应激性高血糖对急性前循环缺血性卒中机械取栓预后的影响
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摘要
目的探讨应激性高血糖对急性前循环缺血性卒中患者机械取栓预后的影响。方法回顾性连续纳入2010年9月至2015年4月东部战区总医院(原南京军区南京总医院)神经内科急性前循环缺血性卒中行机械取栓患者257例,经头部CT或MRI确诊急性缺血性卒中,并经头部CT血管成像或DSA证实存在前循环大血管闭塞。根据90 d时患者预后[改良Rankin量表(mRS)],将257例患者分为预后良好(mRS评分0～2分)组和预后不良(mRS评分3～6分)组。记录两组患者基线资料、临床资料,并进行组间比较。基线资料包括年龄、性别、卒中危险因素(高血压病、高脂血症、糖尿病、冠心病、心房颤动及卒中史),临床资料包括入院随机血糖、术后糖化血红蛋白、机械取栓前溶栓、穿刺至再通时间、颅内出血、改良脑梗死溶栓(m TICI)分级。采用应激性高血糖比率(SHR)评估应激性高血糖强度。以预后不良为因变量,将单因素分析中所有P <0. 1的自变量纳入多因素Logistic回归分析以评估预后的影响因素。结果 (1)与预后良好组比较,预后不良组患者年龄及入院NIHSS评分较高,男性比例较低,组间差异均有统计学意义[70(61,76)岁比62(53,70)岁,18(15,21)分比14(11,17)分,53. 1%(77/145)比66. 1%(74/112);均P <0. 05];余基线资料的组间差异均无统计学意义(均P> 0. 05)。(2)与预后良好组比较,预后不良组入院随机血糖及SHR水平较高,m TICI分级2b～3级比例较低,组间差异均有统计学意义[7. 4(6. 1,9. 1) mmol/L比6. 7(5. 5,8. 5) mmol/L,1. 1 (0. 8,1. 3)比1. 0 (0. 8,1. 2),80. 7%(117/145)比91. 1%(102/112);均P <0. 05];余临床资料的组间差异均无统计学意义(均P> 0. 05)。(3)多因素Logistic回归分析结果显示,SHR≥1. 1(OR=2. 480,95%CI:1. 427～4. 311)、年龄(OR=1. 027,95%CI:1. 002～1. 053)和基线NIHSS评分(OR=1. 130,95%CI:1. 070～1. 192)为急性前循环缺血性卒中机械取栓患者预后不良的危险因素(均P <0. 05)。结论应激性高血糖可能影响急性前循环卒中患者机械取栓的预后,SHR可作为一种预测急性前循环缺血性卒中机械取栓治疗预后的潜在指标。
Objective To analyze the impacts of stress hyperglycemia on outcomes of mechanical thrombectomy in patients with anterior circulation acute ischemic stroke. Methods From September2010 to April 2015,consecutive 257 patients with anterior circulation acute ischemic stroke and received mechanical thrombectomy at the Department of Neurology,General Hospital of Eastern War Zone were consecutively recruited. Acute ischemic stroke was confirmed by head CT or MRI,and anterior circulation large vessel occlusion was diagnosed with head CT angiography or DSA. The patients were divided into the favorable outcome group( modified Rankin scale [mRS]≤2) and the unfavorable outcome group( mRS 3-6) according to the mRS score at 90 d. Baseline and clinical data were recorded and compared between the two groups. Baseline data included age,sex and stroke risk factors( smoking,hypertension,hyperlipidemia,diabetes,coronary heart disease,atrial fibrillation and stroke history). Clinical data included random blood glucose at admission,postoperative glycosylated hemoglobin,intravenous thrombolysis before mechanical thrombectomy,puncture-to-recanalization time,intracranial hemorrhage and modified Thrombolysis in Cerebral Infarction( m TICI) grade. Stress hyperglycemia level was assessed by stress hyperglycemia ratio( SHR). With unfavorable outcome as the dependent variable,all independent variables with P value < 0. 1 in the univariate analysis were included in multivariate logistic regression to determine factors influencing clinical prognosis. Results( 1) Compared with the favorable outcome group,the unfavorable outcome group had higher age and baseline NIHSS score but lower male proportion. The differences were all statistically significant( 70[61,76] vs. 62[53,70 ],18[15,21] vs. 14[11,17 ],53. 1% [77/145] vs. 66. 1% [74/112 ]; all P < 0. 05). Other baseline data were found without significant differences( all P > 0. 05).( 2) Compared with the favorable outcome group,the unfavorable outcome group had higher random blood glucose at admission and SHR level but lower proportion of mTICI 2 b-3. The differences were all statistically significant( 7. 4[6. 1,9. 1]mmol/L vs. 6. 7[5. 5,8. 5]mmol/L,1. 1[0. 8,1. 3] vs. 1. 0[0. 8,1. 2],80. 7% [117/145] vs. 91. 1% [102/112 ]; all P < 0. 05). Other clinical data were found without significant differences( all P > 0. 05).( 3) Multiple logistic regression showed that SHR ≥1. 1( OR =2. 480,95% CI 1. 427-4. 311),age( OR = 1. 027,95% CI 1. 002-1. 053) and baseline NIHSS score( OR =1. 130,95 % CI 1. 070-1. 192) were independent risk factors for unfavorable outcome of mechanical thrombectomy in patients with anterior circulation acute ischemic stroke. Conclusion Stress hyperglycemia may influence the outcomes of mechanical thrombectomy in patients with anterior circulation acute ischemic stroke,and SHR can be used as a potential predictor of prognosis.
Objective To analyze the impacts of stress hyperglycemia on outcomes of mechanical thrombectomy in patients with anterior circulation acute ischemic stroke. Methods From September2010 to April 2015,consecutive 257 patients with anterior circulation acute ischemic stroke and received mechanical thrombectomy at the Department of Neurology,General Hospital of Eastern War Zone were consecutively recruited. Acute ischemic stroke was confirmed by head CT or MRI,and anterior circulation large vessel occlusion was diagnosed with head CT angiography or DSA. The patients were divided into the favorable outcome group( modified Rankin scale [mRS]≤2) and the unfavorable outcome group( mRS 3-6) according to the mRS score at 90 d. Baseline and clinical data were recorded and compared between the two groups. Baseline data included age,sex and stroke risk factors( smoking,hypertension,hyperlipidemia,diabetes,coronary heart disease,atrial fibrillation and stroke history). Clinical data included random blood glucose at admission,postoperative glycosylated hemoglobin,intravenous thrombolysis before mechanical thrombectomy,puncture-to-recanalization time,intracranial hemorrhage and modified Thrombolysis in Cerebral Infarction( m TICI) grade. Stress hyperglycemia level was assessed by stress hyperglycemia ratio( SHR). With unfavorable outcome as the dependent variable,all independent variables with P value < 0. 1 in the univariate analysis were included in multivariate logistic regression to determine factors influencing clinical prognosis. Results( 1) Compared with the favorable outcome group,the unfavorable outcome group had higher age and baseline NIHSS score but lower male proportion. The differences were all statistically significant( 70[61,76] vs. 62[53,70 ],18[15,21] vs. 14[11,17 ],53. 1% [77/145] vs. 66. 1% [74/112 ]; all P < 0. 05). Other baseline data were found without significant differences( all P > 0. 05).( 2) Compared with the favorable outcome group,the unfavorable outcome group had higher random blood glucose at admission and SHR level but lower proportion of mTICI 2 b-3. The differences were all statistically significant( 7. 4[6. 1,9. 1]mmol/L vs. 6. 7[5. 5,8. 5]mmol/L,1. 1[0. 8,1. 3] vs. 1. 0[0. 8,1. 2],80. 7% [117/145] vs. 91. 1% [102/112 ]; all P < 0. 05). Other clinical data were found without significant differences( all P > 0. 05).( 3) Multiple logistic regression showed that SHR ≥1. 1( OR =2. 480,95% CI 1. 427-4. 311),age( OR = 1. 027,95% CI 1. 002-1. 053) and baseline NIHSS score( OR =1. 130,95 % CI 1. 070-1. 192) were independent risk factors for unfavorable outcome of mechanical thrombectomy in patients with anterior circulation acute ischemic stroke. Conclusion Stress hyperglycemia may influence the outcomes of mechanical thrombectomy in patients with anterior circulation acute ischemic stroke,and SHR can be used as a potential predictor of prognosis.
引文
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[10]Tomsick T,Broderick J,Carrozella J,et al.Revascularization results in the interventional management of strokeⅡtrial[J].AJNR Am J Neuroradiol,2008,29(3):582-587.
[11]Hong KS,Saver JL.Quantifying the value of stroke disability outcomes:WHO global burden of disease project disability weights for each level of the modified Rankin scale[J].Stroke,2009,40(12):3828-3833.
[12]Capes SE,Hunt D,Malmberg K,et al.Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients:a systematic overview[J].Stroke,2001,32(10):2426-2432.
[13]Wang L,Zhou Z,Tian X,et al.Impact of relative blood glucose changes on mortality risk of patient with acute ischemic stroke and treated with mechanical thrombectomy[J].J Stroke Cerebrovasc Dis,2019,28(1):213-219.
[14]Bessonov IS,Kuznetsov VA,Potolinskaya YV,et al.Impact of hyperglycemia on the results of percutaneous coronary interventions in patients with acute ST-segment elevation myocardial infarction[J].Ter Arkh,2017,89(9):25-29.
[15]Rau CS,Wu SC,Chen YC,et al.Stress-induced hyperglycemia,but not diabetic hyperglycemia,is associated with higher mortality in patients with isolated moderate and severe traum atic brain injury:analysis of a propensity score-matched population[J].Int J Environ Res Public Health,2017,14(11):E1340.
[16]Pan Y,Cai X,Jing J,et al.Stress hyperglycemia and prognosis of minor ischemic stroke and transient ischemic attack:the CHANCE study(clopidogrel in high-risk patients with acute nondisabling cerebrovascular events)[J].Stroke,2017,48(11):3006-3011.
[17]Mokin M,Primiani CT,Ren Z,et al.Endovascular treatment of middle cerebral artery M2 occlusion strokes:clinical and procedural predictors of outcomes[J].Neurosurgery,2017,81(5):795-802.
[2]Zi W,Wang H,Yang D,et al.Clinical effectiveness and safety outcomes of endovascular treatment for acute anterior circulation ischemic stroke in China[J].Cerebrovasc Dis,2017,44(5/6):248-258.
[3]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治指南2014[J].中华神经科杂志,2015,48(4):246-257.
[4]Kim BJ,Lee SH,Shin CW,et al.Ischemic stroke during sleep:its association with worse early functional outcome[J].Stroke,2011,42(7):1901-1906.
[5]Hao Z,Wu B,Lin S,et al.Association between renal function and clinical outcome in patients with acute stroke[J].Eur Neurol,2010,63(4):237-242.
[6]中华医学会内分泌学分会脂代谢学组.中国2型糖尿病合并血脂异常防治专家共识(2017年修订版)[J].中华内分泌代谢杂志,2017,33(11):925-936.
[7]von Kummer R,Broderick JP,Campbell BC,et al.The Heidelberg bleeding classification:classification of bleeding events after ischemic stroke and reperfusion therapy[J].Stroke,2015,46(10):2981-2986.
[8]Kwah LK,Diong J.National institutes of health stroke scale(NIHSS)[J].J Physiother,2014,60(1):61.
[9]Yang Y,Kim TH,Yoon KH,et al.The stress hyperglycemia ratio,an index of relative hyperglycemia,as a predictor of clinical outcomes after percutaneous coronary intervention[J].Int J Cardiol,2017,241:57-63.
[10]Tomsick T,Broderick J,Carrozella J,et al.Revascularization results in the interventional management of strokeⅡtrial[J].AJNR Am J Neuroradiol,2008,29(3):582-587.
[11]Hong KS,Saver JL.Quantifying the value of stroke disability outcomes:WHO global burden of disease project disability weights for each level of the modified Rankin scale[J].Stroke,2009,40(12):3828-3833.
[12]Capes SE,Hunt D,Malmberg K,et al.Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients:a systematic overview[J].Stroke,2001,32(10):2426-2432.
[13]Wang L,Zhou Z,Tian X,et al.Impact of relative blood glucose changes on mortality risk of patient with acute ischemic stroke and treated with mechanical thrombectomy[J].J Stroke Cerebrovasc Dis,2019,28(1):213-219.
[14]Bessonov IS,Kuznetsov VA,Potolinskaya YV,et al.Impact of hyperglycemia on the results of percutaneous coronary interventions in patients with acute ST-segment elevation myocardial infarction[J].Ter Arkh,2017,89(9):25-29.
[15]Rau CS,Wu SC,Chen YC,et al.Stress-induced hyperglycemia,but not diabetic hyperglycemia,is associated with higher mortality in patients with isolated moderate and severe traum atic brain injury:analysis of a propensity score-matched population[J].Int J Environ Res Public Health,2017,14(11):E1340.
[16]Pan Y,Cai X,Jing J,et al.Stress hyperglycemia and prognosis of minor ischemic stroke and transient ischemic attack:the CHANCE study(clopidogrel in high-risk patients with acute nondisabling cerebrovascular events)[J].Stroke,2017,48(11):3006-3011.
[17]Mokin M,Primiani CT,Ren Z,et al.Endovascular treatment of middle cerebral artery M2 occlusion strokes:clinical and procedural predictors of outcomes[J].Neurosurgery,2017,81(5):795-802.