急性缺血性脑卒中溶栓后早期预后分析
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摘要
目的：
评估影响溶栓后症状性颅内出血的危险因素和溶栓后早期预后的相关因素。
方法：
本研究为回顾性病例对照分析研究。连续入选1994年1月-2011年12月在暨南大学附属第一医院神经内科住院并接受溶栓治疗（包括静脉溶栓、动脉溶栓或动静脉联合溶栓）的急性缺血性脑卒中患者。根据病例记载，收集患者所有临床资料，包括基线神经功能缺损评分［采用美国国立卒中卫生院卒中评分量表（The National Institute of Health stroke scale，NIHSS）］、发病至溶栓时间（onsetto start of treatment time，OTT）以及出院患者改良Rankin量表（modified Rankinscale，mRS）评分和格拉斯哥预后评分（Glasgow outcome scale, GOS），所纳入分析的所有患者严格按照脑梗死OCSP分型标准进行分型，并将纳入病例按照急性基底动脉闭塞与非基底动脉闭塞的急性缺血性脑卒中患者分别进行研究分析，前者早期不良预后指标定义为出院时GOS1～2分，即死亡或植物生存；后者早期不良预后指标定义为出院时mRS5～6分。所有数据采用SPSS13.0软件进行统计学分析，计量资料以均数±标准差或者中位数（四分位数间距）表示，并采用t检验或秩转换的非参数检验（Wilcoxon秩和检验）进行两组间的比较；计数资料以例数（百分数）表示，并采用χ2检验进行两组间的比较。然后采用Logistic回归分析筛选影响溶栓治疗脑梗死患者早期不同预后的相关因素。P＜0.05为有统计学差异。
结果：
共收集符合纳入标准的溶栓病例84例（静脉溶栓68例，动脉溶栓15例，动静脉联合溶栓1例），平均年龄64.8±10.8岁（21～84岁），男性56例（66.7%），基线NIHSS中位数为13分（四分位数间距为3～38分），OTT中位数为3.48小时（四分位数间距为1～504小时），其中动脉溶栓患者OTT中位数为9小时（四分位数间距为1～504小时），出院时mRS中位数为2分（四分位数间距为0～6分）。对所有患者行OCSP分型，其中，TACI患者38例，PACI患者28例，POCI患者16例，LACI患者2例。溶栓后发生症状性颅内出血（symptomatic intracerebralhemorrhage，sICH）的患者9例（10.7%），早期不良预后患者14例（16.7%），其中急性基底动脉闭塞患者6例，非基底动脉闭塞的急性缺血性脑卒中患者8例。统计分析发现急性基底动脉闭塞的早期不良预后患者年龄和基线收缩压明显高于其他患者(P＜0.05)；而对于非基底动脉闭塞的急性缺血性脑卒中溶栓患者来说，单因素分析显示早期不良预后的患者均为TACI（100%，P=0.042），其发病前存在冠状动脉性心脏病的比例较其他患者明显增高（62.5%Vs21.3%，P=0.039），基线NIHSS评分也明显更高（17Vs11，P=0.002），经Logistic回归分析发现，早期不良预后的患者基线NIHSS评分较高。
结论：
基线NIHSS可以预测溶栓患者早期不良预后，尤其对静脉溶栓患者。基底动脉闭塞患者应尽量溶栓治疗，动脉或静脉溶栓都可以获益。症状性颅内出血、高龄、高基线血压和NIHSS、以及OTT均与其早期不良预后有关。
Objects:
To identify variable associated with symptomatic intracerebral hemorrhage(sICH) and early outcomes in patients with acute ischemic stroke who receiverecombinant tissue plasminogen activator (rt-PA).
Methods:
As a retrospectively case control study， all patients hospitalized receivedthrombolytic therapy (intravenous or intra-arterial or combination) were selected fromDepartment of Neurology，the Fist Affiliated Hospital of Jinan University fromJanuary1994to December2011. According to the medical records, collected clinicaldata of all patients, including baseline neurological deficit score (assessed by theNational Institute of Health stroke scale，NIHSS), onset to start of treatmenttime(OTT), modified Rankin scale (mRs) and Glasgow outcome scale (GOS)and soon. All patients were classified into subtypes according to OCSP classification. Thestudy was performed separately according to the basilar artery occlusion or not. Theearly poor outcome of the former was defined as1～2of GOS (death or vegetativestate) at discharge. The latter was defined as5～6of mRS. And statistical analysiswas performed with SPSS for Windows, version13.0. The measurement dates wereexpressed as mean±standard deviation (SD) or median (inter-quartile range). Andthey were compared using t test or the Wilcoxon W test. The enumeration dates wereexpressed as number (percentage). And they were compared using χ2test or fisher’sexact test. The Logistic regression was used to analyse the related factors of earlyoutcome in acute ischemic stroke patients with thrombolysis.
Results:
A total of84consecutive patients (68of intravenous thrombolysis,15ofintra-arterial thrombolysis and1of combination) were evaluated. Mean age was64.8±10.8years (rang21to84years). The men were56(66.7%). The baseline NIHSS score of the series on admission was13(rang3～38). The median of thesymptom onset to start of treatment (OTT) was3.48hours (rang1～504hours). Forthe patients received the intra-arterial thrombolytic therapy, OTT was9hours (1-504hours). The median of mRS was2(0～6) at discharge. According to the classification,the TACI were38patients, PACI were28patients, POCI were16patients and LACIwere2patients. Clinical assessment revealed that sICH occurred in9(10.7%) patientsand14(16.7%) patients with early poor outcome (6of acute basilar artery occlusionand8of non-basilar artery occlusion). Early poor outcome was associatedsignificantly with a higher baseline NIHSS score. The age and baseline systolic bloodpressure of early poor outcome patients were significantly higher than other patientsin acute basilar artery occlusion (P＜0.05). For the non-basilar artery occlusionpatients, univariate analysis revealed that early poor outcome patients were all TACI(100%，P=0.042), and the percentage of the coronary heart disease (62.5%Vs21.3%，P=0.039) and the baseline NIHSS (17Vs11，P=0.002) were significantly higher thanothers. And the baseline NIHSS was keeping on significant difference between earlypoor outcome patients and not in the Logistic regression.
Conclusions:
The baseline NIHSS may be a predictor of the prognosis for the patients withthrombolytic therapy, especially for intravenous thrombolysis. And the aggressivetherapy should be made for the acute basilar artery occlusion (BAO) patients. Theratio of benefit risk would be obviously either intravenous or intra-arterialthrombolytic therapy. The sICH, older age, higher baseline blood pressure and NIHSS,as well as longer OTT may associated with early poor outcome.
评估影响溶栓后症状性颅内出血的危险因素和溶栓后早期预后的相关因素。
方法：
本研究为回顾性病例对照分析研究。连续入选1994年1月-2011年12月在暨南大学附属第一医院神经内科住院并接受溶栓治疗（包括静脉溶栓、动脉溶栓或动静脉联合溶栓）的急性缺血性脑卒中患者。根据病例记载，收集患者所有临床资料，包括基线神经功能缺损评分［采用美国国立卒中卫生院卒中评分量表（The National Institute of Health stroke scale，NIHSS）］、发病至溶栓时间（onsetto start of treatment time，OTT）以及出院患者改良Rankin量表（modified Rankinscale，mRS）评分和格拉斯哥预后评分（Glasgow outcome scale, GOS），所纳入分析的所有患者严格按照脑梗死OCSP分型标准进行分型，并将纳入病例按照急性基底动脉闭塞与非基底动脉闭塞的急性缺血性脑卒中患者分别进行研究分析，前者早期不良预后指标定义为出院时GOS1～2分，即死亡或植物生存；后者早期不良预后指标定义为出院时mRS5～6分。所有数据采用SPSS13.0软件进行统计学分析，计量资料以均数±标准差或者中位数（四分位数间距）表示，并采用t检验或秩转换的非参数检验（Wilcoxon秩和检验）进行两组间的比较；计数资料以例数（百分数）表示，并采用χ2检验进行两组间的比较。然后采用Logistic回归分析筛选影响溶栓治疗脑梗死患者早期不同预后的相关因素。P＜0.05为有统计学差异。
结果：
共收集符合纳入标准的溶栓病例84例（静脉溶栓68例，动脉溶栓15例，动静脉联合溶栓1例），平均年龄64.8±10.8岁（21～84岁），男性56例（66.7%），基线NIHSS中位数为13分（四分位数间距为3～38分），OTT中位数为3.48小时（四分位数间距为1～504小时），其中动脉溶栓患者OTT中位数为9小时（四分位数间距为1～504小时），出院时mRS中位数为2分（四分位数间距为0～6分）。对所有患者行OCSP分型，其中，TACI患者38例，PACI患者28例，POCI患者16例，LACI患者2例。溶栓后发生症状性颅内出血（symptomatic intracerebralhemorrhage，sICH）的患者9例（10.7%），早期不良预后患者14例（16.7%），其中急性基底动脉闭塞患者6例，非基底动脉闭塞的急性缺血性脑卒中患者8例。统计分析发现急性基底动脉闭塞的早期不良预后患者年龄和基线收缩压明显高于其他患者(P＜0.05)；而对于非基底动脉闭塞的急性缺血性脑卒中溶栓患者来说，单因素分析显示早期不良预后的患者均为TACI（100%，P=0.042），其发病前存在冠状动脉性心脏病的比例较其他患者明显增高（62.5%Vs21.3%，P=0.039），基线NIHSS评分也明显更高（17Vs11，P=0.002），经Logistic回归分析发现，早期不良预后的患者基线NIHSS评分较高。
结论：
基线NIHSS可以预测溶栓患者早期不良预后，尤其对静脉溶栓患者。基底动脉闭塞患者应尽量溶栓治疗，动脉或静脉溶栓都可以获益。症状性颅内出血、高龄、高基线血压和NIHSS、以及OTT均与其早期不良预后有关。
Objects:
To identify variable associated with symptomatic intracerebral hemorrhage(sICH) and early outcomes in patients with acute ischemic stroke who receiverecombinant tissue plasminogen activator (rt-PA).
Methods:
As a retrospectively case control study， all patients hospitalized receivedthrombolytic therapy (intravenous or intra-arterial or combination) were selected fromDepartment of Neurology，the Fist Affiliated Hospital of Jinan University fromJanuary1994to December2011. According to the medical records, collected clinicaldata of all patients, including baseline neurological deficit score (assessed by theNational Institute of Health stroke scale，NIHSS), onset to start of treatmenttime(OTT), modified Rankin scale (mRs) and Glasgow outcome scale (GOS)and soon. All patients were classified into subtypes according to OCSP classification. Thestudy was performed separately according to the basilar artery occlusion or not. Theearly poor outcome of the former was defined as1～2of GOS (death or vegetativestate) at discharge. The latter was defined as5～6of mRS. And statistical analysiswas performed with SPSS for Windows, version13.0. The measurement dates wereexpressed as mean±standard deviation (SD) or median (inter-quartile range). Andthey were compared using t test or the Wilcoxon W test. The enumeration dates wereexpressed as number (percentage). And they were compared using χ2test or fisher’sexact test. The Logistic regression was used to analyse the related factors of earlyoutcome in acute ischemic stroke patients with thrombolysis.
Results:
A total of84consecutive patients (68of intravenous thrombolysis,15ofintra-arterial thrombolysis and1of combination) were evaluated. Mean age was64.8±10.8years (rang21to84years). The men were56(66.7%). The baseline NIHSS score of the series on admission was13(rang3～38). The median of thesymptom onset to start of treatment (OTT) was3.48hours (rang1～504hours). Forthe patients received the intra-arterial thrombolytic therapy, OTT was9hours (1-504hours). The median of mRS was2(0～6) at discharge. According to the classification,the TACI were38patients, PACI were28patients, POCI were16patients and LACIwere2patients. Clinical assessment revealed that sICH occurred in9(10.7%) patientsand14(16.7%) patients with early poor outcome (6of acute basilar artery occlusionand8of non-basilar artery occlusion). Early poor outcome was associatedsignificantly with a higher baseline NIHSS score. The age and baseline systolic bloodpressure of early poor outcome patients were significantly higher than other patientsin acute basilar artery occlusion (P＜0.05). For the non-basilar artery occlusionpatients, univariate analysis revealed that early poor outcome patients were all TACI(100%，P=0.042), and the percentage of the coronary heart disease (62.5%Vs21.3%，P=0.039) and the baseline NIHSS (17Vs11，P=0.002) were significantly higher thanothers. And the baseline NIHSS was keeping on significant difference between earlypoor outcome patients and not in the Logistic regression.
Conclusions:
The baseline NIHSS may be a predictor of the prognosis for the patients withthrombolytic therapy, especially for intravenous thrombolysis. And the aggressivetherapy should be made for the acute basilar artery occlusion (BAO) patients. Theratio of benefit risk would be obviously either intravenous or intra-arterialthrombolytic therapy. The sICH, older age, higher baseline blood pressure and NIHSS,as well as longer OTT may associated with early poor outcome.
引文
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