孤立性脑桥梗死患者静脉溶栓的短期预后及安全性探讨
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摘要
目的探讨发病4.5h内孤立性脑桥梗死患者静脉溶栓的短期预后和安全性。方法选择静脉溶栓登记的605例患者,其中静脉溶栓后经头颅MRI证实的孤立性脑桥梗死29例(脑桥梗死组),基底节区梗死59例(基底节区梗死组)。对比分析2组患者临床特征、危险因素、实验室检查和出院时、90d的良好预后(改良Rankin量表评分≤2分)及颅内外出血发生率;同时观察孤立性脑桥梗死患者静脉溶栓后神经功能缺损进展或波动的发生情况。结果脑桥梗死组溶栓前纤维蛋白原水平明显高于基底节区梗死组[(3.7±1.2)g/L vs(3.2±0.9)g/L,P=0.037]。2组良好预后在出院时(51.7%vs 62.7%,P=0.324)和90d(86.2%vs 78.0%,P=0.375)比较,差异无统计学意义。29例脑桥梗死患者中,12例发生进展或波动,6例(50.0%)出院时预后良好,只有1例(8.3%)90d预后不良。结论孤立性脑桥梗死超急性期静脉溶栓可能是有效和安全的。尽管溶栓后神经功能缺损进展或波动发生高,但短期预后仍较好。
Objective To study the short-term outcome and safety of intravenous thrombolysis in isolated pontine infarction patients within 4.5hafter onset.Methods Of the 605 patients admitted for intravenous thrombolysis,29 with MRI-confirmed isolated pontine infarction served as a pontine infarction group and 59 with MRI-confirmed basal ganglia infarction served as a basal ganglia infarction group.Their clinical characteristics,risk factors,laboratory findings,modified Rankin Scale score≤2at discharge and on day 90 after discharge,incidence of intracranial and extracranial hemorrhage were analyzed.The progression or fluctuation of neurological deterioration after intravenous thrombolysis was observed in isolated pontine infarction patients.Results The serum fibrinogen level was significantly higher in pontine infarction group than in basal ganglia infarction group(P<0.05).No significant difference was found in outcome at discharge and on day 90 after discharge between the two groups(P>0.05).Of the 29 pontine infarction patients,12 were diagnosed with neurological deterioration or fluctuation(6with a good outcome at discharge and 1with a poor outcome on day 90 after discharge).Conclusion Intravenous thrombolysis is effective and safe for hyperacute isolated pontine infarction patients.Although the incidence of neurological deterioration or fluctuation is high after intravenous thrombolysis,the short-term outcome is rather good in isolated pontine infarction patients.
Objective To study the short-term outcome and safety of intravenous thrombolysis in isolated pontine infarction patients within 4.5hafter onset.Methods Of the 605 patients admitted for intravenous thrombolysis,29 with MRI-confirmed isolated pontine infarction served as a pontine infarction group and 59 with MRI-confirmed basal ganglia infarction served as a basal ganglia infarction group.Their clinical characteristics,risk factors,laboratory findings,modified Rankin Scale score≤2at discharge and on day 90 after discharge,incidence of intracranial and extracranial hemorrhage were analyzed.The progression or fluctuation of neurological deterioration after intravenous thrombolysis was observed in isolated pontine infarction patients.Results The serum fibrinogen level was significantly higher in pontine infarction group than in basal ganglia infarction group(P<0.05).No significant difference was found in outcome at discharge and on day 90 after discharge between the two groups(P>0.05).Of the 29 pontine infarction patients,12 were diagnosed with neurological deterioration or fluctuation(6with a good outcome at discharge and 1with a poor outcome on day 90 after discharge).Conclusion Intravenous thrombolysis is effective and safe for hyperacute isolated pontine infarction patients.Although the incidence of neurological deterioration or fluctuation is high after intravenous thrombolysis,the short-term outcome is rather good in isolated pontine infarction patients.
引文
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[15]Yue R,Li D,Yu J,et al.Atrial fibrillation is associated with poor outcomes in thrombolyzed patients with acute ischemic stroke:a systematic review and meta-analysis[J].Medicine(Baltimore),2016,95(10):e3054.DOI:10.1097/MD.0000000000003054.
[16]Lee SJ,Saver JL,Liebeskind DS,et al.Safety of intravenous fibrinolysis in imaging-confirmed single penetrator artery infarcts[J].Stroke,2010,41(11):2587-2591.DOI:10.1161/STROKEAHA.110.586248.
[17]朱仁洋,楼敏,徐敏,等.穿支动脉区孤立性梗死静脉溶栓治疗研究[J].中华急诊医学杂志,2012,21(2):193-197.DOI:10.3760/cma.j.issn.1671-0282.2012.02.021.
[18]Brunner F,Tomandl B,Hanken K,et al.Impact of collateral circulation on early outcome and risk of hemorrhagic complications after systemic thrombolysis[J].Int J Stroke,2014,9(8):992-998.DOI:10.1111/j.1747-4949.2012.00922.x.
[19]Leng X,Lan L,Liu L,et al.Good collateral circulation predicts favorable outcomes in intravenous thrombolysis:a systematic review and meta-analysis[J].Eur J Neurol,2016,23(12):1738-1749.DOI:10.1111/ene.13111.
[20]Lescher S,Samaan T,Berkefeld J.Evaluation of the pontine perforators of the basilar artery using digital subtraction angiography in high resolution and 3D rotation technique[J].AJNR Am J Neuroradiol,2014,35(10):1942-1947.DOI:10.3174/ajnr.A3981.
[21]黄如月,易兴阳,邵敏洁,等.急性脑桥梗死进展发生的影像学特点[J].中华老年心脑血管病杂志,2013,15(4):393-396.DOI::10.3969/j.issn.1009-0126.2013.04.017.
[2]Saia V,Pantoni L.Progressive stroke in pontine infarction[J].Acta Neurol Scand,2009,120(4):213-215.DOI:10.1111/j.1600-0404.2009.01161.x.
[3]Oh S,Bang OY,Chung CS,et al.Topographic location of acute pontine infarction is associated with the development of progressive motor deficits[J].Stroke,2012,43(3):708-713.DOI:10.1161/STROKEAHA.111.632307.
[4]Huang R,Zhang X,Chen W,et al.Stroke subtypes and topographic locations associated with neurological deterioration in acute isolated pontine infarction[J].J Stroke Cerebrovasc Dis,2016,25(1):206-213.DOI:10.1016/j.jstrokecerebrovasdis.2015.09.019.
[5]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.DOI:10.3760/cma.j.issn.1006-7876.2015.04.002.
[6]刘扬,高旭光.脑桥梗死与基底动脉分支病[J].中华老年心脑血管病杂志,2009,11(1):77-78.DOI:10.3969/j.issn.1009-0126.2009.01.030.
[7]Vemmos KN,Spengos K,Tsivgoulis G,et al.Aetiopathogenesis and long-term outcome of isolated pontine infarcts[J].J Neurol,2005,252(2):212-217.DOI:10.1007/s00415-005-0639-9.
[8]Shi L,Zhang M,Liu H,et al.Safety and outcome of thrombolysis in mild stroke:a meta-analysis[J].Med Sci Monit,2014,20:2117-2124.DOI:10.12659/MSM.892259.
[9]IST-3collaborative group,Sandercock P,Wardlaw JM,et al.The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6hof acute ischaemic stroke(the third international stroke trial[IST-3]):a randomised controlled trial[J].Lancet,2012,379(9834):2352-2363.DOI:10.1016/S0140-6736(12)60768-5.
[10]Greisenegger S,Seyfang L,Kiechl S,et al.Thrombolysis in patients with mild stroke:results from the Austrian Stroke Unit Registry[J].Stroke,2014,45(3):765-769.DOI:10.1161/STROKEAHA.113.003827.
[11]Sato S,Toyoda K,Uehara T,et al.Baseline NIH Stroke Scale score predicting outcome in anterior and posterior circulation strokes[J].Neurology,2008,70(24Pt 2):2371-2377.DOI:10.1212/01.wnl.0000304346.14354.0b.
[12]Yamamoto Y,Ohara T,Hamanaka M,et al.Predictive factors for progressive motor deficits in penetrating artery infarctions in two different arterial territories[J].J Neurol Sci,2010,288(1-2):170-174.DOI:10.1016/j.jns.2009.08.065.
[13]Wahlgren N,Ahmed N,Eriksson N,et al.Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled trials:safe implementation of thrombolysis in stroke-monitoring study(SITS-MOST)[J].Stroke,2008,39(12):3316-3322.DOI:10.1161/STROKEAHA.107.510768.
[14]Cronin CA,Shah N,Morovati T,et al.No increased risk of symptomatic intracerebral hemorrhage after thrombolysis in patients with European Cooperative Acute Stroke Study(ECASS)exclusion criteria[J].Stroke,2012,43(6):1684-1686.DOI:10.1161/STROKEAHA.112.656587.
[15]Yue R,Li D,Yu J,et al.Atrial fibrillation is associated with poor outcomes in thrombolyzed patients with acute ischemic stroke:a systematic review and meta-analysis[J].Medicine(Baltimore),2016,95(10):e3054.DOI:10.1097/MD.0000000000003054.
[16]Lee SJ,Saver JL,Liebeskind DS,et al.Safety of intravenous fibrinolysis in imaging-confirmed single penetrator artery infarcts[J].Stroke,2010,41(11):2587-2591.DOI:10.1161/STROKEAHA.110.586248.
[17]朱仁洋,楼敏,徐敏,等.穿支动脉区孤立性梗死静脉溶栓治疗研究[J].中华急诊医学杂志,2012,21(2):193-197.DOI:10.3760/cma.j.issn.1671-0282.2012.02.021.
[18]Brunner F,Tomandl B,Hanken K,et al.Impact of collateral circulation on early outcome and risk of hemorrhagic complications after systemic thrombolysis[J].Int J Stroke,2014,9(8):992-998.DOI:10.1111/j.1747-4949.2012.00922.x.
[19]Leng X,Lan L,Liu L,et al.Good collateral circulation predicts favorable outcomes in intravenous thrombolysis:a systematic review and meta-analysis[J].Eur J Neurol,2016,23(12):1738-1749.DOI:10.1111/ene.13111.
[20]Lescher S,Samaan T,Berkefeld J.Evaluation of the pontine perforators of the basilar artery using digital subtraction angiography in high resolution and 3D rotation technique[J].AJNR Am J Neuroradiol,2014,35(10):1942-1947.DOI:10.3174/ajnr.A3981.
[21]黄如月,易兴阳,邵敏洁,等.急性脑桥梗死进展发生的影像学特点[J].中华老年心脑血管病杂志,2013,15(4):393-396.DOI::10.3969/j.issn.1009-0126.2013.04.017.