院内大血管闭塞性卒中血管内治疗患者的临床特征及预后因素分析

doi:10.3969/j.issn.1673-5765.2024.03.009

摘要/Abstract

摘要： 目的探讨院内发生的大血管闭塞性卒中行血管内治疗患者的临床特征、发病机制、血管内治疗及预后，为制订院内大血管闭塞性卒中预防策略提供参考信息。
方法回顾性分析2020年7月—2023年7月因非缺血性卒中原因在徐州市中心医院住院期间发生大血管闭塞性卒中的45例患者（院内组）的临床资料。选择同期通过急诊绿色通道入院的大血管闭塞性卒中患者100例作为对照（院外组）。收集两组患者的基线资料、实验室指标以及血管内治疗相关资料，比较两组人口学信息、危险因素、发病机制及治疗结局。采用多因素logistic回归分析院内发生大血管闭塞性卒中对患者预后的影响。
结果院内组大血管闭塞性卒中患者的首诊住院科室主要有脑外科（10/45，22.2%）、心脏外科（9/45，20.0%）、血甲疝外科（9/45，20.0%）及胸外科（5/45，11.1%）等，23例（51.1%）与外科手术有关。两组患者性别、年龄、烟酒史比例、高血压、糖尿病、高脂血症、冠心病、心脏瓣膜病、心功能不全及既往卒中病史差异无统计学意义。与院外组患者相比，院内组患者合并心房颤动（53.3% vs. 19.0%，P＜0.001）、恶性肿瘤（15.6% vs. 1.0%，P=0.002）、其他动脉栓塞（15.6% vs. 1.0%，P=0.002）以及围手术期（51.1% vs. 1.0%，P＜0.001）的比例更高，发病时NIHSS评分更高[21.0（14.5～35.0）分 vs. 18.0（13.5～24.5）分，P=0.019]。院内组的白细胞计数（U=1385.000，P＜0.001）、D-二聚体（U=654.500，P＜0.001）及IL-6（U=1376.000，P＜0.001）水平高于院外组，血红蛋白（U=1758.000，P=0.035）、收缩压（t=-2.766，P=0.006）和舒张压（U=1317.500，P＜0.001）水平低于院外组，差异均有统计学意义。院内组与院外组卒中在前后循环的分布上差异无统计学意义，院内组大动脉粥样硬化性、心源性、其他原因大血管闭塞性卒中患者分别有7例（15.6%）、22例（48.9%）、16例（35.6%），院外组分别有63例（63.0%）、
26例（26.0%）、11例（11.0%），差异有统计学意义（χ2=29.432，P＜0.001）。两组行血管内治疗前缺血区与梗死区的体积比以及术后TICI血流分级、出血转化/造影剂渗出及死亡患者比例差异无统计学意义。与院外组比较，院内组发病到血管内治疗时间及再通时间更短，术中使用补救措施更少
（P＜0.05）。在校正了发病时NIHSS评分、心房颤动、心脏瓣膜病、缺血区与梗死区的体积比后，院内卒中与大血管闭塞性卒中血管内治疗患者的良好预后结局仍呈负相关（OR 0.213，95%CI 0.063～0.711，P=0.012）。
结论院内外发生大血管闭塞性卒中行血管内治疗的患者有着不同的临床特征、发病机制及治疗结局。院内大血管闭塞性卒中患者的神经系统损伤症状较严重，合并基础疾病较多，病因机制复杂，易预后不良。严格把握手术适应证、预防及控制感染、积极干预危险因素可能会减少院内大血管闭塞性卒中的发生。

文章导读： 院内大血管闭塞性卒中合并基础病较多，病因复杂，易预后不良。临床上应积极干预危险因素，同时加强院内绿色通道建设。

关键词: 院内卒中; 大血管闭塞性卒中; 血管内治疗; 心房颤动; 围手术期

Abstract: Objective To investigate the clinical characteristics, pathogenesis, endovascular treatment and prognosis of patients treated with endovascular treatment for large vessel occlusive stroke occurring in hospital, and to provide reference information for the prevention strategies of large vessel occlusive stroke in hospital.
Methods A retrospective analysis was performed on 45 patients (in-hospital group) who were hospitalized in Xuzhou Central Hospital for non-ischemic stroke from July 2020 to July 2023 and had large vessel occlusive stroke during hospitalization. During the same study period, 100 patients with large vessel occlusive stroke who entered the emergency greenway of our hospital from outside the hospital were used as control cases (out-of-hospital group). Baseline data, laboratory-related indicators, and endovascular treatment-related data were collected to analyze the demographics, risk factors, pathogenesis, and treatment outcomes of the two groups and compared. Multivariate logistic regression was used to analyze the prognostic effects of patients with large vessel occlusive stroke occurring in hospital.
Results Patients with in-hospital large vessel occlusive stroke had a wide variety of first diseases, mainly occurring in brain surgery (10/45, 22.2%), cardiac surgery (9/45, 20.0%), blood nail hernia surgery (9/45, 20.0%), and thoracic surgery (5/45, 11.1%), and 23 cases (51.1%) were associated with surgery. There was no statistically significant difference between the two groups in terms of gender, age, history of smoking and alcohol, hypertension, diabetes mellitus, hyperlipemia, coronary artery heart disease, valvular heart disease, cardiac insufficiency and history of previous stroke. Compared with the out-of-hospital group, more patients in the in-hospital group had a combination of atrial fibrillation (53.3% vs. 19.0%,
P＜0.001), malignant tumor (15.6% vs. 1.0%, P=0.002), other arterial thrombosis (15.6% vs. 1.0%, P=0.002), and perioperative period (51.1% vs. 1.0%, P＜0.001), and the NIHSS score at the onset of the disease was higher [21.0 (14.5-35.0) points vs. 18.0 (13.5-24.5) points, P=0.019]. The levels of white blood cell count (U=1385.000, P＜0.001), D-dimer (U=654.500,
P＜0.001) and IL-6 (U=1376.000, P＜0.001) in the in-hospital group were higher than those in the out-of-hospital group, and the levels of hemoglobin (U=1758.000, P=0.035), systolic blood pressure (t=-2.766, P=0.006) and diastolic blood pressure (U=1317.500, P＜0.001) were lower than those in the out-of-hospital group, and the differences were all statistically significant. The difference between the in-hospital group and the out-of-hospital group in the distribution of anterior and posterior circulation was not statistically significant. There were 7 cases (15.6%), 22 cases (48.9%), and 16 cases (35.6%) of large vessel occlusive stroke with atherosclerosis, cardiogenic type, and other causes in the in-hospital group, and 63 cases (63.0%), 26 cases (26.0%), and 11 cases (11.0%) in the out-of-hospital group, respectively, with a statistically significant difference (χ2=29.432, P<0.001). There were no significant difference in volume ratio of ischemic to infarcted area before endovascular treatment, postoperative TICI blood flow grading, hemorrhagic transformation / contrast leakage, and mortality between the two groups. Compared with the out-of-hospital group, the onset-to-treatment time and recanalization time were shorter in the in-hospital group, and intraoperative use of remedies was less frequent (P<0.05). After adjusting for NIHSS score at onset, atrial fibrillation, valvular heart disease, and volume ratio of ischemic to infarcted area, there was still a negative correlation between in-hospital stroke and good prognosis of patients with large vessel occlusive stroke treated with endovascular treatment (OR 0.213, 95%CI 0.063-0.711, P=0.012).
Conclusions Patients with endovascular treatment for large vessel occlusive stroke in and out of hospitals have different clinical characteristics, pathogenesis and treatment outcomes. In-hospital patients with large vessel occlusive stroke have more severe symptoms of clinical neurological injury, more comorbid underlying diseases, complex etiologic mechanisms, and poor prognosis. Strict control of surgical indications, prevention and control of infection, and active intervention of risk factors may reduce the incidence of large vessel occlusive stroke in clinical practice.

Key words: In-hospital stroke; Large vessel occlusive stroke; Endovascular treatment; Atrial fibrillation; Perioperative period

中图分类号:

张莉, 刘志广, 傅新民, 张洋, 宗海亮. 院内大血管闭塞性卒中血管内治疗患者的临床特征及预后因素分析[J]. 中国卒中杂志, 2024, 19(3): 310-318.

ZHANG Li, LIU Zhiguang, FU Xinmin, ZHANG Yang, ZONG Hailiang. Clinical Characteristics and Prognostic Analysis of Patients with Endovascular Treatment for In-Hospital Large Vessel Occlusive Stroke[J]. Chinese Journal of Stroke, 2024, 19(3): 310-318.

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