急性缺血性卒中机械取栓后出血性转化和临床转归的影响因素

Influencing factors of hemorrhagic transformation and clinical outcomes in acute ischemic stroke after mechanical thrombectomy

目的探讨急性缺血性卒中患者机械取栓治疗后出血性转化（hemorrhagictransformation，HT）和转归不良的危险因素。方法回顾性纳入接受机械取栓治疗的急性缺血性卒中患者，收集患者的人口统计学、血管危险因素和其他临床资料，应用改良Rankin量表（modifiedRankinScale，mRS）评价发病90d时临床转归，转归良好定义为mRS评分0～2分。根据HT情况将患者分为HT组和非HT组，根据mRS评分将患者分为转归良好组和转归不良组。应用多变量logistic回归分析确定HT和转归不良的独立危险因素。结果共纳入48例接受机械取栓治疗的急性缺血性卒中患者，男性25例（52．1％），平均年龄（64．77±9．14）岁，平均美国国立卫生研究院卒中量表（NationalInstitutesofHealthStrokeScale，NIHSS）评分（17．70±3．77）分。22例（45．8％）发生HT，其中9例为有症状HT；24例（50．0％）转归良好。HT组男性比例显著低于非HT组（30．4％对 72．0％ x2=8．293，P=0．004），而糖尿病（65．2％对36．0％；X2=4．090，P=0．043）和心房颤动（78．3％对44．O％；x2=5．880，P=0．015）的患者比例以及基线空腹血糖水平[（8．514±4．400）mmol／L对（6．354±1．472）mmol／L；t=2．319，P=0．025]则显著高于非HT组。多变量logistic回归分析显示，心房颤动[优势比（oddsratio，OR）6．136，95％可信区间（confidenceinterval，c1）1．617-23．291；P=0．042]是机械取栓后发生HT的危险因素。转归良好组基线NIHSS评分[（16．050±4．865）分对（19．210±4．423）分；t=2．354，P=0．023]以及糖尿病（29．2％对70．8％；X2=8．333，P=0．004）、前循环卒中（62．5％对87．5％ x2=4．000，P=0．046）、大脑中动脉闭塞（29．2％对75．0％；x2=10．101，P=0．002）和脑实质血肿（4．1％对3．3％；P=0.011）患者比例显著低于转归不良组，而心房颤动（75．0％对45．8％ x2=4．269，P=0．039）和椎基底动脉闭塞（37．5％对12．5％ x2=10．113，P=0．006）患者比例显著高于转归不良组。多变量logistic回归分析显示，糖尿病（OR5．898，95％CI1．699～20．479；P=0．005）、基线NIHSS评分（OR1．167，95％CI1．011～1．347；P=0．035）和脑实质血肿（OR1．295，95％CI1．099～1．875；P=0．028）是转归不良的独立危险因素。结论心房颤动是急性缺血性卒中患者机械取栓治疗后HT风险的独立预测因素。糖尿病、基线NIHSS评分较高和并发脑实质血肿是转归不良的独立预测因素。因此，在对急性缺血性卒中患者开展机械取栓治疗前应充分评估其HT和转归不良风险。

Objective To investigate the risk factors for hemorrhagic transformation （HT） and poor outcomes in patients with acute ischemic stroke after mechanical thrombectomy.Methods The patients with acute ischemic stroke received mechanical thrombectomy were enrolled retrospectively. The demography, vascular risk factors and other clinical data of the patents were collected. The modified Rankin scale （mRS） was used to evaluate the clinical outcomes at day 90. Good outcome was defmed as mRS score 0-2. The patients were divided into either a HT group or a non-HT group according to their- HT conditions. Multivariate logistic regression analysis was used to identify the independent risk factors for HT and poor outcomes. Results A total of 48 patients with acute ischemic stroke received mechanical thrombectomy were enrolled, including 25 males （52.1%）. Their mean age was 64. 77 ± 9. 14 years. The mean National Institutes of Health Stroke Scale （NIHSS） score was 17.70 ± 3.77. Twenty-two patients （45.8%） occured HT, of which 9 were symptomatic HT; 24 （50.0%） had good outcomes. The proportion of males in the HT group was significantly lower than that in the non-HT group （30. 4%vs. 72.0%;X2 = 8. 293, P = 0. 004）, while the proportions in patients with diabetes （65.2% vs. 36. 0%;X2 =4. 090, P=0. 043） and atrial fibrillation （78.3% vs. 44. 0% ;X2 =5. 880, P =0. 015）, as well as the baseline fasting blood glucose level （8. 514± 4. 400 mmol/L vs. 6. 354 ± 1. 472 mmol/L; t = 2. 319, P = 0. 025） were significantly higher than those in the non-HT group. Multivariate logistic regression analysis showed that the atrial fibrillation （odds ratio [ OR] 6. 136, 95% confidence interval [ CI] 1. 617-23.291 ; P =0. 042） was a risk factor for the occurrence of HT after mechanical thrombectomy. The proportion of diabetic patients （29.2% vs. 70. 8% ; X2 =8. 333,.P = 0. 04） and baseline NIHSS score （16. 050 ± 4. 865 vs. 19. 210 ± 4. 423）; t = 2. 310, P = 0. 026） of the good outcome group were significantly lower than those of the poor outcome group, while the proportions of patients in atrial fibrillation （75.0% vs. 45.8% ;X2 =4. 269, P =0. 039）, anterior circulation stroke （87.5% vs. 62. 5% ;X2 =4. 000, P =0. 046） middle cerebral artery （75.0% vs. 29. 2% ;X2 = 10. 113, P = 0. 006）, vertebral basilar artery （37. 5% vs. 12. 5% ;X2 =10. 113, P =0. 006） occlusion and parenchymal hematoma （33.3% vs. 4.1%; P= 0.011） were significantly higher than the poor outcome group. Multivariate logistic regression analysis showed that diabetes （OR 5. 898, 95% CI 1. 699-20. 479; P= 0. 005）, baseline NIHSS score （OR 1. 167, 95% CI 1. 011-1. 347; P =0. 035）, and parenchymal hematoma （OR 1. 295, 95% CI 1. 099-1. 875; P= 0. 028） were the independent risk factors for poor outcomes. Conclusions Atrial fibrillation is an independent predictor of HT risk in patients with acute ischemic stroke after mechanical thrombectomy. Diabetes mellitus, higher baseline NIHSS score, and concurrent brain parenchymal hematoma are the independent predictors of poor outcomes. Therefore, the risk of HT and adverse outcomes should be fully assessed before mechanical thrombectomy in patients with acute ischemic stroke.