同型半胱氨酸水平与急性缺血性脑卒中老老年患者溶栓预后相关性分析

Correlation in homocysteine level and the prognosis of acute ischemic stroke in old elderly patients after intravenous thrombolysis

目的探讨血清同型半胱氨酸(homocysteine,Hcy)水平与重组组织型纤溶酶原激活剂(recombinant tissue plasminogen activator,rt-PA)溶栓治疗急性缺血性脑卒中(acute ischemic stroke,AIS)老老年患者预后的关系。方法收集符合研究入选标准患者47例,并依据Hcy水平分为Hcy高水平(≥18.54μmol/L)组(A组)24例和Hcy低水平组(<18.54μmol/L)组(B组)23例,分析2组年龄、性别、脑血管疾病危险因素、起病至静脉溶栓时间、血糖、血脂、尿酸、纤维蛋白、血红蛋白、血小板计数、卒中类型和临床结局等指标。所有患者在溶栓治疗24h后行CT/MRI检查以排除脑出血。采用美国国立卫生研究院卒中量表(National Instituteof Health Stroke Scale,NIHSS)与改良Rankin量表(Modified Rankin Scale,MRS)评估神经功能,以溶栓治疗90d后MRS评分≥4分为预后不良。分析影响急性缺血性脑卒中溶栓患者预后的危险因素,并计算Hcy预测预后的潜在界值。结果 2组Hcy水平均高于正常,其水平与糖尿病、吸烟、饮酒、尿酸及血红蛋白有关。治疗1周后,Hcy高水平组NIHSS评分明显高于低水平组(P<0.05),且高水平组24h后症状性出血转化风险增加(P<0.05)。治疗3个月后与Hcy低水平组相比,Hcy高水平组MRS评分较低、临床结局较差(P<0.05)。Hcy水平和初始NIHSS评分是AIS老老年患者接受rt-PA溶栓治疗预后不良的危险因素,Hcy预测预后不良的潜在最佳界值可能为21.35μmol/L(敏感度78.6%,特异度63.3%)。结论 Hcy高水平可能是AIS老老年患者接受rt-PA溶栓治疗预后不良的潜在独立预测因子,最佳界值是21.35μmol/L。

Objective To investigate the relationship between serum homocysteine（Hcy）level and prognosis of acute ischemic stroke（AIS）in the old elderly patients who received thrombolysis of recombinant tissue plasminogen activator（rt-PA）.Methods Forty-seven patients were recruited according to the research criteria and were grouped by their serum Hcy levels.The patients were divided into 24 cases in the high level（Hcy≥18.54μmol/L）group（group A）and23 cases in the low level（Hcy〈18.54μmol/L）group（group B）.The data including age,sex,cerebrovascular disease risk factors,onset to needle time,blood glucose level,blood lipids levels,uric acid level,fibrinogen level,hemoglobin level,platelets count,stroke subtypes and clinical outcome were analyzed.All patients took CT/MRI examination to detect cerebral hemorrhage in 24 hours after rt-PA treatment.Neurological function was evaluated by National Institute of Health Stroke Scale（NIHSS）score and modified Rankin Scale（MRS）score.The clinical outcome was scored according to the MRS and considered as poor when the MRS score was equal or greater than 4 after 90 days of thrombolysis.Risk factors influencing the prognosis of patients with acute ischemic stroke after thrombolysis were assessed and cut-off values of Hcy were calculated if Hcy level can be used as an index to predict the outcome.Results The Hcy mean level of all patients was higher than normal,which were associated with diabetes,smoking,alcohol consumption,uric acid level and hemoglobin level.After 1-week rt-PA treatment,the NIHSS scores of high Hcy level group were significantly higher than those of low level group（P〈0.05）,meantime the high Hcy group showed obvious symptomatic intracerebral hemorrhage risk after 24 hours（P〈0.05）.Poor outcome was presented in MRS score results after 3 months in high Hcy level group,compared with low Hcy level group（P〈0.05）.The Hcy level and initial NIHSS score were risk factors for poor prognosis in old elderly patients with AIS receiving thrombolytic treatment of rt-PA with apotentially optimal cut-off value of Hcy at 21.35μmol/L（sensitivity 78.6%,specificity 63.3%）.Conclusion Elevated Hcy level is a potential independent predicter of poor prognosis in the old elderly patients with AIS after rt-PA treatment,while the probable optimal cutoff value is 21.35μmol/L.