老年不同亚型急性脑梗死患者出血性转化影响因素的研究

Study on the risk factors for hemorrhagic transformation of the different subtypes of acute cerebral infarction in elderly patients

目的探讨急性脑梗死老年患者各亚型出血转化(HT)的影响因素。方法选取2014年1月至2016年12月长沙市某医院神经内科住院治疗的急性脑梗死老年患者(年龄≥60岁)共415例,其中出血转化者56例(观察组),未出血转化者359例(对照组),比较两组各亚型患者的一般人口学信息、既往病史、体格检查以及实验室指标、头颅CT/MRI检查、入院治疗情况以及治疗前后美国国立卫生研究院卒中量表(NIHSS)评分的差异,采用非条件Logistic回归分析急性脑梗死老年患者各亚型出血转化(HT)的影响因素。结果大动脉粥样硬化型HT的发生率为26.61%(29/109),心源性栓塞型发生率为47.50%(19/40),小动脉闭塞型中HT率为3.12%(8/257),此三型HT发生率比较差异有统计学意义(χ^2=77.923,P=0.000);不明原因型(0/7)与其他型(0/2)HT发生率均为0%。多因素Logistic回归分析结果显示,女性(OR=0.171,95%CI:0.037~0.790)是大动脉粥样硬化型HT的保护因素,糖化血红蛋白(HbA1c)水平高(OR=5.949,95%CI:1.199~29.509)、梗死灶面积大(OR=20.619,95%CI:2.869~148.207)是大动脉粥样硬化型HT的危险因素;入院时NIHSS评分高(OR=20.254,95%CI:1.605~255.625)、基质金属蛋白酶-9(MMP-9)浓度高(OR=91.200,95%CI:4.044~2056.710)是心源性栓塞型HT的危险因素;同型半胱氨酸(HCY)水平高(OR=10.231,95%CI:1.202~87.108)、梗死灶面积大(OR=15.251,95%CI:3.371~68.995)是小动脉闭塞型HT的危险因素。结论心源性栓塞型患者HT的发生率最高。各亚型脑梗死HT的影响因素不同,提示临床医生在治疗急性脑梗死患者时,应根据急性卒中治疗试验(TOAST)亚型合理选择治疗方案,尤其注意大动脉粥样硬化型的男性患者、HbA1c水平和梗死面积;注意心源性栓塞型患者的入院NIHSS评分和MMP-9浓度;密切观察小动脉闭塞型患者HCY水平以及梗死面积。

Objective To investigate the risk factors for hemorrhagic transformation(HT)of different subtypes of acute cerebral infarction in elderly patients. Methods A total of 415 elderly hospitalized patients aged ≥60 years with acute cerebral infarction were selected from a hospital in Changsha from January 2014 to December 2016 for the study.Among them, 56 had hemorrhagic transformation(observation group)and 359 had no hemorrhage transformation(control group). The general demographic information, past medical history, physical examination and laboratory indicators, cranial CT/MRI examination, admission treatment and the National Institutes of Health Stroke Scale(NIHSS)score on admission were analyzed and compared between two different subtypes.Multivariate Logistic regression was used to analyze the influencing factors for HT of different subtypes of acute cerebral infarction in elderly patients. Results The incidence of HT was 26.61%(29/109)for large-artery atherothrombosis, 47.50%(19/40)for cardiac embolism and 3.12%(8/257)for small-artery occlusion with a statistically significant differences among the three subtypes(χ2=77.923, P=0.000). The incidence of HT was 0%(0/7)for unknown type, and 0%(0/2)for other types.Multivariate logistic regression showed that female was the protective factor(OR=0.171, 95%CI: 0.037-0.790), but high level of glycated haemoglobin A1c(HbA1c)and large infarct size were the risk factors(OR=5.949 and 20.619, 95%CI: 1.199-29.509 and 2.869-148.207)for HT due to large-artery atherothrombosis.A high score of NIHSS and high level of matrix metalloproteinase-9(MMP-9)were the risk factors for HT due to cardioembolism(OR=20.254 and 91.200, 95%CI: 1.605-255.625 and 4.044-2056.710, respectively). A high level of homocysteine(Hcy)and large infarct size were the risk factors for HT due to small-artery occlusion(OR=10.231 and 15.251, 95%CI: 1.202-87.108 and 3.371-68.995, respectively). Conclusions The incidence of HT due to cardioembolism is the highest.Influencing factors for HT due to different subtypes of acute cerebral infarction are different in the elderly.It is important for clinicians to know that gender, HbA1c levels and infarct size are associated with HT due to large-artery atherothrombosis, NIHSS score on admission and MMP-9 concentration associated with HT due to cardioembolism, and Hcy level and infarct size associated with HT due to small-artery occlusion.