缺血性卒中早期神经功能恶化的临床特征和危险因素分析

Early neurological deterioration in ischemic stroke:Characteristics and risk factors

目的:研究缺血性卒中患者早期神经功能恶化的发生率、临床特征、危险因素以及其对预后的影响,并探讨不同卒中类型与神经功能恶化间的相关性。方法:使用中国神经功能缺损程度评分对首次发病的24小时内入院的脑梗死患者进行早期神经功能恶化的诊断。记录危险因素及使用1个月时的死亡率、改良Rankin评分和Barthel指数判断预后。结果:210例患者中54例发生早期神经功能恶化,运动功能恶化是最主要的形式(25.7%)。logistic回归显示进展与入院距发病时间短(OR 0.958,95%CI 0.919～0.998,P<0.05)和血糖水平升高(OR 1.197,95%CI 1.069～1.342,P<0.01)显著相关。各主要单项神经功能缺损中,意识障碍恶化的预测因素包括糖尿病史和初次神经功能缺损程度评分,而腔隙性梗死患者较少发生意识障碍加重,男性和高血糖是运动障碍加重的危险因素,部分前循环梗死患者容易出现言语功能恶化。早期神经功能恶化显著影响预后。结论:急性缺血性卒中发生早期神经功能恶化相当常见且预后较差。入院高血糖可以预测早期神经功能恶化的发生,识别高危患者并给予积极有效的治疗是改善预后的关键。

Objective： To explore the frequency, characteristics, risky factors and prognosis of early neurological deterioration in ischemic stroke, and to evaluate the correlation between different clinical types and the neurological deterioration. Methods： Neurological assessments were performed daily and consecutively for the first 3 days on patients with first-ever cerebral in- farction admitted within 24h of onset by the Chinese Neurological Functional Deficit Scale. Early neurological deterioration was defined as a decrease of more than 2 points in any of the conscious level, eye movement, arm or leg motor and speech scores in the neurological functional deficit scale in 3 days. Risky factors, neurological examinations, OCSP clinical classifica- tion and TOAST classification, and comprehensive diagnostic tests were recorded. Prognosis was measured with mortality, modified Rankin score and Barthel Index （BI） score in 1 month. Outcome was considered as good when mRS was 0 to 2 or BI was 95 or 100. Results： Of the 210 patients studied 54（25.7%） suffered from early neurological deterioration. Movement deterioration was the major pattern （21.9%）. Deterioration was significantly associated with a less duration before admission （OR 0.958, 95%CI 0.919-0.998, P〈0.05） and an admission hyperglycemia （1.197, 1.069-1.342, P〈0.01） in logistic regression. Conscious aggravation was associated with the history of diabetes and the initial neurological deficit score. Reversely, it rarely occurred in lacunar cerebral infarction. Male and admission hyperglycemia were risky factors of movement deterioration. Speech deterioration was associated with partial anterior circulation infarction. Early neurological deterioration significantly worsened the prognosis. Conclusion： Neurological deterioration after acute ischemic stroke is a frequent phenomenon, which causes poor prognosis. Admission hyperglycemia can predict early neurological deterioration. To identify patients with high risk and give intensive and effective therapy may improve the outcome of ischemic stroke.