment was defined as a good long-term prognosis, indicating that patients could already perform daily work and live independently; an mRS score of 3-6 points at 3 months after treatment was defined as a poor long-term prognosis, indicating that patients were still disabled and could not take care of themselves [15] . An mRS score of 3-6 at 3 months after treatment was defined as a poor long-term prognosis, indicating that the patient was still disabled and could not take care of themselves [15] . 1.2.4 Method of evaluating the SIR value of the middle cerebral artery in head MRA Magnetic resonance imaging (MRI) was performed using a Siemens (AVANTO) 3.0T superconducting MRI system. On the maximum intensity projection (MIP) of the MRA vessels, symmetrical areas of equal area were selected in the lumen distal and proximal to the stenosis of the MI segment of the middle cerebral artery before and after thrombolysis, and the average SI measurement was performed (it was preferred to cover the lumen just enough to avoid the bifurcation of the vessel and the opening of the perforating arteries). At the same time, the background SI of the left and right sides of the area adjacent to the internal carotid artery without vascular signal was calculated, and the average value was taken as the average background SI. Calculation formula: SIR = (average SI of distal stenosis - background SI) / (average SI of proximal stenosis - background SI) [12] . 1.3 Statistical Methods IBM SPSS 23.0 software was used for statistical analysis, and the measurement information was expressed as X±S, and the t-test was used for comparison between two groups. The non-normally distributed measurements were expressed as M (Q1, Q3), and the Mann-Whitney U test was used for comparison between groups, and the count data were expressed as percentages, and the χ2 test was used, and multifactorial logistic regression analysis and Spearman's correlation analysis were used, and the difference was considered statistically significant at P<0.05. Results 2.1 General Clinical Data of Patients with Acute Cerebral Infarction with or without END after Intravenous Thrombolysis Among the 157 patients who underwent intravenous thrombolysis for acute cerebral infarction, 36 patients developed END and the remaining 121 did not develop END. The clinical data of all study subjects were collected according to the grouping, and the statistical analysis revealed that the differences between the END cases and those who did not develop END were statistically significant (P<0. 05) for the 6 indexes, including systolic blood pressure, diastolic blood pressure, hemorrhagic transformation after thrombolysis, NIHSS before thrombolysis, NIHSS at the time of discharge, and mRS scores. were statistically significant (P<0.05). The collected data suggest that the above six factors may be involved in the early indicators of neurological deterioration in patients undergoing intravenous thrombolysis for acute cerebral infarction (Table 1). Table 1 . Comparison of baseline clinical data between END and non-END patients Projects END (n=36) Non-END (n=121) Test Value P-value Sex (cases) 24/12 86/35 0.257 0.612 Age (years) 63.58±10.62 62.29±10.73 -0.637 0.525 Body Mass Index (kg/m2) 24.62±3.56 25.13±3.73 -0.799 0.426 Hypertension (cases, %) 26 (72.2) 80 (66.1) 0.472 0.492 Coronary artery disease (cases, %) 9 (25.0) 16 (13.2) 2.874 0.090 Diabetes mellitus (cases, %) 12 (33.3) 40 (33.1) 0.001 0.975 Cerebral infarction (cases, %) 6（16.7） 25（20.7） 0.279 0.597 Atrial fibrillation (cases, %) 6（16.7） 10（8.3） 2.140 0.143 Hyperlipidemia (cases, %) 3（8.3） 18（14.9） 1.025 0.311 Family history (case, %) 7（19.4） 28（23.1） 0.219 0.640 Smoking (case, %) 20 (55.6) 72 (59.5) 0.178 0.673 Alcohol consumption (case, %) 20 (25.6) 58 (47.9) 0.645 0.422 Systolic Blood Pressure (x±s,mmHg) 150.39±19.49 144.58±13.57 -2.025 0.045 Diastolic blood pressure (mmHg) 90.72±13.63 86.16±10.99 -2.067 0.040 Fasting blood glucose (mmol/L) 7.59±4.63 7.21±3.02 -0.579 0.563 Random blood glucose (mmol/L) 7.93±3.73 8.22±3.19 0.458 0.648 TC (mmol/L) 5.13±1.18 4.73±1.06 -1.916 0.057 TG (mmol/L) 1.72±1.11 1.63±1.31 -0.338 0.735 LDL-C (mmol/L) 3.27±0.84 3.03±0.72 -1.696 0.092 HDL-C (mmol/L) 1.22±0.25 1.35±0.59 1.275 0.204 Homocysteine (μmol/L) 18.06±12.72 16.19±7.94 -1.070 0.286 Uric acid (μmol/L) 347.17±88.85 334.45±99.37 -0.690 0.491 CRP (mg/L) 5.20±6.45 4.63±5.95 -0.499 0.618 Before thrombolysis INR 0.93±0.07 0.95±0.18 0.738 0.462 Fibrinogen 2.92±0.67 2.84±0.63 -0.632 0.528 Prothrombin time 17.38±0.97 17.96±2.94 1.182 0.239 Activated Partial Thromboplastin Time 23.51±4.35 24.07±7.92 0.406 0.685 After thrombolysis INR 1.41±0.55 1.33±0.50 -0.883 0.379 Fibrinogen 2.71±0.51 2.81±0.51 1.026 0.307 Prothrombin Time 18.11±0.88 18.02±1.49 -0.325 0.746 Activated Partial Thromboplastin Time 41.32±15.84 40.08±15.68 -0.417 0.677 <3 hours [number of cases (%) 8（22.2） 15（12.4） 2.142 0.143 3-4.5 hours [Number of cases (%) 28（77.8） 106（87.6） Hemorrhage conversion after thrombolysis 4 (11.1) 1 (0.8) 9.518 0.002 ESSENCE 3.39±1.15 3.27±1.06 -0.567 0.572 NIHSS before thrombolysis 7.61±2.56 5.50±1.41 -6.420 0.000 NIHSS at discharge 4.19±4.00 1.45±1.98 -5.605 0.000 mRS score 2（1,4） 0（0,1） -6.115 0.000 2.2 Comparison of the relationship between the presence or absence of END and SIR levels after thrombolysis in acute cerebral infarction In patients with acute cerebral infarction before intravenous thrombolysis and 24 hours after treatment, the SIR values of patients who developed END in the treated cases were significantly lower than the SIR values of patients in the group who did not develop END. The difference was statistically significant (P<0.05). The experimental results suggest that the presence of END before and 24 hours after intravenous thrombolysis has the potential to predict early neurological deterioration in patients (Table 2). Table 2 . Comparison of SIR levels between the END and non-END groups before and after treating acute stroke Group SIR before thrombolysis SIR 24 hours after thrombolysis END group (n=36) 0.83(0.66,0.97) 0.89(0.70,1.12) Non-END group (n=121) 0.90(0.79,1.17) 1.01(0.79,1.40) t value -2.800 -2.675 P value 0.005 0.007 Note: (SIR: Signal Intensity Ratio of Blood Flow) 2.3 Correlation between pre-thrombolytic SIR and END in patients with acute cerebral infarction receiving IV thrombolysis The SIR value was calculated based on the signal intensity ratio proposed by Leng in 2013, and the pre-thrombolytic blood flow signal intensity (SIR) was grouped according to quartiles [12] . The association between the SIR value and the risk of neurological deterioration in the early stage of intravenous thrombolysis for acute cerebral infarction was analyzed. The results showed that the number of patients in the non-END group tended to increase with increasing SIR level. On the contrary, the number of patients in the END group showed a decreasing trend in the rate of END occurrence as the Q value increased, and the difference in SIR between the two groups was statistically significant when comparing the two groups (P<0.05). The experimental results suggest that there is a correlation between blood flow signal intensity before intravenous thrombolysis for cerebral infarction and the risk of neurological deterioration in the early stage of intravenous thrombolysis for acute cerebral infarction (Table 3). Figure 1 shows two cases demonstrating the use of TOF-MRA to calculate the SIR value and END assessment of the M1 segment of the middle cerebral artery. Table 3 . Correlation analysis between SIR values and risk of END with intravenous thrombolysis in acute stroke Group SIR Horizontal Quartile Group Z* P-value Q1(≤0.74) Q2(0.74-) P-value Q4(1.12-) END group (n=36) 16 10 6 4 -3.086 0.002 Non-END group (n=121) 23 38 26 34 Note: (SIR: Signal Intensity Ratio of Blood Flow) 2.4 Multifactorial Analysis of SIR Values and END in Patients Undergoing Intravenous Thrombolysis for Acute Cerebral Infarction Using the grouping of whether or not neurological deterioration occurred in the early stage of acute cerebral infarction patients undergoing intravenous thrombolysis as the dependent variable (non-END group=0, END group=1), the factors that were statistically significant in the above analysis, including systolic blood pressure, diastolic blood pressure, pre-thrombolysis NIHSS, pre-thrombolysis NIHSS, diastolic blood pressure, pre-thrombolysis NIHSS, pre-thrombolysis SIR value, and post-thrombolysis hemorrhage were transformed to be the independent variables (Table 4) and included in a multifactorial logistic regression model for multifactorial factor analysis. The results showed that pre-thrombolysis NIHSS, pre-thrombolysis SIR, and post-thrombolysis hemorrhage transformation were still associated with early occurrence of neurological deterioration in patients who underwent intravenous thrombolysis for acute cerebral infarction after excluding other confounders (P<0.05) (Table 5). Table 4 . Table of influencing factor variable assignments Variable Name Assignment Description Systolic Blood Pressure (mmHg) Measured Value Diastolic Blood Pressure (mmHg) Measured Value NIHSS before thrombolysis Measured Value SIR before thrombolysis Measured value Hemorrhage conversion after thrombolysis 0=No, 1=Yes Note: (SIR: Signal Intensity Ratio of Blood Flow) Table 5 . Multifactorial logistic regression analysis of END in patients receiving intravenous thrombolysis for acute cerebral infarction Independent variables β SE Wald P OR OR 95% CI Systolic Blood Pressure (mmHg) 0.028 0.018 2.337 0.126 1.028 0.992~1.066 Diastolic Blood Pressure (mmHg) NIHSS before thrombolysis 0.013 0.022 0.310 0.577 1.013 0.969~1.058 SIR before thrombolysis 0.564 0.139 16.518 0.000 1.758 1.339~2.307 Bleeding conversion after thrombolysis -1.858 0.912 4.151 0.042 0.156 0.026~0.932 Systolic Blood Pressure (mmHg) -2.729 1.354 4.555 0.044 0.065 0.005~0.928 Note: (SIR: Signal Intensity Ratio of Blood Flow) 2.5 Comparison of mRS scores between the 2 groups of patients within 3 months of disease onset 157 patients completed the 3-month follow-up by telephone or in person, including 36 in the END group and 121 in the no-END group. The proportion of mRS score ≥3 in the END group was significantly higher than that in the no-END group (36.1% vs. 5. 8%, P < 0.001), and the proportion of mRS score 0-2 was significantly lower than that in the no-END group (63.9% vs. 94.2%, P < 0.001) (Table 6 and Figure 2). Table 6 . Comparison between the 2 patient groups for 3-month mRS scores Projects END group (n=36) Non-END group (n=121) Test Value P-value mRS (0-2Scores) 23(63.9) 114（94.2） 24.954 ＜0.001 mRS (≥3Scores) 13（36.1） 7（5.8） 2.6 Clinical Value of ROC Curve Analysis of SIR in Predicting END of Intravenous Thrombolysis in Acute Cerebral Infarction ROC curve analysis showed that the AUC of the two indicators, baseline NIHSS score and pre-thrombolysis SIR value, for the combined detection of END was 0.791 (95% CI: 0.712-0.870), with a sensitivity and specificity of 60% and 88.9%, respectively, higher than that of the two indicators individually, with P<0.001 (see Figure 3). The AUC was improved by 0.137 compared to detection based on SIR alone (baseline NIHSS score: AUC of 0.770, 95% CI: 0.691 to 0.849, P < 0.001 (Figure 3); pre-thrombolysis SIR: AUC of 0.654, 95% CI: 0.556 to 0.752, P = 0.005 (Figure 3), suggesting that the combined test was more helpful in assessing patient status (Table 7). Table 7 . Predictive value of SIR and baseline NIHSS score for END in patients with Acute cerebral infarction receiving intravenous thrombolysis Projects Cut-off value optimal AUC 95%CI sensitivity specificity P-value Baseline NIHSS Score 5.5 0.770 0.691～0.849 57 86.1 0.000 Pre-thrombolytic SIR 0.75 0.654 0.556～0.752 81 47.2 0.005 Combined test 0.16 0.791 0.712～0.870 60 88.9 0.000 2.7 Biased correlation analysis of baseline NIHSS score in patients with acute cerebral infarction with intravenous thrombolysis The results of the analysis showed that the bias correlation coefficients of baseline NIHSS score with discharge NIHSS score and mRS score were 0.499 and 0.506, which were positively correlated (P < 0.05) under the condition of END as a control variable. This suggests a significant linear correlation between baseline NIHSS score and discharge NIHSS score and 3-month mRS score, and no correlation with post-thrombolytic hemorrhage (P > 0.05), as shown in Table 8. Table 8 . Correlation analysis of biases in baseline NIHSS scores Projects r p Discharge NIHSS Score 0.499 0.000 Bleeding after thrombolysis 0.045 0.579 mRS score 0.506 0.000 2.8 Correlation Analysis of Pre-Thrombolytic SIR in Acute Stroke with Intravenous Thrombolysis Further Spearman correlation analysis was performed in patients with acute cerebral infarction who received intravenous thrombolysis with early neurological dysfunction. The results showed that the pre-thrombolysis SIR value was negatively correlated with the level of mRS score and post-thrombolysis hemorrhagic transformation (r=-0.218, p=0.006; r=-0.166, p=0.038), while it was positively correlated with the post-thrombolysis SIR value (r=0.408, p=0.000) (Table 9). Table 9 . Correlation of pre- and post-thrombolysis SIR values, hemorrhagic conversion, and mRS scores Projects r-value P-value mRS score -0.218 0.006 Post-Thrombolytic SIR Values 0.408 0.000 Hemorrhage conversion after thrombolysis -0.166 0.038 Discussion Although intravenous thrombolysis is currently the mainstay of treatment for patients with acute stroke, not all patients benefit from this therapy. Approximately one-third of patients develop neurological deterioration early after thrombolysis, leading to a poor prognosis [ 5 ] . Among the 157 patients with acute cerebral infarction in this study, the rate of neurological deterioration after 24 hours of intravenous thrombolysis was 22.9%, which is similar to the results reported in previous studies [ 3 ] . It is of clinical significance how to predict early and accurately the occurrence of END after intravenous thrombolysis so that clinical interventions can be made in time. In this study, 157 patients with acute cerebral infarction were selected and treated according to the ESO guidelines for intravenous thrombolysis in acute ischemic stroke [ 16 ] . Comparison of the results between the two groups showed that baseline systolic and diastolic blood pressure, pre-thrombolysis NIHSS score, post-thrombolysis hemorrhagic conversion and mRS scores were significantly higher in the END group than in the non-END group. The number of patients with a poor 3-month prognosis was also significantly higher in the END group than in the no-END group. And the END group was still associated with pre-thrombolysis NIHSS score and post-thrombolysis bleeding conversion after excluding other confounders. This also suggests that the baseline NIHSS score can be used not only to assess the severity of the disease, but also as an indicator to identify patients with potentially poor prognosis before intravenous thrombolysis, which has a certain reference value for early assessment of the occurrence of END [ 17 ] . Previous studies have also shown that higher baseline NIHSS scores tend to indicate more severe neurological deficit symptoms in patients with acute cerebral infarction and are associated with the risk of malignant cerebral edema and hemorrhagic transformation after thrombolysis. This suggests a poor prognosis and is an independent risk factor for the development of END [ 18 ] . The present study is basically consistent with the above findings, and the results of partial correlation analysis showed that there was a significant linear correlation between the baseline NIHSS scores and the NIHSS scores at the time of discharge and the mRS scores at 3 months after discharge. In addition, this study found that the pre- and post-thrombolysis SIR values in the END group were significantly lower than those in the non-END group. And logistic regression further confirmed that in addition to pre-thrombolysis NIHSS score and post-thrombolysis hemorrhagic transformation and other factors, abnormal SIR value is also an important risk factor for END in patients with acute cerebral infarction IV thrombolysis. Furthermore, by Spearman correlation analysis, it was found that pre-thrombolysis SIR value was negatively correlated with 3-month mRS score and post-thrombolysis hemorrhagic transformation in patients with acute cerebral infarction, and positively correlated with post-thrombolysis SIR value. It indicates that the lower the pre-thrombolysis SIR value, the higher the risk of post-thrombolysis hemorrhagic transformation and poor prognosis, and the worse their hemodynamic recovery. It is also shown that lower SIR values are involved in the development of END 24 hours after intravenous thrombolysis and are associated with poor prognosis. A previous study on the relationship between SIR values and cerebral perfusion in patients with unilateral middle cerebral artery stenosis found that SIR values were significantly lower in patients in the underperfused group compared to the normally perfused group, and that an SIR value < 0.9 was independently associated with inadequate cerebral perfusion distal to the stenosis [ 19 ] . Furthermore, Lan et al. found that SIR values were significantly and linearly negatively correlated with cerebral blood volume and blood flow velocity on the ipsilateral side of the lesion when they examined the relationship between SIR values and ipsilateral cerebral perfusion [10]. In our study, we grouped the pre-thrombolysis signal intensity of blood flow (SIR) according to quartiles, and the results showed that the number of patients in the END-free group tended to increase with the increase of the SIR level, while the number of patients in the END group tended to decrease, and the number of patients in the END-free group was significantly increased when the SIR was > 0.9. This may be due to the fact that when atherosclerosis in the brain causes stenosis or occlusion of blood vessels, cerebral perfusion at the distal end of the stenosis decreases, resulting in a change in the hemodynamic index of SIR value, which leads to the occurrence of acute cerebral infarction [ 20 ] . Therefore, SIR value can be measured by MRA before intravenous thrombolysis to monitor hemodynamic information to assess cerebrovascular blood flow to predict the risk of END in patients with acute cerebral infarction. This also suggests that the SIR value can be used as a non-invasive and practical tool to detect changes in cerebral hemodynamics in patients undergoing intravenous thrombolysis for acute cerebral infarction, which is of high value in evaluating efficacy and prognosis. Compared with hemodynamic clinical assessment methods such as transcranial Doppler ultrasound, CT cerebrovascular perfusion imaging, and DSA, the acquisition of SIR values by TOF-MRA has the advantages of being noninvasive, simple, highly reproducible, and independent of contrast media [ 10 ] . In addition, in our study, magnetic resonance imaging (MRI) was performed before and after thrombolysis, which can measure SIR values more accurately and intuitively than in previous studies and can monitor changes in SIR values. The exponential SIR value can be considered as a simple and effective marker of hemodynamic significance before and after thrombolysis. Intravenous thrombolytic therapy with rt-PA achieves the therapeutic effect of recanalization of occluded blood vessels and salvage of ischemic penumbra by reducing blood viscosity, improving blood coagulation, and inhibiting platelet aggregation [ 21 ] . In this study, it was found that the SIR value increased after intravenous thrombolytic therapy compared with that before thrombolysis in both END and no-END groups. And the results of Spearman correlation analysis between pre-thrombolysis SIR values and post-thrombolysis SIR values showed a strong correlation. This also suggests that intravenous rt-PA thrombolysis can improve stenotic vessel dynamics and increase blood flow in the infarct area, which is consistent with previous studies [ 22 ] . Based on the above studies, the clinical value of the three indices of pre-thrombolytic SIR, pre-thrombolytic NIHSS, and post-thrombolytic hemorrhagic conversion in predicting whether END will occur after intravenous thrombolytic therapy was analyzed individually and jointly using ROC curves. The AUC of baseline NIHSS and pre-thrombolysis SIR for the combined detection of END was 0.791, and the sensitivity and specificity were 60% and 88.9%, respectively, higher than the AUC of baseline NIHSS and pre-thrombolysis SIR alone. The results suggest that baseline NIHSS score and pre-thrombolysis SIR value may be auxiliary predictors of END after intravenous thrombolysis for acute cerebral infarction and that the simultaneous detection of both may be a useful predictor of END after intravenous thrombolysis. Adjunctive predictors. The results suggest that the baseline NIHSS score and the pre-thrombolysis SIR value may be additional predictors of END after intravenous thrombolysis in acute cerebral infarction. Previous studies have also found that the SIR value measured by MRA may be a strong predictor of recurrent stroke and can be used for risk stratification of stroke risk within a certain range, which supports the results of this experiment [ 11 ] . Combining the results of the above experiments, the AUC value of early neurological deterioration in patients with acute cerebral infarction predicted based on magnetic resonance imaging information combined with two indicators of cerebral hemodynamics (SIR values) and baseline NIHSS scores reaches 0.791, which provides a method for early screening of END high-risk groups. Declarations Acknowledgements Not applicable. Authors ’ contributions XY.L. First author,wrote the main manuscript text. PR.Z. Partial data collection . B.L. Partial data collection . X.Y. Part of the literature was collected. XY.D. Prepared figures 1. XQ.Y. Prepared figures 2. FF.Z. Prepared figures 2. Y.C. Prepared figures 3. Z.D. Prepared figures 3. PL.Z. Corresponding authors,review papers,verifying that all data, figures, materials. Funding This work was supported by the Tianjin Municipal Health Bureau Key Project (grant no. TJWJ2022XK030). Availability of data and materials The data of this study were collected from two hospitals in the Shenzhen area. Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethical Committee of the Tianjin Huanhu Hospital（Approval number:2022-047; Data:2022.5.10）. Informed consent has been obtained from the participants, their parents and legally authorized representatives in this study. Consent for publication Accepted for publication. Competing interests All authors in this study declare that they have no competing interests. Author details 1, Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin 300222, China. 2, Department of Emergency Medicine, The First Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia 010000, China. 3, The Second Hospital of Tianjin Medical University, Tianjin 300222, China. 4, Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300222, China. References Owolabi MO, Thrift AG, Mahal A, Ishida M, Martins S, Johnson WD, Pandian J, Abd-Allah F, Yaria J, Phan HT, Roth G, Gall SL, Beare R, Phan TG, Mikulik R, Akinyemi RO, Norrving B, Brainin M, Feigin VL; Stroke Experts Collaboration Group. Primary stroke prevention worldwide: translating evidence into action. Lancet Public Health. 2022;7(1):e74-e85. doi: 10.1016/S2468-2667(21)00230-9. Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947. doi: 10.1161/STR.0b013e318284056aIF: 7.8 Q1. Ge JJ , Xing YQ, Chen HX , Wang LL , Cui L . Analysis of young ischemic stroke patients in northeast China. Annals of Translational Medicine. 2020;8(1), 3. 10.21037/atm.2019.12.72. Dharmasaroja PA, Muengtaweepongsa S, Dharmasaroja P. Early outcome after intravenous thrombolysis in patients with acute ischemic stroke. Neurol India. 2011;59(3):351-4. doi: 10.4103/0028-3886.82723. Seners P, Turc G, Oppenheim C, Baron JC. Incidence, causes and predictors of neurological deterioration occurring within 24 h following acute ischaemic stroke: a systematic review with pathophysiological implications. J Neurol Neurosurg Psychiatry. 2015;86(1):87-94. doi: 10.1136/jnnp-2014-308327. Geng HH, Wang Q, Li B, Cui BB, Jin YP, Fu RL, Zhang Q, Wang JJ, Wang PX. Early neurological deterioration during the acute phase as a predictor of long-term outcome after first-ever ischemic stroke. Medicine (Baltimore). 2017;96(51):e9068. doi: 10.1097/MD.0000000000009068. Brassard P, Roy MA, Burma JS, Labrecque L, Smirl JD. Quantification of dynamic cerebral autoregulation: welcome to the jungle! Clin Auton Res. 2023;33(6):791-810. doi: 10.1007/s10286-023-00986-2. Corcoran D, Hennigan B, Berry C. Fractional flow reserve: a clinical perspective. Int J Cardiovasc Imaging. 2017;33(7):961-974. doi: 10.1007/s10554-017-1159-2IF: 2.1 Q3. Kim JM, Moon J, Ahn SW, Shin HW, Jung KH, Park KY. The Etiologies of Early Neurological Deterioration after Thrombolysis and Risk Factors of Ischemia Progression. J Stroke Cerebrovasc Dis. 2016;25(2):383-8. doi: 10.1016/j.jstrokecerebrovasdis.2015.10.010IF: 2.5 Q3. Lan L, Leng X, Abrigo J, Fang H, Ip VH, Soo YO, Leung TW, Yu SC, Wong LK. Diminished Signal Intensities Distal to Intracranial Arterial Stenosis on Time-of-Flight MR Angiography Might Indicate Delayed Cerebral Perfusion. Cerebrovasc Dis. 2016;42(3-4):232-9. doi: 10.1159/000445842IF: 2.9 Q3. Liebeskind DS, Kosinski AS, Lynn MJ, Scalzo F, Fong AK, Fariborz P, Chimowitz MI, Feldmann E. Noninvasive fractional flow on MRA predicts stroke risk of intracranial stenosis. J Neuroimaging. 2015;25(1):87-91. doi: 10.1111/jon.12101IF: 2.4 Q3. Leng X, Wong LK, Soo Y, Leung T, Zou X, Wang Y, Feldmann E, Liu L, Liebeskind D. Signal intensity ratio as a novel measure of hemodynamic significance for intracranial atherosclerosis. Int J Stroke. 2013;8(7):E46. doi: 10.1111/ijs.12080. Ge X, Zhao H, Zhou Z, Li X, Sun B, Wu H, Wan J, Xu J , Villablanca JP, Liu X . Association of fractional flow on 3D-TOF-MRA with cerebral perfusion in patients with MCA stenosis. AJNR Am J Neuroradiol. 2019;40:1124–31. 10.3174/ajnr.A6095. Yu WM, Abdul-Rahim AH, Cameron AC, Kõrv J, Sevcik P, Toni D, Lees KR; SITS Scientific Committee*. The Incidence and Associated Factors of Early Neurological Deterioration After Thrombolysis: Results From SITS Registry. Stroke. 2020;51(9):2705-2714. doi: 10.1161/STROKEAHA.119.028287. Quinn TJ, Dawson J, Walters MR, Lees KR. Reliability of the modified Rankin Scale. Stroke. 2007;38(11):e144; author reply e145. doi: 10.1161/STROKEAHA.107.490110. Berge E, Whiteley W, Audebert H, De Marchis GM, Fonseca AC, Padiglioni C, de la Ossa NP, Strbian D, Tsivgoulis G, Turc G. European Stroke Organisation (ESO) guidelines on intravenous thrombolysis for acute ischaemic stroke. Eur Stroke J. 2021;6(1):I-LXII. doi: 10.1177/2396987321989865. Rehman AU, Mohsin A, Cheema HA, Zahid A, Ebaad Ur Rehman M, Ameer MZ, Ayyan M, Ehsan M, Shahid A, Aemaz Ur Rehman M, Shah J, Khawaja A. Comparative efficacy and safety of tenecteplase and alteplase in acute ischemic stroke: A pairwise and network meta-analysis of randomized controlled trials. J Neurol Sci. 2023;15(445):120537. doi: 10.1016/j.jns.2022.120537. Thorén M, Azevedo E, Dawson J, Egido JA, Falcou A, Ford GA, Holmin S, Mikulik R, Ollikainen J, Wahlgren N, Ahmed N. Predictors for Cerebral Edema in Acute Ischemic Stroke Treated With Intravenous Thrombolysis. Stroke. 2017;48(9):2464-2471. doi: 10.1161/STROKEAHA.117.018223IF: 8.3 Q1. Ge X, Zhao H, Zhou Z, Li X, Sun B, Wu H, Wan J, Xu J, Villablanca JP, Liu X. Association of Fractional Flow on 3D-TOF-MRA with Cerebral Perfusion in Patients with MCA Stenosis. AJNR Am J Neuroradiol. 2019;40(7):1124-1131. doi: 10.3174/ajnr.A6095. Miura M, Nakajima M, Fujimoto A, Shiraishi S, Liebeskind DS, Ando Y. Decreased Signal Intensity Ratio on MRA Reflects Misery Perfusion on SPECT in Patients with Intracranial Stenosis. J Neuroimaging. 2018;28(2):206-211. doi: 10.1111/jon.12489. Psychogios K, Tsivgoulis G. Intravenous thrombolysis for acute ischemic stroke: why not? Curr Opin Neurol. 2022;35(1):10-17. doi:10.1097/WCO.0000000000001004IF: 4.8 Q1. Zhang Z, Pu Y, Mi D, Liu L. Cerebral Hemodynamic Evaluation After Cerebral Recanalization Therapy for Acute Ischemic Stroke. Front Neurol. 2019;3(10):719. doi: 10.3389/fneur.2019.00719. The authors have no conflicts of interest to disclose. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4945314","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":346450002,"identity":"ccd394af-be1e-49e1-9808-9ae7cfcf41d2","order_by":0,"name":"Xiaoyue Long","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIie3QsW7CMBCAYVuWrssJVqOilEcwioTY+ir2wgRSxwyRcBSUDCQ7vEXHjq6QPBm6sjWIFyhbhg6ImapOtw7+5vtl3xESBP8QPOS75qtNI6o/Lo1MUn/SQzsbbysbs8zEonHWn0R8PnpEYKrMzWRwWrEOH0NHBCLQujCzRGkg/XItPbvUpuHTIRtUxh7V25Bwt3/1vHKQQiDAePNeHJUDIvjCk/C54BIYPn+e4UUVrGNigHGqLZBuye3IWWUF1Y5x6Sx6d3kq8935u02XmXb00iZp1C/r35M7+LfxIAiC4EdXfLxNaEA8ylUAAAAASUVORK5CYII=","orcid":"","institution":"Tianjin Medical University","correspondingAuthor":true,"prefix":"","firstName":"Xiaoyue","middleName":"","lastName":"Long","suffix":""},{"id":346450005,"identity":"b37a231b-1903-4f06-9277-12bbe19c102f","order_by":1,"name":"Peiren Zhang","email":"","orcid":"","institution":"Tianjin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Peiren","middleName":"","lastName":"Zhang","suffix":""},{"id":346450007,"identity":"8c0fd1ef-7b83-4be1-a70e-3521d97f0ff5","order_by":2,"name":"Bin Luo","email":"","orcid":"","institution":"Tianjin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Luo","suffix":""},{"id":346450008,"identity":"994b9a9a-0188-4fc5-b7e3-0d8524b16a7a","order_by":3,"name":"Xiao Yang","email":"","orcid":"","institution":"The Second Hospital of Tianjin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiao","middleName":"","lastName":"Yang","suffix":""},{"id":346450010,"identity":"630262f3-f4aa-4ddf-a0fa-a4b4347c35cd","order_by":4,"name":"Yuxuan Du","email":"","orcid":"","institution":"Tianjin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuxuan","middleName":"","lastName":"Du","suffix":""},{"id":346450012,"identity":"2f350df7-8a3e-4c01-a4bf-6dc63d6523b5","order_by":5,"name":"Xiaoqing Yu","email":"","orcid":"","institution":"Tianjin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoqing","middleName":"","lastName":"Yu","suffix":""},{"id":346450013,"identity":"99383aa4-6932-4841-842f-97669c322fd9","order_by":6,"name":"Fangfang Zhang","email":"","orcid":"","institution":"Tianjin Huanhu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fangfang","middleName":"","lastName":"Zhang","suffix":""},{"id":346450014,"identity":"22d88d41-9ea1-4ad0-a436-b3b8aad8c353","order_by":7,"name":"Yan Chen","email":"","orcid":"","institution":"Tianjin Huanhu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Chen","suffix":""},{"id":346450015,"identity":"c5170697-bc06-48e9-8d68-c8280da3a03a","order_by":8,"name":"Zhong Dong","email":"","orcid":"","institution":"Tianjin Huanhu Hospital","correspondingAuthor":false,"prefix":"","firstName":"Zhong","middleName":"","lastName":"Dong","suffix":""},{"id":346450017,"identity":"425c78ac-1c4b-49b3-97c4-cadff824049d","order_by":9,"name":"Peilan Zhang","email":"","orcid":"","institution":"Tianjin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Peilan","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2024-08-20 13:23:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4945314/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4945314/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66839312,"identity":"62ddf012-74b4-445b-97cc-22048bad70cd","added_by":"auto","created_at":"2024-10-17 04:42:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":492012,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eUse of TOF-MRA to calculate the SIR value of the M1 segment of the middle cerebral artery and to determine the END, \u003c/strong\u003eEND: (a-d)\u003cstrong\u003e, \u003c/strong\u003ePatients with severe stenosis of the right MCA before thrombolysis in the END group had lower SIR values (a) and a decrease in SIR values after thrombolysis compared with before thrombolysis (c) and an increase in NIHSS scores of ≥4 points compared with before thrombolysis (b) in the ipsilateral cerebral hemisphere with wider infarcts after thrombolysis (d); non-END: (e-h), Patients with severe stenosis of the right MCA before thrombolysis in the non-END group had higher SIR values (e) and increased SIR values after thrombolysis compared with before thrombolysis (g), and the extent of infarction in the ipsilateral cerebral hemisphere did not change significantly after thrombolysis compared with before thrombolysis (f), and the NIHSS score was decreased by ≥3 points compared with before thrombolysis.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4945314/v1/4d411e4ba476beeb1f966e80.png"},{"id":66838210,"identity":"17c65bb3-0c95-427d-940a-2ae8d80b854c","added_by":"auto","created_at":"2024-10-17 04:34:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":27573,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003emRS Scores were compared between the two groups at 3 months after intravenous thrombolysis.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4945314/v1/f56cbd2ecc54984f4a89a0ee.png"},{"id":66839313,"identity":"5b29b458-cc7f-474e-864d-ed708758b867","added_by":"auto","created_at":"2024-10-17 04:42:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":192029,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe ROC curve was used to analyze the clinical predictive value of SIR, NIHSS score and the combination of the two indexes， －: SIR， －:NIHSS，－: SIR and NIHSS （Combined test）.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4945314/v1/d1cf4615187da9400932b7e8.png"},{"id":85363516,"identity":"32bffc38-1e55-49b6-a2da-991473fc9715","added_by":"auto","created_at":"2025-06-25 06:24:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2453464,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4945314/v1/e575731a-d19a-49fe-965d-2907b97c2779.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Multimodal Nuclear Magnetic Imaging Prediction of Early Neurological Deterioration in Patients with Acute Stroke Using Intravenous Thrombolysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute cerebral infarction (ACI) is a neurological disease associated with high morbidity, disability, and mortality worldwide. According to previous studies, the global incidence of stroke has increased by 70%, the prevalence by 75% and the mortality rate by 43%\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Acute cerebrovascular infarction (ACI) is a class of diseases in which ischemia and hypoxia of brain cells occur due to insufficient blood supply to brain tissues, eventually leading to neurological impairment mainly\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, among which large artery atherosclerotic cerebral infarction (LAA) is more common, accounting for about 25%\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In previous studies, it was reported that in cases of ACI treated with rt-PA intravenous thrombolysis, the risk of death in patients with early neurological deterioration appeared to be 5.28 times higher than that of patients without END, and the prognosis was relatively poor, which is a difficult point of clinical management\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. At present, according to the clinical consensus of ACI intravenous thrombolytic therapy, the time window within 4.5 hours by rt-PA intravenous thrombolytic therapy is still the preferred method. However, early neurological deterioration (END) has been reported to occur in approximately one third of patients treated with intravenous thrombolysis for ACI\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere is still a lack of understanding of the pathogenesis of END after intravenous thrombolytic therapy for ACI. Studies have reported that systolic blood pressure, atrial fibrillation, and baseline NIHSS score are risk factors for END in ischemic stroke patients\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Currently, the NIHSS score is used to assess the severity of acute ischemic stroke patients in terms of 15 aspects such as level of consciousness, speech, and visual field defects. And no single factor leads to END after intravenous thrombolytic therapy for ACI, so screening for early predictive markers that can help predict intravenous thrombolytic therapy for ACI will help clinical diagnosis and treatment.\u003c/p\u003e \u003cp\u003eCerebral hemodynamics is the mechanics of cerebral blood flow through the cerebral arterial system\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Altered cerebral hemodynamics is a pathophysiological factor in LAA type acute cerebral infarction. When the cerebral blood flow fluctuates greatly or when the cerebral arteries are narrowed, hemodynamic changes in the brain are caused. Especially at the branching or turning point of the vasculature, due to the decrease of cerebral perfusion, the deposition of lipids and other substances occurs, leading to the occurrence of vascular atherosclerosis, endothelial cell damage, platelet aggregation, and so on, causing the reduction of blood supply and leading to the occurrence of acute cerebral infarction\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. LAA more likely to develop END\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Time-of-flight magnetic resonance angiography (TOF-MRA) on the basis of the ratio of distal to proximal signal intensity at the stenosis of the middle cerebral artery for blood flow signal intensity (signal intensity ratio, SIR) has been reported to evaluate the degree of cerebral blood perfusion, which is noninvasive, simple, reproducible, and independent of contrast media\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. One study reported using SIR to predict the risk of recurrent ischaemic stroke and found that the risk of recurrent stroke was 5.2 times higher in the SIR\u0026thinsp;\u0026lt;\u0026thinsp;0.9 group than in the SIR\u0026thinsp;\u0026gt;\u0026thinsp;0.9 group.. Furthermore, the degree of stenosis does not reflect the hemodynamic changes, so it is not the only factor used to determine whether or not END occurs \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. It is concluded that SIR levels for hemodynamic evaluation are clinically useful in predicting the effectiveness and prognosis of patients undergoing intravenous thrombolytic therapy for acute stroke.\u003c/p\u003e \u003cp\u003ePrevious studies in patients with symptomatic anterior circulation intracranial atherosclerosis found a significant negative linear correlation between SIR levels and stroke infarct volume (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Additionally, SIR levels were found to be significantly lower in the under-perfused group than in the normal-perfused group in a study of the relationship between unilateral MCA stenosis and cerebral perfusion \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. The measurement of SIR levels by MRA as a non-invasive and easy to perform method has been validated in the previous studies mentioned above.\u003c/p\u003e \u003cp\u003eThe aim of this study is to investigate the clinical value of monitoring cerebral haemodynamics (SIR level), NHISS and post-thrombolytic haemorrhagic transformation using magnetic resonance imaging (MRI)-based MRA technology, to comprehensively and systematically analyse the clinical value of prognostic assessment of patients with acute cerebral infarction treated with intravenous thrombolysis, and to provide basic scientific support for the therapeutic prognosis of acute cerebral infarction.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e1.1\u0026nbsp;Subjects of the research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 157 patients with acute cerebral infarction who were admitted to the Department of Neurology, Tianjin Huanhu Hospital from January 2022 to February 2024 were enrolled, including 110 men and 47 women, aged 22-87 (62.59±10.69) years. Grouping was based on an increase of\u0026nbsp;≥4 points in the baseline NIHSS score at 24 hours after intravenous thrombolysis or death defined as END.Patients were divided into 36 cases in the END group and 121 cases in the non-END group. Inclusion criteria:(1) All patients underwent head MRI+MRA before and after thrombolysis and met the ESO guidelines for intravenous thrombolysis in acute ischemic stroke for screening and treatment\u003csup\u003e[16]\u003c/sup\u003e; (2) unilateral or bilateral stenosis of the M1 segment of the middle cerebral artery ranging from 50% to 99%, with the severe side predominating in cases where both sides were stenotic; (3) age\u0026nbsp;≥18 years; (4) received intravenous thrombolysis within 4. 5 hours of onset; (5) have well-established clinical and imaging data; (6) good compliance. Exclusion criteria: (1) Patients with TIA; (2) Patients with stroke mimics; (3) those who received intravenous thrombolysis and then underwent bridging therapy or neurosurgery; (4) stenosis located at the bifurcation of the vessel or at the orifice of the perforating artery; (5) comorbidities with other diseases, such as inflammation, tumors, hepatic and renal insufficiency, and severe neurological deficits, etc. (6) Incomplete data, such as clinical and imaging data; (7) Poor compliance to participate in the study or refusal to participate in this study. The study was approved by the Ethics Committee of Tianjin Huanhu Hospital (Approval number:2022-047; Data:2022.5.10), and patients signed the corresponding informed consent form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.2\u0026nbsp;Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1.2.1\u0026nbsp; \u0026nbsp;\u0026nbsp;Collection of General Information\u003c/p\u003e\n\u003cp\u003eBaseline clinical data of the enrolled patients were collected and recorded, including age, sex, BMI, smoking, alcohol consumption, and medical history (hypertension, diabetes mellitus, coronary artery disease, atrial fibrillation, previous cerebral infarction). Before thrombolysis, venous blood was collected from the enrolled subjects for blood cytology, coagulation profile and blood glucose; 24 hours after thrombolysis, fasting venous blood was collected in the morning for routine blood count, coagulation profile, blood lipids (LDL, HDL, TC, TG), fasting blood glucose, homocysteine, liver and kidney function and CRP.\u003c/p\u003e\n\u003cp\u003e1.2.2\u0026nbsp; \u0026nbsp;\u0026nbsp;Intravenous Thrombolysis Data Collection\u003c/p\u003e\n\u003cp\u003eESSEN score before thrombolysis; NIHSS score before thrombolysis, 1 hour, 24 hours and 7 days after thrombolysis; mRS score 3 months after hospital discharge; examination results before and after thrombolysis (including head MRI+MRA, head CT, routine electrocardiogram, etc.).\u003c/p\u003e\n\u003cp\u003e1.2.3\u0026nbsp; \u0026nbsp;\u0026nbsp;Methods to Assess Neurological Function and Prognosis\u003c/p\u003e\n\u003cp\u003eEND was defined as an increase of\u0026nbsp;≥4 points in the total NIHSS score from the admission NIHSS score within 24 hours of intravenous thrombolysis or death [14]. Patients were followed up at 3 months, and an mRS score of 0-2 points at 3 months after treatment was defined as a good long-term prognosis, indicating that patients could already perform daily work and live independently; an mRS score of 3-6 points at 3 months after treatment was defined as a poor long-term prognosis, indicating that patients were still disabled and could not take care of themselves \u003csup\u003e[15]\u003c/sup\u003e. An mRS score of 3-6 at 3 months after treatment was defined as a poor long-term prognosis, indicating that the patient was still disabled and could not take care of themselves \u003csup\u003e[15]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e1.2.4\u0026nbsp; \u0026nbsp;\u0026nbsp;Method of evaluating the SIR value of the middle cerebral artery in head MRA\u003c/p\u003e\n\u003cp\u003eMagnetic resonance imaging (MRI) was performed using a Siemens (AVANTO) 3.0T superconducting MRI system. On the maximum intensity projection (MIP) of the MRA vessels, symmetrical areas of equal area were selected in the lumen distal and proximal to the stenosis of the MI segment of the middle cerebral artery before and after thrombolysis, and the average SI measurement was performed (it was preferred to cover the lumen just enough to avoid the bifurcation of the vessel and the opening of the perforating arteries). At the same time, the background SI of the left and right sides of the area adjacent to the internal carotid artery without vascular signal was calculated, and the average value was taken as the average background SI.\u003c/p\u003e\n\u003cp\u003eCalculation formula: SIR = (average SI of distal stenosis - background SI) / (average SI of proximal stenosis - background SI)\u003csup\u003e\u0026nbsp;[12]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1.3\u0026nbsp;Statistical Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIBM SPSS 23.0 software was used for statistical analysis, and the measurement information was expressed as X±S, and the t-test was used for comparison between two groups. The non-normally distributed measurements were expressed as M (Q1, Q3), and the Mann-Whitney U test was used for comparison between groups, and the count data were expressed as percentages, and the χ2 test was used, and multifactorial logistic regression analysis and Spearman's correlation analysis were used, and the difference was considered statistically significant at P\u0026lt;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e2.1\u0026nbsp;General Clinical Data of Patients with Acute Cerebral Infarction with or without END after Intravenous Thrombolysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmong the 157 patients who underwent intravenous thrombolysis for acute cerebral infarction, 36 patients developed END and the remaining 121 did not develop END. The clinical data of all study subjects were collected according to the grouping, and the statistical analysis revealed that the differences between the END cases and those who did not develop END were statistically significant (P\u0026lt;0. 05) for the 6 indexes, including systolic blood pressure, diastolic blood pressure, hemorrhagic transformation after thrombolysis, NIHSS before thrombolysis, NIHSS at the time of discharge, and mRS scores. were statistically significant (P\u0026lt;0.05). The collected data suggest that the above six factors may be involved in the early indicators of neurological deterioration in patients undergoing intravenous thrombolysis for acute cerebral infarction (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e. Comparison of baseline clinical data between END and non-END patients\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"530\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eProjects\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003eEND\u003c/p\u003e\n \u003cp\u003e(n=36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003eNon-END\u003c/p\u003e\n \u003cp\u003e(n=121)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003eTest Value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eSex (cases)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e24/12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e86/35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e0.257\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.612\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e63.58\u0026plusmn;10.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e62.29\u0026plusmn;10.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.637\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.525\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eBody Mass Index (kg/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e24.62\u0026plusmn;3.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e25.13\u0026plusmn;3.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.799\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.426\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eHypertension (cases, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e26 (72.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e80 (66.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e0.472\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.492\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eCoronary artery disease (cases, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e9 (25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e16 (13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e2.874\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eDiabetes mellitus (cases, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e12 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e40 (33.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.975\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eCerebral infarction (cases, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e6（16.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e25（20.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e0.279\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eAtrial fibrillation (cases, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e6（16.7）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e10（8.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e2.140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eHyperlipidemia (cases, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e3（8.3）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e18（14.9）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e1.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.311\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eFamily history (case, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e7（19.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e28（23.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e0.219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.640\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eSmoking (case, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e20 (55.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e72 (59.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e0.178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.673\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eAlcohol consumption (case, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e20 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e58 (47.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e0.645\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.422\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eSystolic Blood Pressure (x\u0026plusmn;s,mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e150.39\u0026plusmn;19.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e144.58\u0026plusmn;13.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-2.025\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eDiastolic blood pressure (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e90.72\u0026plusmn;13.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e86.16\u0026plusmn;10.99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-2.067\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eFasting blood glucose (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e7.59\u0026plusmn;4.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e7.21\u0026plusmn;3.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.563\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eRandom blood glucose (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e7.93\u0026plusmn;3.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e8.22\u0026plusmn;3.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e0.458\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.648\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eTC (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e5.13\u0026plusmn;1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e4.73\u0026plusmn;1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-1.916\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.057\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eTG (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e1.72\u0026plusmn;1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e1.63\u0026plusmn;1.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.338\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.735\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eLDL-C (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e3.27\u0026plusmn;0.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e3.03\u0026plusmn;0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-1.696\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.092\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eHDL-C (mmol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e1.22\u0026plusmn;0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e1.35\u0026plusmn;0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e1.275\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.204\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eHomocysteine (\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e18.06\u0026plusmn;12.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e16.19\u0026plusmn;7.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-1.070\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.286\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eUric acid (\u0026mu;mol/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e347.17\u0026plusmn;88.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e334.45\u0026plusmn;99.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.491\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eCRP (mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e5.20\u0026plusmn;6.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e4.63\u0026plusmn;5.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.499\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.618\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eBefore thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eINR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e0.93\u0026plusmn;0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e0.95\u0026plusmn;0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e0.738\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.462\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eFibrinogen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e2.92\u0026plusmn;0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e2.84\u0026plusmn;0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.632\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.528\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eProthrombin time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e17.38\u0026plusmn;0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e17.96\u0026plusmn;2.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e1.182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.239\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eActivated Partial Thromboplastin Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e23.51\u0026plusmn;4.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e24.07\u0026plusmn;7.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e0.406\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.685\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eAfter thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eINR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e1.41\u0026plusmn;0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e1.33\u0026plusmn;0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.883\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.379\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eFibrinogen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e2.71\u0026plusmn;0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e2.81\u0026plusmn;0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e1.026\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.307\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eProthrombin Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e18.11\u0026plusmn;0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e18.02\u0026plusmn;1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.325\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eActivated Partial Thromboplastin Time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e41.32\u0026plusmn;15.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e40.08\u0026plusmn;15.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.417\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.677\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;3 hours [number of cases (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e8（22.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e15（12.4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e2.142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0.143\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45%\" valign=\"top\"\u003e\n \u003cp\u003e3-4.5 hours [Number of cases (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27%\" valign=\"top\"\u003e\n \u003cp\u003e28（77.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28%\" valign=\"top\"\u003e\n \u003cp\u003e106（87.6）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eHemorrhage conversion after thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e4 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e1 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e9.518\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eESSENCE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e3.39\u0026plusmn;1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e3.27\u0026plusmn;1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-0.567\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.572\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eNIHSS before thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e7.61\u0026plusmn;2.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e5.50\u0026plusmn;1.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-6.420\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003eNIHSS at discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e4.19\u0026plusmn;4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e1.45\u0026plusmn;1.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-5.605\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.9622641509434%\" valign=\"top\"\u003e\n \u003cp\u003emRS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.37735849056604%\" valign=\"top\"\u003e\n \u003cp\u003e2（1,4）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.132075471698112%\" valign=\"top\"\u003e\n \u003cp\u003e0（0,1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.69811320754717%\" valign=\"top\"\u003e\n \u003cp\u003e-6.115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.830188679245284%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e2.2\u0026nbsp;Comparison of the relationship between the presence or absence of END and SIR levels after thrombolysis in acute cerebral infarction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn patients with acute cerebral infarction before intravenous thrombolysis and 24 hours after treatment, the SIR values of patients who developed END in the treated cases were significantly lower than the SIR values of patients in the group who did not develop END. The difference was statistically significant (P\u0026lt;0.05). The experimental results suggest that the presence of END before and 24 hours after intravenous thrombolysis has the potential to predict early neurological deterioration in patients (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e. Comparison of SIR levels between the END and non-END groups before and after treating acute stroke\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"94%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.31313131313131%\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.37373737373738%\"\u003e\n \u003cp\u003eSIR before thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.31313131313131%\"\u003e\n \u003cp\u003eSIR 24 hours after thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.31313131313131%\"\u003e\n \u003cp\u003eEND group (n=36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.37373737373738%\"\u003e\n \u003cp\u003e0.83(0.66,0.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.31313131313131%\"\u003e\n \u003cp\u003e0.89(0.70,1.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.31313131313131%\"\u003e\n \u003cp\u003eNon-END group (n=121)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.37373737373738%\"\u003e\n \u003cp\u003e0.90(0.79,1.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.31313131313131%\"\u003e\n \u003cp\u003e1.01(0.79,1.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.31313131313131%\"\u003e\n \u003cp\u003et value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.37373737373738%\"\u003e\n \u003cp\u003e-2.800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.31313131313131%\"\u003e\n \u003cp\u003e-2.675\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.31313131313131%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.37373737373738%\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.31313131313131%\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote: (SIR: Signal Intensity Ratio of Blood Flow)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 \u0026nbsp;Correlation between pre-thrombolytic SIR and END in patients with acute cerebral infarction receiving IV thrombolysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe SIR value was calculated based on the signal intensity ratio proposed by Leng in 2013, and the pre-thrombolytic blood flow signal intensity (SIR) was grouped according to quartiles\u003csup\u003e[12]\u003c/sup\u003e. The association between the SIR value and the risk of neurological deterioration in the early stage of intravenous thrombolysis for acute cerebral infarction was analyzed. The results showed that the number of patients in the non-END group tended to increase with increasing SIR level. On the contrary, the number of patients in the END group showed a decreasing trend in the rate of END occurrence as the Q value increased, and the difference in SIR between the two groups was statistically significant when comparing the two groups (P\u0026lt;0.05). The experimental results suggest that there is a correlation between blood flow signal intensity before intravenous thrombolysis for cerebral infarction and the risk of neurological deterioration in the early stage of intravenous thrombolysis for acute cerebral infarction (Table 3). Figure 1 shows two cases demonstrating the use of TOF-MRA to calculate the SIR value and END assessment of the M1 segment of the middle cerebral artery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e. Correlation analysis between SIR values and risk of END with intravenous thrombolysis in acute stroke\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth\u003e\u003cbr\u003e\u003c/th\u003e\n \u003cth\u003e\u003cbr\u003e\u003c/th\u003e\n \u003cth\u003e\u003cbr\u003e\u003c/th\u003e\n \u003cth\u003e\u003cbr\u003e\u003c/th\u003e\n \u003cth\u003e\u003cbr\u003e\u003c/th\u003e\n \u003cth\u003e\u003cbr\u003e\u003c/th\u003e\n \u003cth\u003e\u003cbr\u003e\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.346938775510203%\" rowspan=\"2\"\u003e\n \u003cp\u003eGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"63.265306122448976%\" colspan=\"4\"\u003e\n \u003cp\u003eSIR Horizontal Quartile Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.204081632653061%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cem\u003eZ*\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.183673469387756%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25%\"\u003e\n \u003cp\u003eQ1(\u0026le;0.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.666666666666668%\"\u003e\n \u003cp\u003eQ2(0.74-)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.666666666666668%\" valign=\"top\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.666666666666668%\"\u003e\n \u003cp\u003eQ4(1.12-)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.708333333333332%\"\u003e\n \u003cp\u003eEND group (n=36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.625%\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.541666666666666%\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.416666666666666%\" rowspan=\"2\"\u003e\n \u003cp\u003e-3.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.375%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.07792207792208%\"\u003e\n \u003cp\u003eNon-END group (n=121)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.48051948051948%\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.77922077922078%\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.883116883116884%\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.77922077922078%\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: (SIR: Signal Intensity Ratio of Blood Flow)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4\u0026nbsp;Multifactorial Analysis of SIR Values and END in Patients Undergoing Intravenous Thrombolysis for Acute Cerebral Infarction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing the grouping of whether or not neurological deterioration occurred in the early stage of acute cerebral infarction patients undergoing intravenous thrombolysis as the dependent variable (non-END group=0, END group=1), the factors that were statistically significant in the above analysis, including systolic blood pressure, diastolic blood pressure, pre-thrombolysis NIHSS, pre-thrombolysis NIHSS, diastolic blood pressure, pre-thrombolysis NIHSS, pre-thrombolysis SIR value, and post-thrombolysis hemorrhage were transformed to be the independent variables (Table 4) and included in a multifactorial logistic regression model for multifactorial factor analysis. The results showed that pre-thrombolysis NIHSS, pre-thrombolysis SIR, and post-thrombolysis hemorrhage transformation were still associated with early occurrence of neurological deterioration in patients who underwent intravenous thrombolysis for acute cerebral infarction after excluding other confounders (P\u0026lt;0.05) (Table 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e4\u003c/strong\u003e\u003cstrong\u003e. Table of influencing factor variable assignments\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"97%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.45454545454545%\"\u003e\n \u003cp\u003eVariable Name\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.54545454545455%\"\u003e\n \u003cp\u003eAssignment Description\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.45454545454545%\" valign=\"top\"\u003e\n \u003cp\u003eSystolic Blood Pressure (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.54545454545455%\" valign=\"top\"\u003e\n \u003cp\u003eMeasured Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.45454545454545%\" valign=\"top\"\u003e\n \u003cp\u003eDiastolic Blood Pressure (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.54545454545455%\" valign=\"top\"\u003e\n \u003cp\u003eMeasured Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.45454545454545%\" valign=\"top\"\u003e\n \u003cp\u003eNIHSS before thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.54545454545455%\" valign=\"top\"\u003e\n \u003cp\u003eMeasured Value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.45454545454545%\" valign=\"top\"\u003e\n \u003cp\u003eSIR before thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.54545454545455%\" valign=\"top\"\u003e\n \u003cp\u003eMeasured value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"45.45454545454545%\" valign=\"top\"\u003e\n \u003cp\u003eHemorrhage conversion after thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"54.54545454545455%\" valign=\"top\"\u003e\n \u003cp\u003e0=No, 1=Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote: (SIR: Signal Intensity Ratio of Blood Flow)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e5\u003c/strong\u003e\u003cstrong\u003e. Multifactorial logistic regression analysis of END in patients receiving intravenous thrombolysis for acute cerebral infarction\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"96%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003eIndependent variables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e\u003cem\u003eSE\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e\u003cem\u003eWald\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e\u003cem\u003eOR\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003e\u003cem\u003eOR\u003c/em\u003e95%\u003cem\u003eCI\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003eSystolic Blood Pressure (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e0.018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e2.337\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e0.126\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e1.028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003e0.992~1.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003eDiastolic Blood Pressure (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003eNIHSS before thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e0.310\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e0.577\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e1.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003e0.969~1.058\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003eSIR before thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\"\u003e\n \u003cp\u003e0.564\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e16.518\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e1.758\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003e1.339~2.307\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003eBleeding conversion after thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\"\u003e\n \u003cp\u003e-1.858\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e0.912\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e4.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e0.042\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e0.156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003e0.026~0.932\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003eSystolic Blood Pressure (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.24742268041237%\"\u003e\n \u003cp\u003e-2.729\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.371134020618557%\"\u003e\n \u003cp\u003e1.354\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.278350515463918%\"\u003e\n \u003cp\u003e4.555\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e0.044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.34020618556701%\"\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.711340206185568%\"\u003e\n \u003cp\u003e0.005~0.928\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: (SIR: Signal Intensity Ratio of Blood Flow)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5\u0026nbsp;Comparison of mRS scores between the 2 groups of patients within 3 months of disease onset\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e157 patients completed the 3-month follow-up by telephone or in person, including 36 in the END group and 121 in the no-END group. The proportion of mRS score \u0026ge;3 in the END group was significantly higher than that in the no-END group (36.1% vs. 5. 8%, P \u0026lt; 0.001), and the proportion of mRS score 0-2 was significantly lower than that in the no-END group (63.9% vs. 94.2%, P \u0026lt; 0.001) (Table 6 and Figure 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003cstrong\u003e. Comparison between the 2 patient groups for 3-month mRS scores\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.605263157894736%\" valign=\"top\"\u003e\n \u003cp\u003eProjects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.36842105263158%\" valign=\"top\"\u003e\n \u003cp\u003eEND group (n=36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.848684210526315%\" valign=\"top\"\u003e\n \u003cp\u003eNon-END group (n=121)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.664473684210526%\" valign=\"top\"\u003e\n \u003cp\u003eTest Value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.513157894736842%\" valign=\"top\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.605263157894736%\" valign=\"top\"\u003e\n \u003cp\u003emRS (0-2Scores)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.36842105263158%\" valign=\"top\"\u003e\n \u003cp\u003e23(63.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.848684210526315%\" valign=\"top\"\u003e\n \u003cp\u003e114（94.2）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.664473684210526%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e24.954\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.513157894736842%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e＜0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.04555314533623%\" valign=\"top\"\u003e\n \u003cp\u003emRS (\u0026ge;3Scores)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.501084598698483%\" valign=\"top\"\u003e\n \u003cp\u003e13（36.1）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.453362255965292%\" valign=\"top\"\u003e\n \u003cp\u003e7（5.8）\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e2.6\u0026nbsp;Clinical Value of ROC Curve Analysis of SIR in Predicting END of Intravenous Thrombolysis in Acute Cerebral Infarction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eROC curve analysis showed that the AUC of the two indicators, baseline NIHSS score and pre-thrombolysis SIR value, for the combined detection of END was 0.791 (95% CI: 0.712-0.870), with a sensitivity and specificity of 60% and 88.9%, respectively, higher than that of the two indicators individually, with P\u0026lt;0.001 (see Figure 3). The AUC was improved by 0.137 compared to detection based on SIR alone (baseline NIHSS score: AUC of 0.770, 95% CI: 0.691 to 0.849, P \u0026lt; 0.001 (Figure 3); pre-thrombolysis SIR: AUC of 0.654, 95% CI: 0.556 to 0.752, P = 0.005 (Figure 3), suggesting that the combined test was more helpful in assessing patient status (Table 7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003cstrong\u003e. Predictive value of SIR and baseline NIHSS score for END in patients with Acute cerebral infarction receiving intravenous thrombolysis\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"19.791666666666668%\" colspan=\"2\"\u003e\n \u003cp\u003eProjects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\"\u003e\n \u003cp\u003eCut-off value optimal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003eAUC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.833333333333332%\"\u003e\n \u003cp\u003e95%CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.583333333333334%\"\u003e\n \u003cp\u003esensitivity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.541666666666666%\"\u003e\n \u003cp\u003especificity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.708333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eBaseline NIHSS Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.541666666666666%\" colspan=\"2\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.770\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.833333333333332%\"\u003e\n \u003cp\u003e0.691～0.849\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.583333333333334%\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.541666666666666%\"\u003e\n \u003cp\u003e86.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.708333333333332%\" valign=\"top\"\u003e\n \u003cp\u003ePre-thrombolytic SIR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.541666666666666%\" colspan=\"2\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.654\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.833333333333332%\"\u003e\n \u003cp\u003e0.556～0.752\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.583333333333334%\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.541666666666666%\"\u003e\n \u003cp\u003e47.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"17.708333333333332%\" valign=\"top\"\u003e\n \u003cp\u003eCombined test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.541666666666666%\" colspan=\"2\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.333333333333334%\"\u003e\n \u003cp\u003e0.791\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.833333333333332%\"\u003e\n \u003cp\u003e0.712～0.870\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.583333333333334%\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.541666666666666%\"\u003e\n \u003cp\u003e88.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.458333333333334%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e2.7\u0026nbsp;Biased correlation analysis of baseline NIHSS score in patients with acute cerebral infarction with intravenous thrombolysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of the analysis showed that the bias correlation coefficients of baseline NIHSS score with discharge NIHSS score and mRS score were 0.499 and 0.506, which were positively correlated (P \u0026lt; 0.05) under the condition of END as a control variable. This suggests a significant linear correlation between baseline NIHSS score and discharge NIHSS score and 3-month mRS score, and no correlation with post-thrombolytic hemorrhage (P \u0026gt; 0.05), as shown in Table 8.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e8\u003c/strong\u003e\u003cstrong\u003e. Correlation analysis of biases in baseline NIHSS scores\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eProjects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003er\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eDischarge NIHSS Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0.499\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eBleeding after thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0.579\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003emRS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0.506\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e2.8\u0026nbsp;Correlation Analysis of Pre-Thrombolytic SIR in Acute Stroke with Intravenous Thrombolysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFurther Spearman correlation analysis was performed in patients with acute cerebral infarction who received intravenous thrombolysis with early neurological dysfunction. The results showed that the pre-thrombolysis SIR value was negatively correlated with the level of mRS score and post-thrombolysis hemorrhagic transformation (r=-0.218, p=0.006; r=-0.166, p=0.038), while it was positively correlated with the post-thrombolysis SIR value (r=0.408, p=0.000) (Table 9).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003cstrong\u003e. Correlation of pre- and post-thrombolysis SIR values, hemorrhagic conversion, and mRS scores\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"511\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.788649706457925%\" valign=\"top\"\u003e\n \u003cp\u003eProjects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.986301369863014%\" valign=\"top\"\u003e\n \u003cp\u003er-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.22504892367906%\" valign=\"top\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.788649706457925%\"\u003e\n \u003cp\u003emRS score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.986301369863014%\"\u003e\n \u003cp\u003e-0.218\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.22504892367906%\"\u003e\n \u003cp\u003e0.006\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.788649706457925%\"\u003e\n \u003cp\u003ePost-Thrombolytic SIR Values\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.986301369863014%\"\u003e\n \u003cp\u003e0.408\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.22504892367906%\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.788649706457925%\"\u003e\n \u003cp\u003eHemorrhage conversion after thrombolysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"36.986301369863014%\"\u003e\n \u003cp\u003e-0.166\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.22504892367906%\"\u003e\n \u003cp\u003e0.038\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAlthough intravenous thrombolysis is currently the mainstay of treatment for patients with acute stroke, not all patients benefit from this therapy. Approximately one-third of patients develop neurological deterioration early after thrombolysis, leading to a poor prognosis \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Among the 157 patients with acute cerebral infarction in this study, the rate of neurological deterioration after 24 hours of intravenous thrombolysis was 22.9%, which is similar to the results reported in previous studies \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. It is of clinical significance how to predict early and accurately the occurrence of END after intravenous thrombolysis so that clinical interventions can be made in time.\u003c/p\u003e \u003cp\u003eIn this study, 157 patients with acute cerebral infarction were selected and treated according to the ESO guidelines for intravenous thrombolysis in acute ischemic stroke \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Comparison of the results between the two groups showed that baseline systolic and diastolic blood pressure, pre-thrombolysis NIHSS score, post-thrombolysis hemorrhagic conversion and mRS scores were significantly higher in the END group than in the non-END group. The number of patients with a poor 3-month prognosis was also significantly higher in the END group than in the no-END group. And the END group was still associated with pre-thrombolysis NIHSS score and post-thrombolysis bleeding conversion after excluding other confounders. This also suggests that the baseline NIHSS score can be used not only to assess the severity of the disease, but also as an indicator to identify patients with potentially poor prognosis before intravenous thrombolysis, which has a certain reference value for early assessment of the occurrence of END \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Previous studies have also shown that higher baseline NIHSS scores tend to indicate more severe neurological deficit symptoms in patients with acute cerebral infarction and are associated with the risk of malignant cerebral edema and hemorrhagic transformation after thrombolysis. This suggests a poor prognosis and is an independent risk factor for the development of END \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. The present study is basically consistent with the above findings, and the results of partial correlation analysis showed that there was a significant linear correlation between the baseline NIHSS scores and the NIHSS scores at the time of discharge and the mRS scores at 3 months after discharge. In addition, this study found that the pre- and post-thrombolysis SIR values in the END group were significantly lower than those in the non-END group. And logistic regression further confirmed that in addition to pre-thrombolysis NIHSS score and post-thrombolysis hemorrhagic transformation and other factors, abnormal SIR value is also an important risk factor for END in patients with acute cerebral infarction IV thrombolysis. Furthermore, by Spearman correlation analysis, it was found that pre-thrombolysis SIR value was negatively correlated with 3-month mRS score and post-thrombolysis hemorrhagic transformation in patients with acute cerebral infarction, and positively correlated with post-thrombolysis SIR value. It indicates that the lower the pre-thrombolysis SIR value, the higher the risk of post-thrombolysis hemorrhagic transformation and poor prognosis, and the worse their hemodynamic recovery. It is also shown that lower SIR values are involved in the development of END 24 hours after intravenous thrombolysis and are associated with poor prognosis. A previous study on the relationship between SIR values and cerebral perfusion in patients with unilateral middle cerebral artery stenosis found that SIR values were significantly lower in patients in the underperfused group compared to the normally perfused group, and that an SIR value\u0026thinsp;\u0026lt;\u0026thinsp;0.9 was independently associated with inadequate cerebral perfusion distal to the stenosis \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Furthermore, Lan et al. found that SIR values were significantly and linearly negatively correlated with cerebral blood volume and blood flow velocity on the ipsilateral side of the lesion when they examined the relationship between SIR values and ipsilateral cerebral perfusion [10]. In our study, we grouped the pre-thrombolysis signal intensity of blood flow (SIR) according to quartiles, and the results showed that the number of patients in the END-free group tended to increase with the increase of the SIR level, while the number of patients in the END group tended to decrease, and the number of patients in the END-free group was significantly increased when the SIR was \u0026gt;\u0026thinsp;0.9. This may be due to the fact that when atherosclerosis in the brain causes stenosis or occlusion of blood vessels, cerebral perfusion at the distal end of the stenosis decreases, resulting in a change in the hemodynamic index of SIR value, which leads to the occurrence of acute cerebral infarction \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Therefore, SIR value can be measured by MRA before intravenous thrombolysis to monitor hemodynamic information to assess cerebrovascular blood flow to predict the risk of END in patients with acute cerebral infarction. This also suggests that the SIR value can be used as a non-invasive and practical tool to detect changes in cerebral hemodynamics in patients undergoing intravenous thrombolysis for acute cerebral infarction, which is of high value in evaluating efficacy and prognosis.\u003c/p\u003e \u003cp\u003eCompared with hemodynamic clinical assessment methods such as transcranial Doppler ultrasound, CT cerebrovascular perfusion imaging, and DSA, the acquisition of SIR values by TOF-MRA has the advantages of being noninvasive, simple, highly reproducible, and independent of contrast media \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. In addition, in our study, magnetic resonance imaging (MRI) was performed before and after thrombolysis, which can measure SIR values more accurately and intuitively than in previous studies and can monitor changes in SIR values. The exponential SIR value can be considered as a simple and effective marker of hemodynamic significance before and after thrombolysis.\u003c/p\u003e \u003cp\u003eIntravenous thrombolytic therapy with rt-PA achieves the therapeutic effect of recanalization of occluded blood vessels and salvage of ischemic penumbra by reducing blood viscosity, improving blood coagulation, and inhibiting platelet aggregation \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. In this study, it was found that the SIR value increased after intravenous thrombolytic therapy compared with that before thrombolysis in both END and no-END groups. And the results of Spearman correlation analysis between pre-thrombolysis SIR values and post-thrombolysis SIR values showed a strong correlation. This also suggests that intravenous rt-PA thrombolysis can improve stenotic vessel dynamics and increase blood flow in the infarct area, which is consistent with previous studies \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBased on the above studies, the clinical value of the three indices of pre-thrombolytic SIR, pre-thrombolytic NIHSS, and post-thrombolytic hemorrhagic conversion in predicting whether END will occur after intravenous thrombolytic therapy was analyzed individually and jointly using ROC curves. The AUC of baseline NIHSS and pre-thrombolysis SIR for the combined detection of END was 0.791, and the sensitivity and specificity were 60% and 88.9%, respectively, higher than the AUC of baseline NIHSS and pre-thrombolysis SIR alone. The results suggest that baseline NIHSS score and pre-thrombolysis SIR value may be auxiliary predictors of END after intravenous thrombolysis for acute cerebral infarction and that the simultaneous detection of both may be a useful predictor of END after intravenous thrombolysis. Adjunctive predictors. The results suggest that the baseline NIHSS score and the pre-thrombolysis SIR value may be additional predictors of END after intravenous thrombolysis in acute cerebral infarction. Previous studies have also found that the SIR value measured by MRA may be a strong predictor of recurrent stroke and can be used for risk stratification of stroke risk within a certain range, which supports the results of this experiment \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCombining the results of the above experiments, the AUC value of early neurological deterioration in patients with acute cerebral infarction predicted based on magnetic resonance imaging information combined with two indicators of cerebral hemodynamics (SIR values) and baseline NIHSS scores reaches 0.791, which provides a method for early screening of END high-risk groups.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e’\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eXY.L. \u0026nbsp;First author,wrote the main manuscript text. PR.Z. Partial data collection . B.L. \u0026nbsp; \u0026nbsp; Partial data collection . X.Y. \u0026nbsp; \u0026nbsp; Part of the literature was collected. XY.D. Prepared figures 1. XQ.Y. Prepared figures 2. FF.Z. Prepared figures 2. Y.C. \u0026nbsp; \u0026nbsp;Prepared figures 3. Z.D. \u0026nbsp; Prepared figures 3. PL.Z. \u0026nbsp;Corresponding authors,review papers,verifying that all data, figures, materials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the\u0026nbsp;Tianjin Municipal Health Bureau Key Project\u0026nbsp;(grant no. TJWJ2022XK030).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data of this study were collected from two hospitals in the Shenzhen area.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethical Committee of the Tianjin Huanhu Hospital（Approval number:2022-047; Data:2022.5.10）.\u0026nbsp;Informed consent has been obtained from the participants, their parents and legally authorized representatives in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccepted for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors in this study declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1, Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin 300222, China.\u003c/p\u003e\n\u003cp\u003e2, Department of Emergency Medicine, The First Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia 010000, China.\u003c/p\u003e\n\u003cp\u003e3, The Second Hospital of Tianjin Medical University, Tianjin 300222, China.\u003c/p\u003e\n\u003cp\u003e4, Department of Neurology, Tianjin Huanhu Hospital, Tianjin 300222, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eOwolabi MO, Thrift AG, Mahal A, Ishida M, Martins S, Johnson WD, Pandian J, Abd-Allah F, Yaria J, Phan HT, Roth G, Gall SL, Beare R, Phan TG, Mikulik R, Akinyemi RO, Norrving B, Brainin M, Feigin VL; Stroke Experts Collaboration Group. Primary stroke prevention worldwide: translating evidence into action. Lancet Public Health. 2022;7(1):e74-e85. doi: 10.1016/S2468-2667(21)00230-9.\u003c/li\u003e\n \u003cli\u003eJauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947. doi: 10.1161/STR.0b013e318284056aIF: 7.8 Q1.\u003c/li\u003e\n \u003cli\u003eGe JJ , Xing YQ, Chen HX , Wang LL , Cui L . Analysis of young ischemic stroke patients in northeast China. 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Diminished Signal Intensities Distal to Intracranial Arterial Stenosis on Time-of-Flight MR Angiography Might Indicate Delayed Cerebral Perfusion. Cerebrovasc Dis. 2016;42(3-4):232-9. doi: 10.1159/000445842IF: 2.9 Q3.\u003c/li\u003e\n \u003cli\u003eLiebeskind DS, Kosinski AS, Lynn MJ, Scalzo F, Fong AK, Fariborz P, Chimowitz MI, Feldmann E. Noninvasive fractional flow on MRA predicts stroke risk of intracranial stenosis. J Neuroimaging. 2015;25(1):87-91. doi: 10.1111/jon.12101IF: 2.4 Q3.\u003c/li\u003e\n \u003cli\u003eLeng X, Wong LK, Soo Y, Leung T, Zou X, Wang Y, Feldmann E, Liu L, Liebeskind D. Signal intensity ratio as a novel measure of hemodynamic significance for intracranial atherosclerosis. Int J Stroke. 2013;8(7):E46. doi: 10.1111/ijs.12080.\u003c/li\u003e\n \u003cli\u003eGe X, Zhao H, Zhou Z, Li X, Sun B, Wu H, Wan J, Xu J , Villablanca JP, Liu X . Association of fractional flow on 3D-TOF-MRA with cerebral perfusion in patients with MCA stenosis. 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The authors have no conflicts of interest to disclose.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"acute cerebral infarction, hemodynamics, intravenous thrombolysis, multimodal imaging, neurological function","lastPublishedDoi":"10.21203/rs.3.rs-4945314/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4945314/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e To explore the relationship between Signal intensity ratio (SIR) levels, a cerebral hemodynamic index, and early neurological function deterioration in patients with acute cerebral infarction under the guidance of multimodal nuclear magnetic resonance imaging (NMRI) with intravenous thrombolysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003e157 patients with acute cerebral infarction who received intravenous thrombolysis within 4.5 hours of stroke were obtained from Tianjin Huanhu Hospital between January 2022 and February 2024. early neurological deterioration (END) was defined as an increase in National Institutes of Health Stroke Scale (NIHSS) score of ≥4 points from baseline at 24 hours after intravenous thrombolysis or death. The patients were divided into 36 cases in the END group and 121 cases in the non-END group. Baseline, clinical, and imaging data were collected from patients. Patients who received treatment were followed for 3 months. Magnetic resonance angiography (MRA) was used to determine SIR levels before and after thrombolysis and to analyze the correlation between SIR levels and END.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003ePatients in the END group had higher baseline systolic blood pressure, diastolic blood pressure, post-thrombolysis hemorrhage conversion, baseline NIHSS score, discharge NIHSS score, and modified Rankin Scale (mRS) score than those in the no-END group, whereas pre- and post-thrombolysis SIR levels were lower than those in the no-END group (P\u0026lt;0.05). Multifactorial logistic regression analysis showed that baseline NIHSS score, post-thrombolytic hemorrhagic conversion, and pre-thrombolytic SIR were independent risk factors for the development of END in patients with acute cerebral infarction treated with intravenous thrombolysis. Receiver operating curve (ROC) analysis showed that the area under the curve (AUC) of END detected by the combination of baseline NIHSS score and pre-thrombolysis SIR level was 0.791 (95% CI: 0.712-0.870), with sensitivity and specificity of 60% and 88.9%, respectively, and P\u0026lt;0.001 (Figure 1), which was higher than that of END detected by the two measures alone (baseline NIHSS score: AUC 0.770, 95% CI: 0.691-0.849, p=0.000; pre-thrombolytic SIR: AUC 0.654, 95% CI: 0.556-0.752, p=0.005). Spearman's correlation analysis showed that pre-thrombolysis SIR level was negatively correlated with the level of mRS score and post-thrombolysis hemorrhagic conversion (r=-0.218, p=0.000; r=-0.166, p=0.038), whereas it was positively correlated with post-thrombolysis SIR level (r=0.408, p=0.000).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e SIR levels can be used as a simple, non-invasive and highly reproducible method in combination with baseline NIHSS scores to determine the occurrence of END after intravenous thrombolysis, providing a method for early screening of individuals at risk for END.\u003c/p\u003e","manuscriptTitle":"Multimodal Nuclear Magnetic Imaging Prediction of Early Neurological Deterioration in Patients with Acute Stroke Using Intravenous Thrombolysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-17 04:34:49","doi":"10.21203/rs.3.rs-4945314/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95e08859-986c-4cd7-b59e-ec33e40631c6","owner":[],"postedDate":"October 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-25T06:23:52+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-17 04:34:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4945314","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4945314","identity":"rs-4945314","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}