伴有中重度脑白质疏松的急性脑梗死患者静脉溶栓疗效分析

Influence of intravenous thrombolysis on prognosis of acute ischemic stroke in patients with moderate to severe leukoaraiosis

目的 探讨合并中重度脑白质疏松（LA）的急性脑梗死患者接受rt-PA静脉溶栓治疗后的安全性及肢体运动功能恢复状况，并分析影响肢体运动功能的因素。方法 回顾性分析就诊于常州市第二人民医院急诊科或神经内科合并中重度LA的急性大脑中动脉M1段闭塞患者101例，根据是否溶栓分为溶栓组和未溶栓组，采用简式Fugl-Meyer量表（FMS）评估患者肢体运动功能及美国国立卫生研究院卒中量表（NIHSS）评估患者神经功能；比较两组间的基线资料、各时间点的NIHSS评分、FMS评分、90 d mRS评分、出血转化及症状性颅内出血比例、90 d病死率及再发卒中比例；根据90 d随访，记录各时间点主要终点事件（包括再发卒中及死亡）及次要终点事件（其他血管疾病）的发生情况，并分析影响肢体运动功能的危险因素。结果 共纳入101例MCA M1段闭塞患者，其中溶栓组37例（36.6%），未溶栓组64例（63.4%）。溶栓组出血转化及症状性颅内出血比例明显高于未溶栓组[32.4%（12/37）比9.4%（6/64），χ2＝8.511，P＝0.004；13.5%（5/37）比1.6%（1/64），χ2 ＝5.993，P＝0.014]；但各时间点的NIHSS评分及治疗前后的FMS评分方面差异无统计学意义。两组患者90 d后的FMS评分较入院FMS评分虽稍有升高[（83±9）分比（80±12）分；（86±8）分比（80±10）分]，但差异无统计学意义。主要终点事件发生率为31.9%（32/101），再发梗死18例（17.8%），死亡14例（13.9%），其中溶栓组发生率32.4%（12/37）与未溶栓组31.3%（20/64）比较，差异无统计学意义。多因素线性回归分析发现，症状性颅内出血（t＝－2.318; P＝0.023）、入院NIHSS评分（t＝－4.263; P＝0.000）、再发梗死（t＝－9.114; P＝0.000）及出血转化（t＝－2.121; P＝0.037）是影响中重度LA急性脑梗死患者肢体运动功能恢复的危险因素，但溶栓的选择不是影响患者肢体运动功能恢复的危险因素（t＝0.328; P＝0.744）。结论 对于合并中重度LA的急性脑梗死患者静脉溶栓可增加出血转化及症状性颅内出血的风险，而肢体运动功能的恢复与溶栓的选择无明显相关性。

Objective To investigate the influence of intravenous thrombolysis on prognosis of acute ischemic stroke in patients with moderate to severe leukoaraiosis and to analyze influencing factors of the clinical prognosis.Methods We consecutively included acute ischemic stroke patients with middle cerebral artery occlusion （n=101） from Department of Neurology or Emergency, and patients were divided into two groups according to whether on intravenous thrombolysis therapy （IVT） or not. The Fugl-Meyer scale score （FMS） was used to assess motor function outcome and the National Institutes of Health Stroke Scale （NIHSS） score was used to assess neurologic function. Clinical data were obtained and compared between the two groups. Patients were followed up for 90 days, the primary clinical endpoint events included stroke recurrence and death, and the key secondary endpoint events included other vascular events after IVT. Multivariate linear regression analysis was used to analyze the relevant factors influencing the motor function 90 days later.Results Among the 101 enrolled patients, 37 （36.6%） were classified as IVT group and 64 （63.4%） as no IVT group. In IVT group, hemorrhagic transformation and symptomatic intracranial hemorrhage were observed in 32.4% （12/37） and 13.5% （5/37） of the patients, which were higher than those in the no IVT group （9.4% （6/64） and 1.6% （1/64） , respectively） （χ2=8.511, P=0.004; χ2=5.993, P=0.014）. And there was no significant difference between the two groups in NIHSS score and FMS score at any time point. In addition, there was no significant increase in 90-day FMS score in the two groups compared with the FMS score on admission （83±9 vs 80±12; 86±8 vs 80±10）. After followed up for 90 days, the primary clinical endpoints were obtained in 32 patients （32/101; 31.9%）, including 18 cases of stroke recurrence （18/101; 17.8%） and 14 cases of death （14/101; 13.9%）. No significant difference was found in primary clinical endpoints between the two groups. Multivariate linear regression analysis revealed that symptomatic intracranial hemorrhage （t=-2.318; P=0.023）, baseline NIHSS score （t=-4.263; P=0.000）, recurrent stroke （t=-9.114; P=0.000） and hemorrhage transformation （t=-2.121; P=0.037） were risk factors of poor 90-day motor function recovery, but not application of intravenous thrombolysis therapy （t=0.328; P=0.744）.Conclusions Acute ischemic stroke patients with moderate to severe LA have higher risk of hemorrhagic transformation and symptomatic intracranial hemorrhage after intravenous thrombolysis. However, there is no association of intravenous thrombolysis therapy with motor function recovery.