大脑中动脉闭塞部位对急性缺血性卒中患者静脉溶栓治疗后转归的影响

Effect of the locations of middle cerebral artery occlusion on outcomes after intravenous thrombolysis in patients with acute ischemic stroke

目的探讨大脑中动脉（middle cerebral artery, MCA）闭塞部位对急性缺血性卒中患者静脉重组组织型纤溶酶原激活剂（recombinant tissue plasminogen activator, rtPA）溶栓治疗后转归的影响。方法连续纳入在发病4.5 h内接受rtPA静脉溶栓治疗的急性MCA闭塞性卒中患者。将MCA闭塞部位分为MCA近段（M1近段）和MCA远段（M1远段、M2段及以远）。早期神经功能改善定义为溶栓后24 h美国国立卫生研究院卒中量表（National Institutes of Health Stroke Scale, NIHSS）评分较基线时改善≥4分或NIHSS评分为0分。根据90 d时改良Rankin量表（modified Rankin Scale, mRS）评分分为转归良好组（0～2分）和转归不良组（3～6分）。结果共纳入70例MCA闭塞缺血性卒中患者，其中MCA近段闭塞患者22例（31.4%），MCA远段闭塞患者48例（68.6%）；转归良好52例（74.3%），转归不良18例（25.7%）。MCA近段闭塞组心房颤动（χ^2＝4.541，P＝0.033）患者比例以及入院时（t＝5.192，P＝0.026）和溶栓后24 h时（t＝5.365，P＝0.024）NIHSS评分均高于MCA远段闭塞组。MCA近段闭塞组早期神经功能改善的患者比例显著低于MCA远段闭塞组（χ^2＝9.434，P＝0.002），而有症状颅内出血发生率（χ^2＝9.563，P＝0.002）和7 d内病死率（χ^2＝14.491，P〈0.001）均显著高于MCA远段闭塞组。转归不良组发病至溶栓时间（t＝6.346，P＝0.014）以及入院时（t＝4.498，P＝0.038）和溶栓后24 h时（t＝4.866，P＝0.028）NIHSS评分以及MCA近段闭塞的患者比例（χ^2＝18.710，P〈0.001）显著长于或高于转归良好组。多变量logistic回归分析显示，MCA近段闭塞[优势比（odds ratio, OR）14.385，95%可信区间（confidence interval, CI）2.525～81.925；P＝0.003]、发病至溶栓时间较长（OR 12.927，95% CI 2.624～61.748；P＝0.002）、溶栓后24 h时NIHSS评分较高（OR 3.492，95% CI 1.027～11.880；P＝0.045）是90 d时转归不良的独立预测因素。结论不同部位MCA闭塞患者静脉溶栓的转归存在差异。MCA闭塞部位、发病至溶栓时间、溶栓后24 h时NIHSS评分和年龄是MCA供血区急性缺血性卒中患者静脉溶栓后转归的独立预测因素。

Objective To investigate the effect of the location of middle cerebral artery （MCA） occlusion on outcomes after intravenous thrombolysis with recombinant tissue plasminogen activator （rtPA） in patients with acute ischemic stroke. Methods The consecutive patients with stroke of acute MCA occlusion treated with rtPA intravenous thrombolysis within 4. 5 h after onset were included. The locations of MCA occlusion were divided into either a proximal MCA segment （proximal M1 segment） or a distal MCA segment （distal M1 segment, M2 segment and more distally）. Early neurological improvement wasdefined as National Institutes of Health Stroke Scale （NIHSS） score improvement ≥4 points from baseline or NIHSS 0 point at 24 h after thrombolysis. They were divided into a good outcome group （0-2） and a poor outcome group （3-6） according to the modified Rankin Scale （mRS） scores. Results A total of 70 patients with MCA occlusion were enrolled in the study, including 22 （31.4%） with proximal MCA occlusion and 48 （68.6%） with distal MCA occlusion; 52 （74. 3% ） with good outcome and 18 （25.7%） with poor outcome. The proportion of atrial fibrillation （χ^2 = 4. 541, P = 0. 033）, the NIHSS scores on admission （t = 5.192, P = 0. 026） and 24 h after thrombolysis （t = 5.365, P = 0. 024） in the proximal MCA occlusion group were higher than those in the distal MCA occlusion group. The proportion of early neurological improvement in the proximal MCA occlusion group was significantly lower than that in the distal MCA occlusion group （χ^2 =9. 434, P =0. 002）, and the incidence of symptomatic intracranial hemorrhage （χ^2 =9. 563, P =0. 002） and the mortality rate within 7 d （χ^2 = 14. 491, P 〈0. 001） were significantly higher than those in the distal MCA occlusion group. The time from onset to thrombolysis （t = 6. 346, P = 0. 014）, NIHSS scores on admission （t =4. 498, P =0. 038） and at 24 h after thrombolysis （t =4. 866, P =0. 028）, and the proportion of proximal MCA occlusion （χ^2 = 18. 710, P 〈0. 001） in the poor outcome group were significantly longer or higher than those in the good outcome group. Multivariate logistic regression analysis showed that the proximal MCA occlusion （odds ratio [ OR] 14. 385, 95% confidence interval [ CI] 2. 525-81. 925; P = 0. 003）, longer time from onset to thrombolysis （OR 12. 927, 95% CI 2. 624-61. 748; P = 0. 002）, higher N/HSS score at 24 h after thrombolysis （OR 3.492, 95% CI 1.027-11.880; P= 0.045） were the independent predictors for poor outcome at 90 d. Conclusions There are differences in the outcomes after intravenous thrombolysis in patients with MCA occlusion at different locations. The locations of MCA occlusion, time from onset to thrombolysis, and NIHSS score at 24 h after thrombolysis, and age are the independent predictors for the outcomes after intravenous thrombolysis in patients with acute MCA ischemic stroke.