中重度脑白质疏松对急性脑梗死静脉溶栓患者出血转化及预后的影响被引量：58

Influence of moderate to severe leukoaraiosis on hemorrhagic transformation and prognosis of acute ischemic stroke patients after intravenous thrombolysis

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摘要目的探讨中重度脑白质疏松（leukoaraiosis,LA）与前循环梗死静脉溶栓患者脑出血转化及预后的关系.方法连续收集2014年1月至2017年3月于我院急诊科或神经内科（发病4.5h内）接受重组组织型纤溶酶原激活剂（rt-PA）静脉溶栓治疗的前循环梗死患者78例.所有患者均为首发脑梗死且溶栓后完善头颅MRI检查（包含DWI及FLAIR）;根据Fazekas量表评分将其分为LA组和无LA组,比较两组间的一般资料及临床特征;观察患者90 d预后情况,并分析脑白质疏松对预后的影响.结果在78例脑梗死患者中,合并LA者24例（30.8％）,无LA者54例（69.2％）.LA组中静脉溶栓后脑出血转化发生率为33.3％（8/24）,无LA组为11.1％（6/54）,差异有统计学意义（x2 =5.571,P=0.018）;而症状性颅内出血发生率分别为16.7％（4/24）及5.6％（3/54）,两组间差异无统计学意义（x2=2.304,P=0.129）.LA组3个月内卒中的复发比例高于无LA组[20.8％（5/24）与5.6％（3/54）],但差异亦无统计学意义（x2=3.850,P=0.050）;在肢体运动功能恢复[（92.3±3.4）分与（72.9±7.8）分;t=22.345,P＜0.01]和90 d改良Rankin量表评分为0～2分的患者比例[83.3％（45/54）与50.0％（12/24）,x2=9.383,P=0.002）方面,无LA组明显优于LA组.LA组患者的年龄[（73.7±6.7）岁与（61.3±10.6）岁,t=6.567,P=0.012]也明显高于无LA组.通过发病后90 d随访发现,在78例患者中,有预后良好者57例（73.1％）,预后不良21例（26.9％）,预后不良患者中死亡6例（7.7％）.其中,预后不良患者合并LA[57.1％（12/21）与21.1％（12/57）,x2=9.383,P=0.002]、存在陈旧性腔隙性脑梗死[66.7％（14/21）与35.1％（20/57）,x2=6.224,P=0.013]以及3.0～4.5 h内溶栓的比例[71.4％（15/21）与38.6％（22/57）,x2=6.634,P=0.010]更高,年龄[（72.8±7.9）岁与（61.5±11.7）岁,t=4.423,P=0.039]、闭塞部位血管管径[66.7％（14/21）与38.6％（22/57）,x2=4.865,P=0.027]及梗死面积[52.4％（11/21）与12.3％（7/57）,x2=14.053,P=0.001]更大,入院时NIHSS评分[（16.9±6.7）分与（9.5±4.5）分,t=5.426,P=0.022]亦更高.Logistic回归分析提示中重度脑白质疏松（OR=4.564,95％ CI1.199～67.724,P=0.033）是影响静脉溶栓患者90 d预后的危险因素.结论脑梗死合并中重度LA患者静脉溶栓后的出血转化发生率高,发病90 d后肢体运动功能恢复较差.中重度LA是脑梗死患者预后不良的独立危险因素. Objective To investigate the influence of moderate to severe leukoaraiosis （LA） on hemorrhagic transformation and prognosis of patients after intravenous recombinant tissue plasminogen activator thrombolysis for acute ischemic stroke and analyze influencing factors of the clinical prognosis.Methods We consecutively collected patients with acute infarct on anterior circulation （n =78） in Department of Neurology or Emergency of our hospital between January 2014 and March 2017,and all patients received intravenous thrombolysis therapy within the 4.5-hour time window.All patients processed brain MRI after intravenous thrombolysis therapy.According to the degree of LA,all subjects were classified into two groups;LA group （moderate to severe） vs no LA group （absent to mild）.Clinical data were obtained and compared among patients with different grades of LA.Logistic regression analysis was used to confirm the relevant factors of prognosis 90 days after stroke.Results Among 78 enrolled patients,24 （30.8%） were classified as LA and 54 （69.2%） as no LA.In the group of LA,33.3% （8/24） patients conducted hemorrhagic transformation,whereas 11.1% （6/54） patients also underwent hemorrhagic transformation in the group of no LA.There was a significant difference between the two groups （x2 =5.571,P =0.018）.But symptomatic intracranial hemorrhage accounted for 16.7% （4/24） and 5.6% （3/54） respectively in the two groups without significant difference （x2 =2.304,P =0.129）.Three-month recurrence of stroke in the groups of LA and no LA was 20.8% （5/24） and 5.6% （3/54） respectively,also without significant difference between the two groups （x2 =3.850,P =0.050）.Age （（73.7 ± 6.7）years vs （61.3 ± 10.6） years,t =6.567,P =0.012）,90 d Fugl-Meyer Scale （FMS） score （92.3 ± 3.4 vs 72.9 ± 7.8,t =22.345,P 〈 0.01） and proportion of 90 d modified Rankin Scale score 0-2 （83.3%（45/54） vs 50.0% （12/24）,x2 =9.383,P =0.002） were significantly different between the two groups.Follow-up 90-day after onset showed that the good outcome was found in 57 cases （73.1%）,poor outcome in 21 patients （26.9%） and death in six cases （7.7%）.The grade of LA （57.1% （12/21） vs 21.1% （12/57）,x2 =9.383,P =0.002）,silent lacunar infarction （66.7% （14/21） vs 35.1% （20/57）,x2 =6.224,P =0.013）,age （（72.8 ± 7.9） vs （61.5 ± 11.7） years,t =4.423,P =0.039）,proportion of thrombolysis within 3.0-4.5 hours （71.4% （15/21） vs 38.6% （22/57）,x2 =6.634,P =0.010）,vascular occlusion size （66.7% （14/21） vs 38.6% （22/57）,x2 =4.865,P =0.027）,infarction size （52.4% （11/21） vs 12.3% （7/57）,x2 =14.053,P =0.001） and baseline NIHSS score （16.9 ±6.7 vs 9.5 ± 4.5,t =5.426,P =0.022） were significantly different between the two groups.After adjusting for age,thrombolysis time,baseline NIHSS score,infarction size,vascular occlusion size and silent lacunar infarction,multivariate analysis revealed that moderate to severe LA （OR =4.564,95% CI 1.199-67.724,P =0.033） was risk factor for worse outcome of patients after intravenous thrombolysis.Conclusions Acute ischemic stroke patients with moderate to severe LA have high hemorrhagic transformation after intravenous thrombolysis and may have poor 90-day FMS score.And moderate to severe LA was found to be an independent risk factor for prognosis in cerebral infarction patients with intravenous thrombolysis.

作者刘艳艳张敏恽文伟周先举 Liu Yanyan;Zhang Min;Yun Wenwei;Zhou Xianju(Department of Neurology, Changzhou No. 2 People＇s Hospital, the Affiliated Hospital of Nanjing Medical University, Changzhou 213003, China)

机构地区南京医科大学附属常州市第二人民医院神经内科

出处《中华神经科杂志》 CAS CSCD 北大核心 2017年第12期885-891,共7页 Chinese Journal of Neurology

基金国家自然科学基金资助项目（81471338）

关键词脑梗死组织型纤溶酶原激活物血栓溶解疗法脑白质疏松预后 Cerebral infarction Tissue plasminogen activator Thrombolytic therapy Leukoaraiosis Prognosis

分类号 R743.3 [医药卫生—神经病学与精神病学]

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2张长青,王伊龙,王春雪,赵性泉,王拥军.脑白质疏松和陈旧性腔隙性脑梗死对首发缺血性卒中患者预后的影响[J].中国卒中杂志,2015,10(11):923-929. 被引量：12
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