老年急性脑梗死患者静脉溶栓治疗临床预后的影响因素分析
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摘要
目的探讨老年急性脑梗死患者静脉溶栓治疗临床预后的影响因素。方法回顾性分析我院所有接受静脉溶栓治疗的急性老年脑梗死患者151例,预后终点为发病3个月后改良的Rankin量表评分,其中0~2分(预后良好组)77例,≥3分(预后不良组)74例。比较2组患者的基线临床资料、溶栓时间窗、溶栓前美国国立卫生研究院卒中量表(NIHSS)评分、溶栓前脑卒中分型、早期症状改善、溶栓后脑出血等因素。结果预后不良组患者溶栓前血糖、C反应蛋白、溶栓前NIHSS评分≥9分、心房颤动、溶栓后脑出血等显著高于预后良好组(P<0.05,P<0.01)。多因素logistic回归分析显示:溶栓前NIHSS评分(OR=1.262,95%CI:1.075~1.482,P=0.005)、OCSP(牛津郡社区卒中项目)分型(OR=0.203,95%CI:0.066~0.628,P=0.006)、溶栓前血糖(OR=1.264,95%CI:1.042~1.532,P=0.017)、溶栓后24h症状改善(OR=25.764,95%CI:5.131~129.361,P=0.000)是患者预后的独立影响因素。结论老年急性脑梗死患者行静脉溶栓治疗的预后受多种因素影响,溶栓前NIHSS评分、OCSP分型、溶栓前血糖及溶栓后24h症状改善等因素是患者临床预后的独立影响因素。
Objecfive To study the influencing factors of clinical outcome in elderly acute ischemic stroke(AIS)patients after intravenous thrombolysis.Methods One hundred and fifty-one AIS patients admitted to our hospital for intravenous thrombolysis were divided into good outcome group(n=77)and poor outcome group(n=74)according to their modified Rankin scale score 3 months after the onset of AIS.The baseline data,thrombolysis time window,NIHSS score and ischemic stroke typing before thrombolysis,early symptom improvement,cerebral hemorrhage after thrombolysis were compared between the two groups.Results The serum levels of blood glucose and CRP,NIHSS score≥9 before thrombolysis,incidence of AF and cerebral hemorrhage were significantly higher in poor outcome group than in good outcome group(P<0.05,P<0.01).Multivariate logistic regression analysis showed that NIHSS score,OCSP typing,blood glucose before thrombolysis,24 hsymptom improvement were the independent influencing factors of clinical outcome in elderly AIS patients(OR=1.262,95%CI:1.075-1.482,P=0.005;OR=0.203,95%CI:0.066-0.628,P=0.006;OR=1.264,95%CI:1.042-1.532,P=0.017;OR=25.764,95%CI:5.131-129.361,P=0.000).Conclusion NIHSS score,OCSP typing,blood glucose before thrombolysis and 24 hsymptom improvement are the independent influencing factors of clinical outcome in elderly AIS patients after intravenous thrombolysis.
Objecfive To study the influencing factors of clinical outcome in elderly acute ischemic stroke(AIS)patients after intravenous thrombolysis.Methods One hundred and fifty-one AIS patients admitted to our hospital for intravenous thrombolysis were divided into good outcome group(n=77)and poor outcome group(n=74)according to their modified Rankin scale score 3 months after the onset of AIS.The baseline data,thrombolysis time window,NIHSS score and ischemic stroke typing before thrombolysis,early symptom improvement,cerebral hemorrhage after thrombolysis were compared between the two groups.Results The serum levels of blood glucose and CRP,NIHSS score≥9 before thrombolysis,incidence of AF and cerebral hemorrhage were significantly higher in poor outcome group than in good outcome group(P<0.05,P<0.01).Multivariate logistic regression analysis showed that NIHSS score,OCSP typing,blood glucose before thrombolysis,24 hsymptom improvement were the independent influencing factors of clinical outcome in elderly AIS patients(OR=1.262,95%CI:1.075-1.482,P=0.005;OR=0.203,95%CI:0.066-0.628,P=0.006;OR=1.264,95%CI:1.042-1.532,P=0.017;OR=25.764,95%CI:5.131-129.361,P=0.000).Conclusion NIHSS score,OCSP typing,blood glucose before thrombolysis and 24 hsymptom improvement are the independent influencing factors of clinical outcome in elderly AIS patients after intravenous thrombolysis.
引文
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[11]Uchimura I,Kaibara M,Nagasawa M,et al.Effect of circulating tissue factor on hypercoagulability in type 2diabetes mellitus studied by rheometry and dielectric blood coagulometry[J].Biorheology,2016,53(5-6):209-219.DOI:10.3233/BIR-16107.
[12]Lin Y,Xu M,Wan J,et al.Docosahexaenoic acid attenuates hyperglycemia-enhanced hemorrhagic transformation after transient focal cerebral ischemia in rats[J].Neuroscience,2015,301:471-479.DOI:10.1016/j.neuroscience.2015.06.024.
[13]Ritter L,Davidson L,Henry M,et al.Exaggerated neutrophilmediated reperfusion injury after ischemic stroke in a rodent model of type 2diabetes[J].Microcirculation,2011,18(7):552-561.DOI:10.1111/j.1549-8719.2011.00115.x.
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[15]Kobayashi A,Wardlaw JM,Lindley RI,et al.Oxfordshire community stroke project clinical stroke syndrome and appearances of tissue and vascular lesions on pretreatment ct in hyperacute ischemic stroke among the first 510patients in the Third International Stroke Trial(IST-3)[J].Stroke,2009,40(3):743-748.DOI:10.1161/STROKEAHA.108.526772.
[16]Yang Y,Wang A,Zhao X,et al.The Oxfordshire Community Stroke Project classification system predicts clinical outcomes following intravenous thrombolysis:a prospective cohort study[J].Ther Clin Risk Manag,2016,12:1049-1056.DOI:10.2147/TCRM.S107053.
[17]Sung SF,Wu CS,Hsu YC,et al.Oxfordshire Community Stroke Project classification but not NIHSS predicts symptomatic intracerebral hemorrhage following thrombolysis[J].J Neurol Sci,2013,324(1-2):65-69.DOI:10.1016/j.jns.2012.10.003.
[18]Dziadkowiak E,Chojdak-ukasiewicz J,Guziński M,et al.The usefulness of the TOAST classification and prognostic significance of pyramidal symptoms during the acute phase of cerebellar ischemic stroke[J].Cerebellum,2016,15(2):159-164.DOI:10.1007/s12311-015-0676-6.
[19]尤寿江,曹勇军,肖国栋,等.伴有心房颤动的急性缺血性卒中患者重组组织型纤溶酶原激活剂静脉溶栓的疗效及预后[J].中华神经科杂志,2013,46(10):681-686.DOI:10.3760/cma.j.issn.1006-7876.2013.10.009.
[20]Liu X,Liu M,Chen M,et al.Serum uric acid is neuroprotective in Chinese patients with acute ischemic stroke treated with intravenous recombinant tissue plasminogen activator[J].J Stroke Cerebrovasc Dis,2015,24(5):1080-1086.DOI:10.1016/j.jstrokecerebrovasdis.2015.01.011.
[21]Ye Z,Zhang Z,Zhang H,et al.Prognostic value of C-reactive protein and homocysteine in large-artery atherosclerotic stroke:aprospective observational study[J].J Stroke Cerebrovasc Dis,2017,26(3):618-626.DOI:10.1016/j.jstrokecerebrovasdis.2016.11.016.
[2]凌倚峰,程忻,杨璐萌,等.急性缺血性卒中患者静脉溶栓治疗的临床预后影响因素分析[J].中华神经科杂志,2014,47(7):449-454.DOI:10.3760/cma.j.issn.1006-7876.2014.07.003.
[3]Mishra NK,Diener HC,Lyden PD,et al.Influence of age on outcome from thrombolysis in acute stroke:a controlled comparison in patients from the Virtual International Stroke Trials Archive(VISTA)[J].Stroke,2010,41(12):2840-2848.DOI:10.1161/STROKEAHA.110.586206.
[4]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.
[5]Saqqur M,Shuaib A,Alexandrov AV,et al.The correlation between admission blood glucose and intravenous rt-PA-induced arterial recanalization in acute ischemic stroke:a multicentre TCD study[J].Int J Stroke,2015,10(7):1087-1092.DOI:10.1111/ijs.12517.
[6]González RG,Furie KL,Goldmacher GV,et al.Good outcome rate of 35%in IV-tPA-treated patients with computed tomography angiography confirmed severe anterior circulation occlusive stroke[J].Stroke,2013,44(11):3109-3113.DOI:10.1161/STROKEAHA.113.001938.
[7]Chang JY,Park H,Jang SY,et al.Early partial recanalization after intravenous thrombolysis leads to prediction of favorable outcome in cases of acute ischemic stroke with major vessel occlusion[J].J Clin Neurosci,2017,46:30-36.DOI:10.1016/j.jocn.2017.08.053.
[8]Poppe AY,Majumdar SR,Jeerakathil T,et al.Admission hyperglycemia predicts a worse outcome in stroke patients treated with intravenous thrombolysis[J].Diabetes Care,2009,32(4):617-622.DOI:10.2337/dc08-1754.
[9]Putaala J,Sairanen T,Meretoja A,et al.Post-thrombolytic hyperglycemia and 3-month outcome in acute ischemic stroke[J].Cerebrovasc Dis,2011,31(1):83-92.DOI:10.1159/000321332.
[10]Desilles JP,Meseguer E,Labreuche J,et al.Diabetes mellitus,admission glucose,and outcomes after stroke thrombolysis:a registry and systematic review[J].Stroke,2013,44(7):1915-1923.DOI:10.1161/STROKEAHA.111.000813.
[11]Uchimura I,Kaibara M,Nagasawa M,et al.Effect of circulating tissue factor on hypercoagulability in type 2diabetes mellitus studied by rheometry and dielectric blood coagulometry[J].Biorheology,2016,53(5-6):209-219.DOI:10.3233/BIR-16107.
[12]Lin Y,Xu M,Wan J,et al.Docosahexaenoic acid attenuates hyperglycemia-enhanced hemorrhagic transformation after transient focal cerebral ischemia in rats[J].Neuroscience,2015,301:471-479.DOI:10.1016/j.neuroscience.2015.06.024.
[13]Ritter L,Davidson L,Henry M,et al.Exaggerated neutrophilmediated reperfusion injury after ischemic stroke in a rodent model of type 2diabetes[J].Microcirculation,2011,18(7):552-561.DOI:10.1111/j.1549-8719.2011.00115.x.
[14]Ahmed N,Dávalos A,Eriksson N,et al.Association of admission blood glucose and outcome in patients treated with intravenous thrombolysis:results from the Safe Implementation of Treatments in Stroke International Stroke Thrombolysis Register(SITS-ISTR)[J].Arch Neurol,2010,67(9):1123-1130.DOI:10.1001/archneurol.2010.210.
[15]Kobayashi A,Wardlaw JM,Lindley RI,et al.Oxfordshire community stroke project clinical stroke syndrome and appearances of tissue and vascular lesions on pretreatment ct in hyperacute ischemic stroke among the first 510patients in the Third International Stroke Trial(IST-3)[J].Stroke,2009,40(3):743-748.DOI:10.1161/STROKEAHA.108.526772.
[16]Yang Y,Wang A,Zhao X,et al.The Oxfordshire Community Stroke Project classification system predicts clinical outcomes following intravenous thrombolysis:a prospective cohort study[J].Ther Clin Risk Manag,2016,12:1049-1056.DOI:10.2147/TCRM.S107053.
[17]Sung SF,Wu CS,Hsu YC,et al.Oxfordshire Community Stroke Project classification but not NIHSS predicts symptomatic intracerebral hemorrhage following thrombolysis[J].J Neurol Sci,2013,324(1-2):65-69.DOI:10.1016/j.jns.2012.10.003.
[18]Dziadkowiak E,Chojdak-ukasiewicz J,Guziński M,et al.The usefulness of the TOAST classification and prognostic significance of pyramidal symptoms during the acute phase of cerebellar ischemic stroke[J].Cerebellum,2016,15(2):159-164.DOI:10.1007/s12311-015-0676-6.
[19]尤寿江,曹勇军,肖国栋,等.伴有心房颤动的急性缺血性卒中患者重组组织型纤溶酶原激活剂静脉溶栓的疗效及预后[J].中华神经科杂志,2013,46(10):681-686.DOI:10.3760/cma.j.issn.1006-7876.2013.10.009.
[20]Liu X,Liu M,Chen M,et al.Serum uric acid is neuroprotective in Chinese patients with acute ischemic stroke treated with intravenous recombinant tissue plasminogen activator[J].J Stroke Cerebrovasc Dis,2015,24(5):1080-1086.DOI:10.1016/j.jstrokecerebrovasdis.2015.01.011.
[21]Ye Z,Zhang Z,Zhang H,et al.Prognostic value of C-reactive protein and homocysteine in large-artery atherosclerotic stroke:aprospective observational study[J].J Stroke Cerebrovasc Dis,2017,26(3):618-626.DOI:10.1016/j.jstrokecerebrovasdis.2016.11.016.