重组组织型纤溶酶原激活剂静脉溶栓治疗颈内动脉系统急性脑梗死的疗效安全性与分层研究

Effective safety and subtypes snalysis of recombinant tissue plasminogen activator on the treatment of acute anterior circulation infarction

目的探讨重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗颈内动脉系统急性脑梗死的疗效及安全性,并评估不同TOAST分型急性脑梗死的疗效差异。方法选择颈内动脉系统急性脑梗死患者51例,分为溶栓组33例(其中起病3 h内者25例,3～4.5 h者8例)和对照组18例,溶栓组予rt-PA0.9 mg/kg静脉溶栓,对照组予常规治疗。观察比较两组患者治疗前、治疗后(2 h、24 h、7 d、90 d)的神经功能缺损程度(NIHSS)评分以及治疗前、治疗后(7 d、90 d)的Barthel指数(BI),并将3 h溶栓组按TOAST分型分亚组进行分层分析。结果①3 h溶栓组治疗后2 h、24 h、7 d的NIHSS评分与治疗后7d、90 d的BI均较治疗前有统计学差异(P<0.05),且与对照组比较90 d的BI有统计学差异(P<0.05);②3～4.5 h溶栓组治疗后7 d NIHSS评分和90 d后BI较治疗前有统计学差异(P<0.05),且与对照组比较24 h、7 d NIHSS评分与90 d BI有统计学差异(P<0.05);③3 h溶栓组亚组分析提示大动脉粥样硬化组(LAA组)治疗后2 h、治疗后7 d的NIHSS评分与治疗后90 d的BI评分较治疗前有统计学差异(P<0.05);心源性栓塞组(CE组)治疗后2 h的NIHSS评分与90 d的BI评分较治疗前有统计学差异(P<0.05);小动脉闭塞组(SAA组)治疗后的NIHSS评分与治疗后BI评分均较治疗前无统计学差异(P>0.05);④3 h溶栓组出血事件的发生率高于对照组(P<0.05),而出现脑疝、死亡等不良事件的发生率相当(P>0.05)。亚组分析显示CE组的出血事件发生率高于LAA组和SAA组(P<0.05)。结论3 h内rt-PA静脉溶栓治疗可显著改善神经功能缺损症状和预后,出血风险较对照组增加。小样本3～4.5 h溶栓病例也取得了较好的临床疗效。3 h溶栓组亚组分析显示LAA组疗效优于CE组,而SAA组疗效欠佳。CE组的出血风险高于LAA组和SAA组。

Objective To study the efficacy and safety of recombinant tissue plasminogen activator（rt-PA）on the treatment of acute anterior circulation infarction and to analyze the difference of stroke subtypes on the base of TOAST classification.MethodsThere were 51 patients of acute anterior ciculation infarction who were divided into thrombolysis group（33 cases）and control group（18 cases）.Among the thrombolysis group,25 cases were adminstered with rt-PA within 3 h onset of stroke and 8 cases were adminstered with rt-PA within 3 to 4.5 h in a dose of 0.9 mg/kg body weight.The control group was given the conventional therapy.A contrast of the NIHSS score,Barthel Index（BI）was made before treatment and on the different time after treatment.And the TOAST subtype analysis was done in the 3 h thrombolysis group.Results①There was a significant difference between before and after the treatment in the 3 h thrombolysis group by all the NIHSS and BI（P0.05）.And there was a significant difference between the 3 h thrombolysis group and the control group by the BI of 90 d.②There was a significant difference between before and after the treatment in the 3 to 4.5 h thrombolysis group by the NIHSS of 7 d and BI of 90 d（P0.05）.③The TOAST subtypes analysis showed that there was a significant difference between before and after the treatment in the large-artery atherosclerotic（LAA）group by the NIHSS of 2 h,7 d and BI of 90 d（P0.05）.And there was a significant difference between before and after the treatment in the cardio embolism（CE）group by the NIHSS of 2 h and BI of 90 d（P0.05）.However,there was no significant difference in the lacunare（SAA）group by all the NIHSS and BI（P0.05）.④The incidence of hemorrhage in 3 h thrombolysis group was higher than that of the control group,while the incidence of harmful event such as brain hernia and death was no significant difference between the two groups.The TOAST subtypes analysis showed that the incidence of hemorrhage of the CE group was higher than that of the SAA group and the LAA group.ConclusionIn 3 h thrombolysis group,intravenous thrombolysis with rt-PA is effective in spite of higher incidence of hemorrhage.And the small sample of 3-4.5 h group also has good result.Subtype analysis shows that the therapeutic effect of the SAA group might be better than that of CE group,while the therapeutic effect of LAA group is poor.And the CE group might have higher incidence of hemorrhage.