血液学指标对复发脑梗死的诊疗价值

Clinical values of hematological indicators for recurrent cerebral infarction

目的探讨血液学指标对预测脑梗死复发的价值,为缺血性脑血管病的二级预防开辟新的思路。方法将200例急性脑梗死患者根据头颅MRI结果分为首发性脑梗死组(FIS)109例,复发性脑梗死组(RIS)91例。记录其复发的危险因素,如年龄、吸烟、高血压、糖尿病、高脂血症等,同时于发病72h内测定d-二聚体、蛋白S、蛋白C、抗凝血酶Ⅲ、血栓调节蛋白(TM)、组织型纤溶酶原激活物(t-PA)、组织型纤溶酶原激活物抑制物、同型半胱氨酸(Hcy)以及抗心磷脂抗体等9项血液学指标。结果①RIS组患者平均年龄为(59±9)岁,FIS组患者为(56±10)岁;RIS组患者合并高血压的比率(83.5%)明显高于FIS组(71.6%)。②与FIS组患者相比,RIS组患者血液学指标紊乱严重,9项中有6项表现出明显的差异:蛋白S在RIS和FIS组分别为(23±7)μg/ml、(25±6)μg/ml,P=0.002;蛋白C在RIS和FIS组分别为(4.5±1.5)μg/ml、(4.9±1.7)μg/ml,P=0.05,显示蛋白S和蛋白C在RIS组降低。RIS组TM增高[(30±13)μg/L、(26±7)μg/L,P=0.01];RIS组t-PA较FIS组增多[(7.6±3.0)μg/L、(6.7±2.6)μg/L,P=0.025]。RIS组患者血浆Hcy浓度[(23±10)μmol/L]较FIS组[(17±6)μmol/L]升高,P<0.01。RIS组患者抗心磷脂抗体IgG(ACAIgG)阳性的比例比FIS组高(18.7%、5.5%,P=0.004)。③多因素Logistic回归分析显示,高血压(OR=2.050;95%CI:1.53～6.53)、高龄(OR=1.025;95%CI:1.00～1.05)、蛋白C降低(OR=0.692;95%CI:0.54～0.88)、高同型半胱氨酸血症(OR=1.074;95%CI:1.03～1.12)以及抗心磷脂抗体IgG阳性(OR=3.426;95%CI:1.19～9.84)是预测脑梗死复发的独立危险因素。结论血液学指标失衡可增加脑梗死复发风险,定期检测血液学相关指标有助于早期预测脑梗死的复发。

Objectives To investigate the value of hematological indicators for predicting recurrent cerebral infarction and to open up new ideas for the secondary prevention of ischemic cerebrovascular disease. Methods A total of 200 patients with acute cerebral infarction were divided into first attack of ischemic stroke （FIS） group （n = 109） and recurrent ischemic stroke （RIS） group （ n = 91 ） according to the results of cranial MRI. The risk factors for recurrence, such as age, smoking, hypertension, diabetes, and hyperlipidemia, etc. were documented. At the same time, 9 hematological indicators including plasma d-dime, protein S, protein C, antithrombin Ⅲ, thrombomodulin, tissue plasminogen activator, tissue plasminogen activator inhibitor, hyperhomocysteine and anticardiolipin antibodies were detected within 72 hours after symptom onset. Results ①The mean age of patients in the RIS group was 59 ± 9 years and that of the patients in the FIS group was 56 ± 10 years; the hypertension ratio （83.5%） of the former group was significantly higher than that of the latter group（71.6% ）. ②The hematological indicators of the patients in the RIS group were seriously disordered as compared to the patients of FIS group, and 6 of the 9 items showed significant differences between the 2 groups. The protein S （PS） anticoagulant system in the RIS and FIS groups were 23 ± 7 μg/ml and 25 ± 6 μg/ml, respectively （ P = 0. 002 ） ; The protein C （ PC ） in the RIS and FIS groups were 4.5 ± 1.5 μg/ml and 4.9 ± 1.7 μg/ml （ P = 0.05 ） respectively. It showed that the PS and PC were decreased in the RIS group. The thrombomodulin （TM） in the RIS group was higher （30 ± 13 μg/L） than that in FIS group （26± 7 μg/L）, P = 0. 01 ; the fibrinolytic system tissue plasminogen activator （t-PA） in the RIS group was higher than that in the FIS group （7.6 ±3.0 μg/L and 6.7 ±2. 6 μg/L, P = 0. 025）. The plasma homocysteine （Hey） concentration was 23 ± 10 μmol/L in the RIS group,it was higher than 17 ±＋6 μmol/L in the FIS group （P 〈0.01 ）. The proportion of the anti-cardiolipin antibody IgG （ACA IgG） -positive patients in RIS group was higher than that in FIS group （ 18.7% vs. 5.5%, P = 0, 004）. @Multivariate Logistic regression analysis showed that hypertension （OR = 2. 050 ;95% CI： 1.53 - 6. 53 ）, advanced age （ OR = 1. 025 ;95% CI： 1.00 - 1.05 ）, PC decreasing （ OR = 0.692 ; 95% CI： O. 54 - 0. 88 ）, hyperhomocysteinemia （ OR = 1. 074 ; 95% CI： 1.03 - 1.12）, and ACA IgG-positive （OR = 3. 426 ;95% CI： 1.19 -9.84） were the independent risk factors for predicting recurrence of cerebral infarction. Conclusion The imbalance of hematological indicators may increase the risk of recurrence of cerebral infarction. Detecting these hematology-related indicators regularly may contribute to early predict the risk of recurrence cerebral infarction.