早期神经功能改善对缺血性卒中患者静脉溶栓预后的预测作用

摘要/Abstract

摘要：

目的探究缺血性卒中患者静脉溶栓后基于美国国立卫生研究院卒中量表（National I nstitutes o f Health Stroke Scale，NIHSS）评分的早期神经功能改善（early neurologic improvement，ENI）对患者3个月结局的预测作用。方法本研究的入选患者来自中国急性缺血性卒中溶栓监测登记研究（Thrombolysis Implementation and Monitoring of Acute Ischemic Stroke in China，TIMS-China），从中选取所有进行溶栓前NIHSS评分、溶栓后2 h和24 h NIHSS评分的患者，将ENI定义为溶栓后2 h NIHSS评分减少≥5分或NIHSS评分等于0分，以及溶栓后24 h NIHSS评分减少≥8分或NIHSS评分等于0分，结局指标包括溶栓后90 d的改良Rankin量表（modified Rankin Scale，mRS）评分、症状性颅内出血（symptomatic intracranial hemorrhage，SICH）情况及患者的死亡率，采用Logistics回归模型分析早期神经功能改善对患者3个月结局的预测作用。结果共纳入1100例患者，在溶栓后2 h，310（28.18%）例患者具有ENI，在溶栓后24 h，272（24.73%）例患者具有ENI 。在多因素Logi sti c回归分析模型中，调整了年龄、心房颤动病史、基线血糖水平、基线NIHSS评分水平及其他相关变量后发现，无论是溶栓后2 h还是溶栓后24 h，ENI组患者与非-ENI 组患者相比，均具有更好的3个月良好功能结局（2 h：OR 3.772；95%CI 2.676～5.316，P <0.001；24 h： OR 16.392；95%CI 10.370～25.912，P <0.001）以及更低的死亡率（2 h：OR 0.504；95%CI 0.268～0.950， P =0.034；24 h：OR 0.149；95%CI 0.061～0.366，P <0.001），同时，其出血风险（2 h：OR 1.979； 95%CI 0.621～6.301，P =0.248；24 h：OR -；95%CI -，P =0.928）均未增加。结论静脉注射重组组织纤溶酶原激活剂（recombinant tissue-type plasminogen activator，rt-PA）溶栓后早期神经功能改善的缺血性卒中患者具有更加良好的3个月功能预后。

文章导读： 本研究显示阿替普酶静脉溶栓后具有早期神经功能改善的患者具有更好的3个月功能预后。

关键词: 急性缺血性卒中; 静脉溶栓; 预后; 早期神经功能改善

Abstract:

Objective To evaluate the role of early neurologic improvement (ENI) in predicting the outcome of acute ischemic stroke (AIS) patients with intravenous (IV) recombinant tissue plasminogen activator (rt-PA) at 90 days, by using the National Institutes of Health Stroke Scale (NIHSS) score. Methods Data were collected from the Thrombolysis Implementation and Monitoring of Acute Ischemic Stroke in China (TIMS-China) registry study. NIHSS scores were recorded before IV rt- PA, at 2 and 24 hours after IV rt-PA. ENI at 2 hours was defined as a reduction in NIHSS score by 5 or more points from baseline or a total NIHSS score of 0 at 2 hours. ENI at 24 hours was defined as a reduction in NIHSS score by 8 or more points from baseline or a total NIHSS score of 0 at 24 hours. The outcome indexes included symptomatic intracranial hemorrhage (SICH), mortality, and 90-day functional outcomes. Logistic regression analysis was used to evaluate the role of ENI in predicting the 3-month outcome of patients. Results A total of 1100 patients were included. Among which, 310 (28.18%) had ENI at 2 hours

and 272 (24.73%) had ENI at 24 hours after intravenous thrombolysis. In the multivariable Logistic regression model, after adjusted for potential confounding factors including age, history of atrial fibrillation, baseline level of blood glucose, baseline NIHSS score level and other correlated variates, no matter 2 hours or 24 hours after intravenous thrombolysis, patients in ENI group had a significant improvement of favorable outcome (2 h: OR 3.772; 95%CI 2.676~5.316, P <0.001; 24 h: OR 16.392; 95%CI 10.370~25.912, P <0.001; respectively), lower mortality (2 h: OR 0.504; 95%CI 0.268~0.950, P =0.034; 24 h: OR 0.149; 95%CI 0.061~0.366, P <0.001; respectively) and the risk of SICH (2 h: OR 1.979; 95%CI 0.621~6.301, P =0.248; 24 h: OR -; 95%CI -, P =0.928; respectively) was not increased at the 3-month follow-up. Conclusion IV rt-PA appears to have a favorable outcome at month 3 in ENI of patients with AIS.

Key words: Acute ischemic stroke; Thrombolysis; Outcome; Early neurologic improvement

杨寓玲，廖晓凌，王春娟，赵性泉，王春雪，刘丽萍，王安心，王拥军，王伊龙，曹亦宾. 早期神经功能改善对缺血性卒中患者静脉溶栓预后的预测作用[J]. 中国卒中杂志, 2016, 11(04): 277-282.

YANG Yu-Ling, LIAO Xiao-Ling, WANG Chun-Juan, et al.. Role of Early Neurologic Improvement in Predicting Outcome after Intravenous Recombinant Tissue Plasminogen Activator Therapy[J]. Chinese Journal of Stroke, 2016, 11(04): 277-282.

参考文献

1 Hacke W，Kaste M，Bluhmki E，et al. Thrombolysis

with alteplase 3 to 4.5 hours after acute ischemic

stroke[J]. N Engl J Med，2008，359：1317-1329.

2 Del Zoppo GJ，Saver JL，Jauch EC，et al. Expansion

of the time window for treatment of acute ischemic

stroke with intravenous tissue plasminogen activator：

a science advisory f rom the Amer ican Hear t

Association/American Stroke Association[J]. Stroke，

2009，40：2945-2948.

3 Mazighi M，Ser faty JM，Labreuche J，e t a l .

Compar ison of int ravenous alteplase with acombined intravenous-endovascular approach in

patients with stroke and confirmed arterial occlusion

(RECANALISE study)：a prospective cohort study[J].

Lancet Neurol，2009，8：802-809.

4 Mu r e s a n I P，Fav role P，Lev y P，et a l. Ver y

early neurologic improvement after intravenous

thrombolysis[J]. Arch Neurol，2010，67：1323-1328.

5 Takagi T，Kato T，Sakai H，et al. Early neurologic

improvement based on the National Institutes of

Health Stroke Scale score predicts favorable outcome

within 30 minutes after undergoing intravenous

recombinant tissue plasminogen activator therapy[J]. J

Stroke Cerebrovasc Dis，2014，23：69-74.

6 Liao XL，Wang CX，Wang YL，et al. Implementation

and outcome of thrombolysis with alteplase 3 to

4.5 h after acute stroke in Chinese patients[J]. CNS

Neurosci Ther，2013，19：43-47.

7 Saposnik G，Di Legge S，Webster F，et al. Predictors

of major neurologic improvement after thrombolysis

in acute stroke[J]. Neurology，2005，65：1169-1174.

8 Hallevi H，Grotta JC. SITS-MOST：old myths laid to

rest[J]. Lancet Neurol，2007，6：292-293.

9 Sulter G，Steen C，De Keyser J. Use of the Barthel

index and modified Rankin scale in acute stroke

trials[J]. Stroke，1999，30：1538-1541.

10 Haley EC，Jr，Lewandowski C，Tilley BC. Myths

regarding the NINDS rt-PA Stroke Trial：setting the

record straight[J]. Ann Emerg Med，1997，30：676-

682.

11 Rha JH，Saver JL. The impact of recanalization on

ischemic stroke outcome：a meta-analysis[J]. Stroke，

2007，38：967-973.12 Alexandrov AV，Burgin WS，Demchuk AM，et

al. Speed of intracranial clot lysis with intravenous

tissue plasminogen activator therapy：sonographic

classif ication and shor t-term improvement[J].

Circulation，2001，103：2897-2902.

13 Alexandrov AV，Demchuk AM，Felberg RA，et al.

High rate of complete recanalization and dramatic

cl inical recover y dur ing tPA infusion when

continuously monitored with 2-MHz transcranial

doppler monitoring[J]. Stroke，2000，31：610-614.

14 Yeo LL，Paliwal P，Teoh HL，et al. Timing of

recanalization after intravenous thrombolysis and

functional outcomes after acute ischemic stroke[J].

JAMA Neurol，2013，70：353-358.

15 Christou I，Alexandrov AV，Burgin WS，et al. Timing

of recanalization after tissue plasminogen activator

therapy determined by transcranial doppler correlates

with clinical recovery from ischemic stroke[J]. Stroke，

2000，31：1812-1816.

16 K imu r a K，I g u ch i Y，Sh iba z a k i K，e t a l .

Recanalization within one hour after intravenous tissue

plasminogen activator is associated with favorable

outcome in acute stroke patients[J]. Eur Neurol，2010，

63：331-336.

17 Malferrari G，Bertolino C，Casoni F，et al. The

eligible study：ultrasound assessment in acute

ischemic stroke within 3 hours[J]. Cerebrovasc Dis，

2007，24：469-476.

18 Molina CA，Alexandrov AV，Demchuk AM，et al.

Improving the predictive accuracy of recanalization

on stroke outcome in patients treated with tissue

plasminogen activator[J]. Stroke，2004，35:151-156.

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