急性缺血性卒中围静脉溶栓时间窗临床症状波动的静脉溶栓研究

doi:10.3969/j.issn.1673-5765.2020.09.015

摘要/Abstract

摘要：

目的探讨急性缺血性卒中患者围静脉溶栓时间窗临床症状波动的患者进行静脉溶栓治疗的临床特征及预后分析。方法前瞻性纳入绵阳市中心医院2013年10月-2018年6月连续登记的发病4.5 h内进行静脉溶栓的患者，以实施静脉溶栓时NIHSS评分较入院时NIHSS评分上下波动2分作为临床症状波动判断标准，将所有纳入患者分为无变化组、波动组。分析比较两组患者的临床特征及24 h出血转化率、出院NIHSS 评分、3个月预后良好（mRS评分≤2分）和全因死亡率，多因素Logistic回归分析围静脉溶栓时间窗发生临床症状波动的影响因素。结果共纳入156例，其中男性110例（70.5%），年龄范围42～87岁，平均65±13岁，发生围静脉溶栓时间窗临床症状波动41例（26.3%）。与无变化组患者相比，波动组患者年龄、基线NIHSS评分、糖尿病比例、高血压比例、随机血糖水平、后循环梗死比例较高，差异均具有统计学意义。两组患者的24 h出血转化率、出院NI HSS评分、3个月良好预后率、3个月时全因死亡率差异无统计学意义。Logistic回归分析发现年龄（每增加10岁：OR 1.143，95%CI 1.016～1.836，P =0.040）、基线NIHSS 评分（每增加1分：OR 1.353，95%CI 1.053～1.393，P =0.006）、随机血糖（每增加1 mmol/L：OR 2.120， 95%CI 1.185～2.748，P =0.001）、后循环梗死（OR 2.603，95%CI 1.037～3.950，P =0.042）是围静脉溶栓时间窗临床症状波动的独立危险因素。结论尽管高龄、NIHSS评分高、血糖水平高、后循环梗死患者容易出现围静脉溶栓时间窗临床症状波动，但对终点事件并无影响。对于出现临床症状波动的患者，溶栓可使患者获益。

文章导读： 患者在溶栓准备实施前出现症状波动会影响医患双方溶栓决策。本文以围静脉溶栓时间窗临床症状波动为观察切入点，为解决这一临床难点做了有益探索。

关键词: 卒中; 静脉溶栓; 时间窗; 临床症状波动

Abstract:

Objective To investigate the clinical characteristics and prognosis of thrombolytic therapy for acute ischemic stroke (AIS) patients with fluctuating clinical symptoms in the perivenous thrombolytic time window. Methods Data of consecutive AIS patients who underwent intravenous thrombolysis within 4.5 hours of stroke onset in Mianyang Central Hospital from October 2013 to June 2018 from stroke registry database were analyzed. Clinical symptom fluctuation was defined as the NIHSS score fluctuating ≥2 points (increase or decrease) at the time of intravenous thrombolysis compared to at admission. All the patients were divided into no change group and fluctuation group. The clinical features, 24-hour hemorrhagic transformation, NIHSS score at discharge, 90-day good prognosis (mRS ≤2), and all-cause mortality were compared between the two groups. Multivariate logistic regression analysis was used to analyze the factors affecting the clinical symptom fluctuation. Results A total of 156 patients were included, with a mean age of 65±13 years old (range: 42-87years) and 110 males (70.5%), and 41 patients (26.3%) in fluctuation group. Compared to the no change group, the fluctuation group had higher age, NIHSS score at admission, percentage of diabetes and hypertension and posterior circulation infarction, and random blood glucose level (all P <0.05). The rate of hemorrhagic transformation, the NIHSS score at discharge, the rate of patients with 90- day good prognosis and all-cause mortality had no statistical difference between the two groups. Multivariate analysis showed that age (per 10-year increase: OR 1.143, 95%CI 1.016-1.836, P =0.040), NIHSS score at admission (OR 1.353, 95%CI 1.053-1.393, P =0.006), random blood glucose level (OR 2.120, 95%CI 1.185-2.748, P =0.001), posterior circulation infarction (OR 2.603, 95%CI 1.037- 3.950, P =0.042) were independent risk factors for clinical symptom fluctuation in the perivenous thrombolytic time window. Conclusions Although patients with elder age, high NIHSS score at admission, high blood glucose level, and posterior circulation infarction were prone to occur fluctuating clinical symptoms in perivenous thrombolysis time window, while the symptom fluctuation was not associated with the outcome. Intravenous thrombolysis therapy is profitable for patients with fluctuating clinical symptoms after screening.

Key words: Stroke; Intravenous thrombolysis; Time window; Fluctuating clinical symptom

陈忠伦，张杉杉，张献文，李肇坤，浦明军，都泓材，段劲峰. 急性缺血性卒中围静脉溶栓时间窗临床症状波动的静脉溶栓研究[J]. 中国卒中杂志, 2020, 15(09): 1010-1014.

CHEN Zhong-Lun, ZHANG Shan-Shan, ZHANG Xian-Wen, LI Zhao-Kun,PU Ming-Jun, DU Hong-Cai, DUAN Jin-Feng. Intravenous Thrombolysis for Acute Ischemic Stroke Patients with Fluctuating Clinical Symptoms in the Perivenous Thrombolysis Time Window[J]. Chinese Journal of Stroke, 2020, 15(09): 1010-1014.

参考文献

[1] YANG G H，WANG Y，ZENG Y X，et al. Rapid

health transition in China，990-2010：findings from

the Global Burden of Disease Study 2010[J]. Lancet，

2013，381（9882）：1987-2015.

[2] WANG Y L，LIAO X L，ZHAO X Q，et al. Using

recombinant tissue plasminogen activator to treat

acute ischemic stroke in China：analysis of the

results from the Chinese National Stroke Registry

（CNSR）[J]. Stroke，2011，42（6）：1658-1664.

[3] The National Institute of Neurological Disorders

and Stroke rt-PA Stroke Study Group. Tissue

plasminogen activator for acute ischemic stroke[J].

N Engl J Med，1995，333（24）：1581-1587.

[4] HACHE W，KASTE M，BLUHMKI E，et al.

Thrombolysis with alteplase 3 to 4. 5 hours after

acute ischemic stroke[J]. N Engl J Med，2008，359

（13）：1317-1329.

[5] WAHLGREN N，AHMED N，DÁVALOS A，et

al. Thrombolysis with alteplase for acute ischaemic

stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study（SITS-MOST）：an

observational study[J]. Lancet，2007，369（9558）：

275-282.

[6] WAHLGREN N，AHMED N，DÁVALOS A，et

al. Thrombolysis with alteplase 3-4.5 h after acute

ischaemic stroke（SITS-ISTR）：an observational

study[J]. Lancet，2008，372（9646）：1303-1309.

[7] BABER P A，DEMCHUK A M，ZHANG J，et al.

Validity and reliability of a quantitative computed

tomography score in predicting outcome of

hyperacute stroke before thrombolytic therapy.

ASPECTS Study Group. Alberta Stroke Programme

Early CT Score[J]. Lancet，2000，355（9216）：1670-

1674.

[8] BALUCANI C，LEVINE S R. Mild stroke and

rapid improving symptoms：it’s not always a happy

ending[J]. Stroke，2011，42（11）：3005-3007.

[9] RUSSO T，FELZANI G，MARINI C，et al. Stroke

in the very old：a systematic review of studies on

incidence，outcome，and resource use[J/OL]. J Aging

Res，2011，2011（1）：108785[2019-03-24]. https：//

doi.org/10.4061/2011/108785.

[10] EUTER B，GUMBINGER C，SAUER T，et al.

Intravenous thrombolysis for acute ischaemic stroke

in the elderly：data from the Baden-Wuerttemberg

stroke registry[J]. Eur J Neurol，2016，23（1）：13-20.

[11] MIONE G，DUCROCQ X，THILLY N，et al.

Outcome of intravenous recombinant tissue

plasminogen activator for acute ischemic stroke in

patients aged over 80 years[J]. Geriatr Gerontol Int，

2016，16（7）：843-849.

[12] WHITELEY W N，SLOT K B，FERNANDES P，et

al. Risk factors for intracranial hemorrhage in acute

ischemic stroke patients treated with recombinant

tissue plasminogen activator：a systematic review

and meta analysis of 55 studies[J]. Stroke，2012，43

（11）：2904-2909.

[13] STRBIAN D，MERETOJA A，PUTAALA J，et al.

Cerebral edema in acute ischemic stroke patients

treated with intravenous thrombolysis[J]. Int J Stroke，

2013，8（7）：529-534.

[14] SAQQUR M，SHUAIB A，ALEXANDROV A V，et

al. The correlation between admission blood glucose

and intravenous rt-PA-induced arterial recanalization

in acute ischemic stroke：a multi-centre TCD

study[J]. Int J Stroke，2015，10（7）：1087-1092.

[15] ALVAREZ-SABIN J，MOLINA CA，MONTANER

J，et al. Effects of admission hyperglycemia on

stroke outcome in reperfused tissue plasminogen

activator-treated patients[J]. Stroke，2003，34（5）：

1235-1241.

[16] ENNIS S R，KEEP R A. Effect of sustained-mild

and transient-severe hyperglycemia on ischemiainduced

blood-brain barrier opening[J]. J Cereb

Blood Flow Metab，2007，27（9）：1573-1582.

[17] 鞠奕，王拥军，赵性泉，等. 后循环缺血性脑梗死患

者病后1年观察[J]. 中华老年心脑血管病杂志，2006，

1（10）：684-687.

[18] SAND K M，NAESS H，NILSEN R M，et al. Less

thrombolysis in posterior circulation infarction-a

necessary evil?[J]. Acta Neurol Scand，2017，135（5）：

546-552.