侧支循环对急性脑梗死患者静脉溶栓疗效的影响
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摘要
目的探讨侧支循环对急性脑梗死患者静脉溶栓疗效的影响。方法选取2017年1月至2018年1月就诊于首都医科大学附属北京友谊医院的急性脑梗死溶栓患者34例,根据电子计算机断层扫描血管造影(CTA)/磁共振血管造影(MRA)中是否存在良好的颅内外侧支循环血管,将纳入患者分为侧支循环良好组(n=13)和侧支循环不良组(n=21)。比较两组患者的脑出血转化率和神经功能改善的情况。为了控制其他混杂因素对溶栓预后的影响,采用多因素线性回归模型和Logistic回归模型对P值进行校正。结果侧支循环良好组和侧支循环不良组溶栓后脑出血的发生率分别为23.1%和14.3%,差异无统计学意义(P> 0.05)。就短期预后而言,侧支循环良好组和侧支循环不良组溶栓后1 h美国国立卫生研究院卒中量表(NIHSS)评分分别为(2.77±1.23)分和(3.24±2.66)分(P=0.492,校正P=0.390);溶栓后24 h NIHSS评分分别为(1.54±0.88)分和(2.52±1.83)分(P=0.044,校正P=0.071)。侧支循环良好组3个月mRS评分明显低于侧支循环不良组,OR值(95%CI)为0.20(0.05～0.78),校正OR值(95%CI)为0.15(0.03～0.73)。结论虽然没有证据提示侧支循环的建立对急性脑梗死患者溶栓后早期的安全性和有效性产生影响,但是其可能显著改善溶栓患者的长期预后。
Objective To explore the efficacy of collateral circulation on patients with acute ischemic stroke treated with intravenous thrombolysis.Methods A total of 34 patients with acute ischemic stroke underwent rt-PA intravenous infusion in this hospital during January 2017 to January 2018 were enrolled consecutively in this study.According to the extent of establishment of collateral circulation,the involved patients were grouped into good collateral circulation group(n = 13) and poor collateral circulation group(n = 21).The hemorrhagic transformation and the neurological functional improvement between these two groups were compared.In order to rule out the confounding effects on the outcomes of patients treated with thrombolysis,multifactor linear regression model and Logistic regression model were used to obtain the adjusted P-value.Results The rates of intracranial hemorrhage were 23.1% and 14.3% in good and poor collateral group respectively.The difference was not significant(P > 0.05).As regard to the short-term outcomes,the 1-hour NIHSS scores were 2.77 ± 1.23 and 3.24 ± 2.66 in good and poor collateral groups respectively(P = 0.492,adjusted P = 0.390); and the 24-hours NIHSS scores were 1.54 ± 0.88 and 2.52 ± 1.83 in good and poor collateral group respectively(P = 0.044,adjusted P = 0.071).The 3-month mRS scores in good collateral group were sinificantly lower than those in poor collateral group,the OR(95% CI) for which was 0.20(0.05 ～ 0.78) and the adjusted OR(95% CI) was 0.15(0.03 ～0.73).Conclusion Although there was no convincing evidence supporting collateral circulation associated with the safety and efficacy of thrombolysis in patients with acute ischemic stroke in short term,the good collateral circulation might improve the long-term outcomes.
Objective To explore the efficacy of collateral circulation on patients with acute ischemic stroke treated with intravenous thrombolysis.Methods A total of 34 patients with acute ischemic stroke underwent rt-PA intravenous infusion in this hospital during January 2017 to January 2018 were enrolled consecutively in this study.According to the extent of establishment of collateral circulation,the involved patients were grouped into good collateral circulation group(n = 13) and poor collateral circulation group(n = 21).The hemorrhagic transformation and the neurological functional improvement between these two groups were compared.In order to rule out the confounding effects on the outcomes of patients treated with thrombolysis,multifactor linear regression model and Logistic regression model were used to obtain the adjusted P-value.Results The rates of intracranial hemorrhage were 23.1% and 14.3% in good and poor collateral group respectively.The difference was not significant(P > 0.05).As regard to the short-term outcomes,the 1-hour NIHSS scores were 2.77 ± 1.23 and 3.24 ± 2.66 in good and poor collateral groups respectively(P = 0.492,adjusted P = 0.390); and the 24-hours NIHSS scores were 1.54 ± 0.88 and 2.52 ± 1.83 in good and poor collateral group respectively(P = 0.044,adjusted P = 0.071).The 3-month mRS scores in good collateral group were sinificantly lower than those in poor collateral group,the OR(95% CI) for which was 0.20(0.05 ～ 0.78) and the adjusted OR(95% CI) was 0.15(0.03 ～0.73).Conclusion Although there was no convincing evidence supporting collateral circulation associated with the safety and efficacy of thrombolysis in patients with acute ischemic stroke in short term,the good collateral circulation might improve the long-term outcomes.
引文
[1]重组组织型纤溶酶原激活剂治疗缺血性卒中共识专家组.重组组织型纤溶酶原激活剂静脉溶栓治疗缺血性卒中中国专家共识(2012版)[J].中华内科杂志,2012,51(12):1006-1100.
[2]Liu M,Wang HR,Liu JF,et al.Therapeutic effect of recombinant tissue plasminogen activator on acute cerebral infarction at different times[J].World J Emerg Med,2013,4(3):205-209.
[3]李建彬,段伟,陈秀丽.重组组织型纤溶酶原激活剂静脉溶栓治疗心源性脑梗死及非心源性脑梗死的疗效及安全性对比[J].临床和实验医学杂志,2017,16(14):1404-1406.
[4]Powers WJ,Rabinstein AA,Ackerson T,et al.2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke:A Guideline for Healthcare Professionals From the American Heart Association/A-merican Stroke Association[J].Stroke,2018,49(3):e46-e110.
[5]Liebeskind DS.Collateral circulation[J].Stroke,2003,34(9):2279-2284.
[6]Liebeskind DS,Cotsonis GA,Saver JL,et al.Collateral circulation in symptomatic intracranial atherosclerosis[J].J Cereb Blood Flow Metab,2011,31(5):1293-1301.
[7]中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组.中国急性缺血性脑卒中诊疗指南2018[J].中华神经科杂志,2018,51(9):666-682.
[8]Liu L,Ding J,Leng X,et al.Guidelines for evaluation and management of cerebral collateral circulation in ischaemic stroke 2017[J].Stroke Vasc Neurol,2018,3(3):117-130.
[9]Bang OY,Saver JL,Kim SJ,et al.Collateral flow predicts response to endovascular therapy for acute ischemic stroke[J].Stroke,2011,42(3):693-699.
[10]Goyal M,Demchuk AM,Menon BK,et al.Randomized assessment of rapid endovascular treatment of ischemic stroke[J].N Engl J Med,2015,372(11):1019-1030.
[11]Bang OY,Saver JL,Kim SJ,et al.Collateral flow averts hemorrhagic transformation after endovascular therapy for acute ischemic stroke[J].Stroke,2011,42(8):2235-2239.
[12]Liebeskind DS,Cotsonis GA,Saver JL,et al.Collaterals dramatically alter stroke risk in intracranial atherosclerosis[J].Ann Neurol,2011,69(6):963-974.
[13]Fanou EM,Knight J,Aviv RI,et al.Effect of Collaterals on Clinical Presentation,Baseline Imaging,Complications,and Outcome in Acute Stroke[J].AJNR Am J Neuroradiol,2015,36(12):2285-2291.
[14]Goyal M,Demchuk AM,Menon BK,et al.Randomized assessment of rapid endovascular treatment of ischemic stroke[J].N Engl J Med,2015,372(11):1019-1030.
[15]Schellinger PD,K9hrmann M,Liu S,et al.Favorable vascular profile is an independent predictor of outcome:a post hoc analysis of the safety and efficacy of NeuroFlo Technology in Ischemic Stroke trial[J].Stroke,2013,44(6):1606-1608.
[16]Liebeskind DS,Cotsonis GA,Saver JL,et al.Collaterals dramatically alter stroke risk in intracranial atherosclerosis[J].Ann Neurol,2011,69(6):963-974.
[17]Lau AY,Wong EH,Wong A,et al.Significance of good collateral compensation in symptomatic intracranial atherosclerosis[J].Cerebrovasc Dis,2012,33(6):517-524.
[18]何斌,邵斌霞,张劲松,等.侧支循环对急性脑梗死溶栓患者预后的影响[J].中华急诊医学杂志,2017,26(8):910-913.
[2]Liu M,Wang HR,Liu JF,et al.Therapeutic effect of recombinant tissue plasminogen activator on acute cerebral infarction at different times[J].World J Emerg Med,2013,4(3):205-209.
[3]李建彬,段伟,陈秀丽.重组组织型纤溶酶原激活剂静脉溶栓治疗心源性脑梗死及非心源性脑梗死的疗效及安全性对比[J].临床和实验医学杂志,2017,16(14):1404-1406.
[4]Powers WJ,Rabinstein AA,Ackerson T,et al.2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke:A Guideline for Healthcare Professionals From the American Heart Association/A-merican Stroke Association[J].Stroke,2018,49(3):e46-e110.
[5]Liebeskind DS.Collateral circulation[J].Stroke,2003,34(9):2279-2284.
[6]Liebeskind DS,Cotsonis GA,Saver JL,et al.Collateral circulation in symptomatic intracranial atherosclerosis[J].J Cereb Blood Flow Metab,2011,31(5):1293-1301.
[7]中华医学会神经病学分会,中华医学会神经病学分会脑血管病学组.中国急性缺血性脑卒中诊疗指南2018[J].中华神经科杂志,2018,51(9):666-682.
[8]Liu L,Ding J,Leng X,et al.Guidelines for evaluation and management of cerebral collateral circulation in ischaemic stroke 2017[J].Stroke Vasc Neurol,2018,3(3):117-130.
[9]Bang OY,Saver JL,Kim SJ,et al.Collateral flow predicts response to endovascular therapy for acute ischemic stroke[J].Stroke,2011,42(3):693-699.
[10]Goyal M,Demchuk AM,Menon BK,et al.Randomized assessment of rapid endovascular treatment of ischemic stroke[J].N Engl J Med,2015,372(11):1019-1030.
[11]Bang OY,Saver JL,Kim SJ,et al.Collateral flow averts hemorrhagic transformation after endovascular therapy for acute ischemic stroke[J].Stroke,2011,42(8):2235-2239.
[12]Liebeskind DS,Cotsonis GA,Saver JL,et al.Collaterals dramatically alter stroke risk in intracranial atherosclerosis[J].Ann Neurol,2011,69(6):963-974.
[13]Fanou EM,Knight J,Aviv RI,et al.Effect of Collaterals on Clinical Presentation,Baseline Imaging,Complications,and Outcome in Acute Stroke[J].AJNR Am J Neuroradiol,2015,36(12):2285-2291.
[14]Goyal M,Demchuk AM,Menon BK,et al.Randomized assessment of rapid endovascular treatment of ischemic stroke[J].N Engl J Med,2015,372(11):1019-1030.
[15]Schellinger PD,K9hrmann M,Liu S,et al.Favorable vascular profile is an independent predictor of outcome:a post hoc analysis of the safety and efficacy of NeuroFlo Technology in Ischemic Stroke trial[J].Stroke,2013,44(6):1606-1608.
[16]Liebeskind DS,Cotsonis GA,Saver JL,et al.Collaterals dramatically alter stroke risk in intracranial atherosclerosis[J].Ann Neurol,2011,69(6):963-974.
[17]Lau AY,Wong EH,Wong A,et al.Significance of good collateral compensation in symptomatic intracranial atherosclerosis[J].Cerebrovasc Dis,2012,33(6):517-524.
[18]何斌,邵斌霞,张劲松,等.侧支循环对急性脑梗死溶栓患者预后的影响[J].中华急诊医学杂志,2017,26(8):910-913.