【作者】 刘洁；

【导师】 戴海斌；

【作者基本信息】 浙江大学 ， 药学， 2015， 硕士

【摘要】 目的：探讨重组组织型纤溶酶原激活剂(爱通立,rt-PA)发病4.5小时内治疗急性脑梗死影响早期疗效的因素。方法：回顾分析2012年1月-2015年8月接受rt-PA(爱通立)静脉溶栓治疗的急性脑梗死患者的一般资料,并记录溶栓后24h,第3d,第7d的NIHSS评分和溶栓后出血转化。以24h,第3d,第7d的NIHSS评分较溶栓前减少≥4分或神经功能缺损症状完全消失视为早期有效,其余的视为早期无效；以第7d的NIHSS评分较溶栓前增加≥4分的视为早期恶化,溶栓后24h症状性颅内出血转化根据ECASSⅡ标准评定。比较206例患者在年龄、性别、酗酒史、房颤、高血压史、糖尿病史、中风史、入院至溶栓时间间隔、入院LDL-C水平、入院葡萄糖水平、入院糖化血红蛋白、入院收缩压和舒张压、入院NIHSS水平等临床数据对早期预后的影响。结果：入选患者共206例,男123例,女83例；年龄18-80岁,平均(65.32±12.79)岁；溶栓后第7d累积有效例数为121例(58.7%),死亡累积为5例(2.4%)。分析发现入院LDL-C水平(≤3.1mmol/L)和房颤是rt-PA静脉溶栓早期神经功能改善(24h,第3d,第7d)的独立影响因素(P<0.05)。24hNIHSS评分则是溶栓后3d,7d早期神经功能改善的预测因子(P<0.01)。Logistic多因素分析结果显示房颤(OR:4.106,95%CI:1.314～12.833, P=0.015)和入院葡萄糖水平(>10mmol/L) (OR:4.749,95%CI:1.196～18.857, P=0.027)是静脉溶栓后7d早期恶化的影响因素；而入院舒张压(OR:1.162,95%CI:1.020～1.325, P=0.024)和入院葡萄糖浓度(OR:1.698,95%CI:1.041～2.770, P=0.034)则是7d死亡的影响因素。206例rt-PA治疗急性脑梗死的患者中有49例发生了出血转化,其中13例为症状性出血转化。Logistic多因素分析结果显示,症状性颅内出血转化与入院NIHSS评分(OR:1.129, 95%CI:1.005～1.269, P=0.041),入院舒张压(OR:1.042,95%CI:1.002～ 1.084,P=0.041)和房颤(OR:4.549,95%CI:1.093～18.933,P=0.037)相关。结论：1入院LDL-C水平(≤3.1mmol/L)和房颤是rt-PA静脉溶栓早期有效的独立影响因素。2溶栓后24h NIHSS评分对溶栓后3d、7d的神经功能改善具有预测作用。3房颤和入院葡萄糖水平(>10mmol/L)是溶栓后7d发生神经功能恶化的独立影响因素；入院舒张压和入院葡萄糖浓度则是7d死亡的影响因素。4入院NIHSS评分,入院舒张压和房颤是溶栓后发生症状性颅内出血转化的预测因素。更多还原

【Abstract】 Objective:To analyze the factors affecting on early efficacy of intravenous thrombolysis with rt-PA treatment to cerebral infarction within 4.5 hours onset.Methods:The clinical, laboratory data of consecutive acute cerebral infarction patients undergoing intravenous thrombolysis therapy in Second Affiliated Hospital, Zhejiang University School of Medicine from January 2012 to August 2015 was retrospectively analyzed. The national institute of health stroke scale (NIHSS) score was recorded respectively to evaluate the recovery of neurological functions before treatment and after the treatment for 24h,3d, and 7d. Early improving efficacy was defined by a 4-point improvement in NIHSS score or complete recovery at 24h,3d, and 7d. We defined the increase of NIHSS score at 7d as the deterioration. Assessment of symptomatic intracerebral hemorrhage within the first 24h was according to ECASSⅡ criteria. The following stroke risk factors were assessed:age, sex, alcohol history, atrial fibrillation, hypertension, diabetes, prior stroke, onset-to-treatment time, admission LDL-C level, admission glucose level, admission HbAlc, admission systolic pressure, diastolic pressure, and admission NIHSS score.Results:Of the 206 acute cerebral infarction patients treated by intravenous thrombolysis with rt-PA,123 patients were males, aged 18-80 years, with an average (65.32±12.79) years old. At the seventh day of thrombolysis, the cumulative number of effective cases was 120(58.3%), and the mortality was 5(2.4%). Analysis showed that admission LDL-C level (<3.1mmol/L) and atrial fibrillation were the independent factors for the early neurological improvement (24h,3d,7d).24h NIHSS score was the predictive factor for early neurological improvement of 3d and 7d after thrombolysis (P< 0.01). Multivariate logistic regression analysis showed that atrial fibrillation (OR:4.106, 95%CI:1.314-12.833, P=0.015) and admission glucose level (> 10mmol/L)(OR:4.749,95%CI:1.196～18.857, P=0.027) were the risk factors of early deterioration; while admission diastolic pressure(OR:1.162,95%CI:1.020-1.325, P=0.024) and admission glucose (OR:1.698,95%CI:1.041-2.770, P=0.034) were the risk factors associated with death. Of the 206 patients,49 patients had hemorrhagic transformation, and 13 patients were symptomatic intracerebral hemorrhage. Multivariate logistic regression analysis showed that the admission NIHSS score (OR:1.129,95%CI:1.005-1.269, P=0.041), admission diastolic pressure(OR:1.042, 95%CI:1.002-1.084,P=0.041) and atrial fibrillation (OR:4.549,95%CI:1.093-18.933,P=0.037) were the factors associated with symptomatic intracerebral hemorrhagic transformation.Conclusion:1 The admission LDL-C level (≤3.1mmol/L) and atrial fibrillation were the independent factors that influenced the early efficacy after intravenous thrombolysis in patients with acute cerebral infarction.2 24h NIHSS score was the predictive factor of the early neurological improvement.3 The atrial fibrillation and admission glucose level(>10mmol/L) were the risk factors of early deterioration; Admission diastolic pressure and admission glucose were the risk factors associated with death.4 The admission NIHSS score, atrial fibrillation, admission diastolic pressure were the factors associated with symptomatic intracerebral hemorrhagic transformation.更多还原