急性缺血性卒中患者静脉溶栓后24小时血压变异与血流再灌注的相关性研究

Relationship between early blood pressure variability and reperfusion in acute ischemic stroke patients with intravenous thrombolysis

目的：明确急性缺血性卒中患者静脉溶栓后24h血压变异对脑组织再灌注以及3个月后神经功能结局的影响。方法：连续收集2009年6月至2014年9月期间在浙江大学医学院附属第二医院行多模式MRI检查或CT灌注扫描，接受静脉溶栓治疗的急性缺血性卒中患者的临床、影像、溶栓后24h内动态血压监测资料，评估溶栓后24h再灌注情况及3个月改良Rankin评分。记录血压均值和变异指标，后者包括标准差（sd）、连续变异度（SV）、上升变异（sv-rise）和下降变异（sv-drop）。采用二元logistic回归分析血压变异指标对再灌注及神经功能结局的影响。结果：最终纳入188例患者，其中114例（60．6％）达到再灌注，74例（39．4％）未达到再灌注。二元logistic回归分析提示，静脉溶栓后24h内收缩压连续变异（SBPsv），尤其是上升变异（SBPsv—rise）较大者不易达到再灌注（SV：OR=0．421，95％CI：0．187—0．950，P=0．037；sv—rise：OR=0．311，95％凹：0．137～0．704，P=0．005）。同时，静脉溶栓后24hSBPsv—rise高者不易达到早期神经功能恢复（OR=0．372，95％CI：0．166～0．832，P=0．016）；SBPsv、SBPsv-rise和SBPsv—drop是溶栓治疗3个月后患者神经功能不良结局的独立危险因素（SV：OR=6．381，95％a：2．132～19．096，P=0．001；SV．rise：OR=5．615．95％CI：2．152～14．654，P〈0．001；sv．drop：OR=3．009，95％CI：1．263～7．169，P=0．013）。结论：急性缺血性卒中患者早期收缩压变异越大越不利于脑组织再灌注和早期神经功能恢复，并与静脉溶栓治疗后3个月患者神经功能不良结局有关。

Objective ： To investigat the impacts of blood pressure （BP） variability on reperfusion and long-term outcome in patients with acute ischemic stroke after intravenous thrombolysis （IVT）. Methods： The clinical data of 188 patients with acute ischemic stroke receiving IVT in Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine from June 2009 to September 2014, including hour-to-hour BP measurements, clinical manifestations, laboratory tests and radiologic findings were retrospectively analyzed. The mean 24-h BP values, and BP variability profiles, including standard deviation （sd）, average squared difference between successive measurements （sv） , average squared difference between rise and drop successive measurements （sv-rise and sv-drop ） were calculated. Reperfusion, defined as 〉 50% reduction in Tmax 〉 6 s perfusion lesion volume from baseline to follow-up scans, and clinical neurological outcome based on modified Rankin scale （mRS） at 3 months after onset were also analyzed. The favorable outcome was defined as mRS 0-1 and unfavorable outcome as mRS 2-6. The binary logistic-regression model was performed to determine the independent risk factors of reperfusion and favorable outcome, respectively. Results： Among 188 patients, 114 （60. 6%） achieved reperfusion. During the 0-to-24 h blood pressure course, only systolic blood pressure （SBP） variability parameters were negatively correlated with reperfusion （sv： OR = 0.421, 95%CI：0. 187 -0. 950, P =0.037; sv-rise： OR =0. 311, 95% CI：0. 137 - 0.704, P = 0. 005） and long-term clinical outcomes （sv： OR = 6. 381, 95% CI： 2. 132 - 19. 096, P = 0. 001 ; sv-rise ： OR = 5. 615, 95% CI： 2. 152 - 14. 654, P 〈 0. 001 ; sv-drop： OR = 3. 009, 95% CI： 1. 263 - 7. 169, P = 0. 013 ）. Conclusion： SBP variability during the first 24 hours after IVT is negatively associated with cerebral reperfusion and unfavorable neurological outcome in patients with acute ischemic stroke receiving IVT.