【摘要】 目的分析和探讨急性缺血性卒中阿替普酶静脉溶栓后早期神经功能恶化(early neurological deterioration,END)的危险因素。方法选择2015年1月至2018年9月接受静脉阿替普酶溶栓治疗的186例急性缺血性卒中(acute ischemic stroke,AIS)患者作为研究对象,将溶栓后24 h内美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分较溶栓前增加≥4分归为早期神经功能恶化组(END组),NIHSS评分减少或增加<4分归为非恶化组(nEND 组)。通过单因素分析及多因素Logistic回归分析比较两组人口统计学信息、脑血管病危险因素、临床特征、影像学特征、溶栓后并发症和治疗90d预后良好率[即改良Rankin量表(modified Rankin scale,mRS)评分0～2分]的差别,并分析END的独立危险因素。结果 186例AIS患者中,共发生END22例(11.8%),END组溶栓前NIHSS评分较nEND组更高[(11.59±5.78)分比(8.80±6.27)分,t=3.78,P=0.02],发病-溶栓时间(onset-to-treatment time,OTT)更长[(212.95±44.70)min比(178.98±52.40)min,P<0.05],溶栓前随机血糖更高[(10.54±4.49)mmol/L比(6.95±2.67)mmol/L,P=0.02],发病前较少接受抗血小板(9.09%比34.15%,P=0.03),责任大血管狭窄更严重(72.73%比39.63%,P=0.03),TOAST分型为心源性栓塞占比更高(54.55%比22.56%,P=0.01)。多因素Logistic回归分析提示:长OTT(OR=1.01,P=0.01)、心源性栓塞(OR=6.29,P<0.05)、溶栓前高NIHSS评分(OR=1.21,P<0.05)、责任大血管闭塞(OR=11.72,P<0.05)是AIS阿替普酶静脉溶栓后发生END的独立危险因素。高龄(OR=1.08,P=0.01)、溶栓前高NIHSS评分(OR=1.13,P<0.05)、END(OR=12.25,P<0.05)、症状性颅内出血(OR=9.55,P<0.05)为预后不良的独立危险因素。结论 END发生不利于静脉阿替普酶溶栓治疗AIS的良好转归,其中长OTT、心源性栓塞、溶栓前高NIHSS评分、责任大血管闭塞是END发生的独立危险因素。更多还原

【Abstract】 Objective To analyze the risk factors of early neurological deterioration (END) in using Alteplase thrombolysis to treat acute ischemic stroke (AIS).Methods The data of 186 patients with AIS who underwent thrombolytic therapy with intravenous alteplase from January 2015 to September 2018 were reviewed.According to National Institutes of Health Stroke Scale (NIHSS),an increase of 4 points or more within 24 hours after thrombolysis was classified as the early neurological deterioration group (END group),and patients whose NIHSS score decreased or increased <4 points were classified as the non-deteriorating group (nEND group).Univariate analysis and multivariate logistic regression analysis were used to compare the difference between demographic information,risk factors of cerebrovascular disease,clinical features,imaging features,post-thrombotic complications,and prognosis (mRS 0～2) after 90 days.Results Twenty-two patients suffered from END and the incidence was 11.8% among all of the 186 patients.Univariate analysis showed that the END group had higher NIHSS score before thrombolysis (11.59±5.78 vs 8.80±6.27,P=0.02),longer onset-to-treatment time (OTT) [(212.95±44.70)min vs (178.98±52.40)min,P<0.05],higher admission blood glucose [(10.54±4.49)mmol/L vs (6.95±2.67)mmol/L,P=0.02],and less anti-platelet therapy before onset (9.09% vs 34.15%,P=0.03),more severe offending macro-vascular stenosis (72.73% vs 39.63%,P=0.03),cardiogenic embolism as one of the categories from TOAST classification (54.55% vs 22.56%,P=0.01).Multivariate logistic regression analysis indicated that longer OTT(OR=1.01,P=0.01),cardiogenic embolism (OR=6.29,P<0.05),NIHSS score before thrombolysis (OR=1.21,P<0.05),and offending large vessel occlusion (OR=11.72,P<0.05) were independent risk factors for END after intravenous thrombolysis.Age (OR=1.08,P=0.01),high initial NIHSS score (OR=1.13,P<0.05),END (OR=12.25,P<0.05),sICH (OR=9.55,P<0.05) were independent risk factors for poor prognosis.Conclusion END may lead to unfavorable outcome in thrombolytic therapy with intravenous alteplase for the treatment of AIS.Long OTT,cardiogenic embolization,high NIHSS score before thrombolysis,and offending large vessel occlusion are independent risk factors for END.更多还原