进展性缺血性卒中预测指标的临床研究

Clinical study of predictors for progressive ischemic stroke

目的研究进展性缺血性卒中的预测指标,为早期识别及治疗进展性卒中提供科学依据。方法连续收集2013年1月至2015年3月北京航天总医院神经内科收治的202例急性缺血性卒中患者的临床资料,并进行回顾性分析。根据美国国立卫生院脑卒中量表（NIHSS评分）将202例患者分为进展性卒中115例（PIS组）和非进展性卒中87例（NPIS组）。观察两组患者一般情况、既往史、入院后24 h内的检验结果、超声影像学及并发症等指标,采用SPSS 17.0软件进行t检验和χ~2检验,对差异有统计学意义的指标进行多因素logistic回归分析,筛选进展性卒中的危险因素。对比两组患者在不同脑梗死分型中进展性卒中的发病率。结果 PIS组高血压史、糖尿病史、高脂血症史、并发感染、消化道出血、发热、急性肾功能不全、治疗后低血压、脑梗死后出血、颈动脉狭窄及不稳定斑块等发生率高于NPIS组,差异均有统计学意义（P〈0.05,P〈0.01）;PIS组患者糖化血红蛋白（Hb Al C）、空腹血糖（FPG）、总胆固醇（TC）、低密度脂蛋白胆固醇（LDL-C）、超敏C反应蛋白（hs-CRP）、脑利钠肽（BNP）、纤维蛋白原（FI）、D-二聚体（D-D）及平均动脉压（MAP）、收缩压（SBP）、舒张压（DBP）等均明显高于NPIS组,差异均有统计学意义（P〈0.05,P〈0.01）。多因素logistic回归分析结果显示,糖尿病（OR=7.011,95%CI：2.313~21.253）、颈动脉狭窄率（OR=1.029,95%CI：1.002~1.058）、脑梗死病灶的最大直径（OR=1.728,95%CI：1.048~2.850）、MAP（OR=1.030,95%CI：1.002~1.060）、FPG（OR=1.360,95%CI：1.011~1.829）、TC（OR=1.803,95%CI：1.217~2.673）、FI（OR=2.490,95%CI：1.437~4.315）、D-D（OR=1.002,95%CI：1.000~1.004）、hs-CRP（OR=1.118,95%CI：1.017~1.206）和BNP（OR=1.001,95%CI：1.000~1.002）是影响进展性卒中的高危因素,差异均有统计学意义（P〈0.05,P〈0.01）。在进展性卒中组中完全性前循环梗死（46.95%）及大血管硬化闭塞（51.30%）发生率最高。结论糖尿病、颈动脉狭窄、梗死最大直径及MAP、FPG、TC、FI、D-D、hs-CRP、BNP水平的升高是进展性卒中的独立危险因素,是预测进展性卒中的敏感指标。大面积前循环脑梗死也是预示卒中患者病情进展的重要因素之一。

Objective To study the predictors for progressive ischemic stroke, and to provide the scientific basis for early identification and treatment of progressive ischemic stroke. Methods From January of 2013 to March of 2015, 202 cases with acute ischemic stroke in Beijing aerospace general hospital served as the subjects, and retrospective analysis was performed.According to the NIHSS stroke severity score of the United States, 202 cases were divided into progressive ischemic stroke group（PIS, 115 cases） and non-progressing ischemic stroke（NPIS, 87 cases） group. General condition, case history, test results within24 hours after admission, ultrasound imaging and complication indexes for two groups were observed. The t test, χ~2test and multivariate logistic regression were used to analyze the data with SPSS software to determine the risk factors and morbidities of progressive ischemic stroke for two groups. Results As compared with NPIS group, the history of hypertension or diabetes and hyperlipidemia, concurrent infections, gastrointestinal bleeding, fever, acute renal failure, low blood pressure after treatment,bleeding after cerebral infarction, carotid artery stenosis and unstable plaque in PIS group significantly enhanced（P〈0.05, P〈0.01）; and the levels of Hb A1 C, FPG,TC, LDL-C, hs-CRP, BNP, fibrinogen（FI）, d-dimer（D-D）, mean arterial pressure（MAP）,systolic blood pressure（SBP） and diastolic blood pressure（DBP） in PIS group significantly increased（P〈0.05, P〈0.01）. Multivariate logistic regression results showed that diabetes（OR=7.011,95%CI： 2.313-21.253）, MAP（OR=1.030, 95%CI： 1.002-1.060）, carotid artery stenosis rate（OR=1.029, 95%CI： 1.002-1.058）, maximum diameter of cerebral infarction（OR=1.728, 95%CI： 1.048-2.850）,FPG（OR=1.360, 95%CI： 1.011-1.829）, TC（OR=1.803, 95%CI： 1.217-2.673）, FI（OR=2.490, 95%CI： 1.437-4.315）, D-D（OR=1.002, 95%CI： 1.000-1.004）,hs-CRP（OR=1.118, 95%CI： 1.017-1.206） and BNP（OR=1.001, 95%CI： 1.000-1.002） were risk factors for progressive stroke（P〈0.05）. The morbidities（46.96% and 51.30%） of total anterior circulation infarct and large artery atherosclerosis in progressing stroke group were the highest. Conclusion Diabetes, carotid artery stenosis rate, maximum diameter of cerebral infarction and the elevated levels of MAP, FPG,TC, FI, D-D, hs-CRP and BNP are the independent risk factors for progressive stroke, also are the sensitive indicators of predicting the progressive ischemic stroke. Large area cerebral infarction in anterior circulation is also an important factor for predicting progression in stroke patients.