多模式CT指导下静脉溶栓治疗觉醒型缺血性卒中的效果

Efficacy of intravenous thrombolysis for the treatment of wake-up ischemic stroke under the guidance of multimode CT

目的观察多模式CT指导下应用重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗觉醒型缺血性卒中(WUS)患者的疗效及安全性。方法回顾性纳入自2012年10月至2014年10月湖北省十堰市中西医结合医院神经内科收治的,经多模式CT影像学筛查,适合静脉溶栓的WUS患者18例(溶栓组)。另回顾性纳入2010年2月至2012年2月行多模式CT影像学筛查,适合静脉溶栓但因超过时间窗或拒绝溶栓等原因而未行溶栓的WUS患者20例(对照组)。对照组采用缺血性卒中常规治疗方法;溶栓组给予rt-PA 0.9 mg/kg静脉溶栓治疗,分别观察治疗前及治疗后24 h,7、14 d的纤维蛋白原(Fib)、凝血功能[凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)]、血小板计数(PLT)、高敏C反应蛋白(hs-CRP)、美国国立卫生研究院卒中量表(NIHSS)评分、生活能力评分(Barthel指数)等指标,记录不良事件及并发症,并与对照组进行比较。结果溶栓组与对照组治疗前Fib、PT、APTT、PLT、hs-CRP、NIHSS评分、Barthel指数比较,差异均无统计学意义(均P>0.05);溶栓组治疗后7、14 d,与治疗前比较,Fib(治疗后14 d)、PLT、hs-CRP均降低,PT、APTT均延长,NIHSS评分均降低,Barthel指数均升高,差异均有统计学意义(均P<0.05);治疗后14 d时,两组Fib、PT、APTT、hs-CRP、NIHSS评分、Barthel指数比较,差异均有统计学意义[Fib:(3.25±0.38)g/L比(3.55±0.28)g/L;PT:(15.7±3.2)s比(12.9±2.5)s;APTT:(42.7±3.5)s比(38.7±2.6)s;PLT:(189±26)×109/L比(201±23)×109/L;hs-CRP:(5.7±0.6)mg/L比(11.3±2.2)mg/L;NIHSS评分:(5.6±2.4)分比(9.2±4.5)分;Barthel指数:(68±15)分比(47±5)分;均P<0.05]。溶栓组除1例溶栓后发生症状性脑出血外,无其他严重并发症发生。对照组1例出现应激性胃溃疡并胃出血,未发生症状性脑出血。结论多模式CT指导可作为WUS患者扩大静脉溶栓时间窗的可靠影像学依据,在多模式CT指导下应用rt-PA静脉溶栓治疗有一定疗效。

Objective To observe the efficacy and safety of recombinant tissue type plasminogen activator（ rt-PA） for the treatment of the patients with wake-up ischemic stroke（ WUS） under the guidance of multimode CT. Methods Eighteen patients with WUS（ a thrombolytic group） suitable for intravenous thrombolysis after multimode CT imaging screen at the Department of Neurology,Shiyan Hospital of Integrated Traditional and Western Medicine,Hubei Province from October 2 0 1 2 to October 2 0 1 4 were enrolled retrospectively. Twenty patients with WUS（ a control group） who underwent multimode CT imaging screen were suitable for intravenous thrombolysis,but because of exceeding time window or rejecting thrombolysis and other reasons without having intravenous thrombolysis from February 2012 to February 2014 were enrolled retrospectively. The control group was treated with conventional therapy and the thrombolytic group was treated with rt-PA（ 0. 9 mg / kg） intravenous thrombolytic therapy. The indicators including fibrinogen（ Fib）,coagulation function（ prothrombin time [PT]）,activated partial thromboplastin time（ APTT）,platelet（ PLT）,high-sensitivity C-reactive protein（ hs-CRP）,National Institute of Health Stroke Scale（ NIHSS） scores,and activities of daily living scores（ Barthel index） at before treatment and 24 h,7 and14 days after treatment were observed respectively. The adverse events and complications were documented and compared with the control group. Results There were no significant differences in Fib,PT,APTT,PLT,hs-CRP,NIHSS score and Barthel index before treatment between the thrombolytic group and the control group（ all P 0. 05）; at day 7 and 14 after treatment in the thrombolytic group,compared with before treatment,Fib（ 14 d after treatment）,PLT,and hs-CRP were decreased,PT and APTT were prolonged,the NIHSS scores were decreased,and Barthel indexes were increased. There were significant differences（ all P 0. 05）. At day 14 after treatment,there were significant differences in Fib,PT,APTT,hs-CRP,NIHSS scores,and Barthel indexes（ Fib： 3. 25 ± 0. 38 g / L vs. 3. 55 ± 0. 28 g / L; PT： 15. 7 ± 3. 2 s vs. 12. 9 ± 2. 5 s;APTT： 42. 7 ± 3. 5 s vs. 38. 7 ± 2. 6 s; PLT： [189 ± 26] × 109/ L vs. [201 ± 23] × 109/ L; hs-CRP： 5. 7 ±0. 6 mg / L vs. 11. 3 ± 2. 2 mg / L; NIHSS scores： 5. 6 ± 2. 4 vs. 9. 2 ± 4. 5; and Barthel indexes： 68 ± 15 vs.47 ± 5） between the two groups（ all P 0. 05）. Except 1 patient occurred symptomatic intracerebral hemorrhage after thrombolysis,no other serious complications were observed in the thrombolytic group.One patient in the control group had stress gastric ulcer and bleeding,no symptomatic intracerebral hemorrhage occurred. Conclusion Multimode CT guidance can be used as a reliable imaging evidence for patients with WUS expanding intravenous thrombolytic time window. Under the multimode CT guidance,using rt-PA for intravenous thrombolytic therapy has a certain efficacy.