磁共振成像指导觉醒型卒中患者静脉溶栓的安全性及预后分析

ANALYSIS OF THE SAFETY AND PROGNOSIS OF INTRAVENOUS THROMBOLYSIS IN PATIENTS WITH WAKE UP STROKE BY MAGNETIC RESONANCE IMAGING

目的分析以磁共振成像DWI-FLAIR不匹配指导觉醒型卒中患者静脉溶栓治疗安全性及预后。方法选择华北理工大学附属医院2012年9月—2015年10月住院的缺血性脑卒中患者247例。根据发病时间是否明确分为觉醒型卒中组（觉醒组）和缺血性卒中组（明确发病组）,其中觉醒组64例,明确发病组183例。二组患者入院后均行16层颅脑CT检查以排除脑出血。对于发病时间不确定的患者需另行MRI＋DWI检查。对二组中符合预先设定的临床入选标准,并且无溶栓禁忌证的患者给予重组组织型纤溶酶原激活物（rt-PA）溶栓治疗。溶栓治疗的安全性通过溶栓后脑出血来评价;预后采用90d mRS评分和90d死亡率来评价。采用t检验和χ2检验分析觉醒型卒中患者溶栓治疗的安全性和预后。结果二组患者在性别、年龄、入院时NIHSS评分及发病危险因素方面差异均无统计学意义（P均〉0.05）。二组患者溶栓治疗后症状性颅内出血（sICH）发生率分别为3.12%和2.79%,差异无统计学意义;轻微颅内出血发生率分别为6.25%和9.50%,差异无统计学意义。二组患者90d mRS评分0~1分分别为35.94%和37.99%（χ2=0.085,P=0.771）、90d mRS评分0~2分分别为53.12%和63.13%（χ2=1.974,P=0.160）差异均无统计学意义。二组患者90d病死率分别为3.12%和1.68%,差异无统计学意义（χ2=0.035,P〉0.05）。结论根据患者发病时间来作为溶栓治疗的时间窗,可能会有相当一部分觉醒型卒中患者被排除于溶栓治疗之外。以DWI-FLAIR指导下的静脉溶栓治疗是安全、有效的,并不增加脑出血的风险,可以改善患者的预后;对于觉醒型卒中以DWI-FLAIR不匹配进行筛查,仍有一部分患者可通过溶栓治疗获益。

Objective To analyze the safety and prognosis of intravenous thrombolytic therapy in patients with wake up stroke by magnetic resonance imaging （MRI）. Methods Two hundred and forty- seven pa- tients with ischemic stroke admitted in author＇s hospital from September 2012 to October 2015, which were divided into wake- up groups （n = 64） and clear- onset time stroke group（n = 183） according to whether know the onset time of their disease. The baseline data of two groups were collected tocompare the differ- ence between the two groups. The two groups of patients were excluded intracranial hemorrhage by 256 lay- ers of brain CT examination. If the patients do not clear the time of onset, MRI and DWI need to be per- formed. Patients in the two groups were in accordance with the preset clinical inclusion criteria, and no ex- clusion criteria were given to the patients with recombinant tissue type plasminogen activator （rt- PA）. The safety of thrombolytic therapy was evaluated by cerebral hemorrhage after thrombolysis, and the prog- nosis was evaluated by mRS score and mortality rate after 90 days. T test and Chi square test were used to analyze the safety and efficacy of thrombolytic therapy in wake up stroke patients. Results There was no significant difference in gender, age, the NIHSS score and risk factors between the two groups （P〉0.05）. There was no significant difference in the incidence of cerebral hemorrhage after thrombolytic therapy be- tween the two groups （sICH： 3.1% vs. 2.8%; minor incidence of intracranial hemorrhage： 6.3% vs.9.5%）. Two groups of patients 90 days mRS score 0-1 were 35.9% vs 38.0% （P=0.771）, 90 days mRS score 0 - 2 were 53.1% vs 63.1% （P = 0. 160）, the difference was not statistically significant. Two groups of patients 90 days mortality rates were 3.1% and 1.7%,respectively,the difference was not statis- tically significant（P〉0.05）. Conclusions Quite a few wake-up stroke patients are excluded from throm- bolytic therapy according to the onset time as the time window for thrombolytic therapy. Intravenous thrombolytic therapy under the guidance of the DWI- FLAIR is safe and effective, does not increase the risk of cerebral hemorrhage and prognosis of patients can be improved. For the wake up stroke b） DWI- FLAIR mismatch, there are still some patients can benefit from thrombolytic therapy.