阿替普酶静脉溶栓治疗不同程度脑白质高信号的急性脑梗死患者预后的影响因素分析

White matter hyperintensities and prognosis of patients with acute cerebral infarction treated by intravenous thrombolysis with alteplase: an analysis of influencing factors

目的探讨阿替普酶静脉溶栓治疗合并不同程度脑白质高信号(WMH)的急性脑梗死预后的影响因素。方法回顾性连续纳入2016年9月至2019年1月徐州市中心医院神经内科住院的使用阿替普酶静脉溶栓治疗的合并不同程度WMH的急性脑梗死患者326例,采用Fazekas量表评估WMH程度,美国国立卫生研究院卒中量表(NIHSS)评估患者溶栓前神经功能缺损情况,改良Rankin量表(mRS)评估90d预后,根据mRS评分将患者分为预后良好组(mRS0~2分,247例)和预后不良组(mRS>2分,79例),比较两组患者的年龄、性别、既往卒中相关危险因素、相关生化指标及溶栓前NIHSS评分,将年龄、心房颤动、冠状动脉粥样硬化性心脏病、WMH、溶栓前NIHSS评分纳入二元多因素Logistic回归分析,探讨影响阿替普酶静脉溶栓治疗合并不同程度WMH的急性脑梗死患者临床预后不良的危险因素。结果预后良好组与预后不良组年龄[(65±12)岁比(70±12)岁,t=-2.984,P=0.003)],既往心房颤动史[10.1%(25/247)比21.5%(17/79),χ^2=6.928,P=0.008]、冠状动脉粥样硬化性心脏病史[8.1%(20/247)比21.5%(17/79),χ^2=10.717,P=0.001]、溶栓前NIHSS评分[6(4,10)比12(8,19)分,Z=-7.183,P<0.01]及WMH[无WMH、轻度WMH、中度WMH、重度WMH:5.3%(13/247)、55.9%(138/247)、24.3%(60/247)、14.6%(36/247)比0、36.7%(29/79)、34.2%(27/79)、29.1%(23/79),χ^2=17.631,P<0.01]差异均有统计学意义。二元多因素Logistic回归分析显示,中、重度WMH(OR=2.145,95%CI1.17~3.49,P=0.014)及溶栓前NIHSS评分≥9分(OR=1.131,95%CI1.08~1.18,P<0.01)是影响阿替普酶静脉溶栓治疗合并不同程度WMH的急性脑梗死患者预后不良的独立危险因素。结论中、重度WMH和溶栓前NIHSS评分是阿替普酶静脉溶栓治疗不同程度WMH的急性脑梗死患者临床预后不良的独立危险因素。

Objective To investigate the influencing factors of intravenous thrombolysis with alteplase on acute cerebral infarction patients with different degrees of white matter hyperintensity(WMH).Methods From September 2016 to January 2019,consecutive 326 acute cerebral infarction patients who had WMH and were treated with alteplase for intravenous thrombolysis at Department of Neurology,Xuzhou Central Hospital were retrospectively recruited.All patients completed cranial MRI examination after onset.Fazekas scale was used to evaluate WMH.National Institute of Health stroke scale (NIHSS) score was used to evaluate the pre-thrombolytic neurological deficiency of the patients.The modified Rankin scale (mRS) was used to evaluate the prognosis at 90 days.According to the mRS score,patients were divided into the good prognosis group (mRS≤ 2,247 cases) and the poor prognosis group (mRS>2,79 cases).Age,gender,previous risk factors related with cerebrovascular diseases,the pathogenesis of cerebral infarction,related biochemical indexes and NIHSS score before thrombolysis were compared between the two groups.Through the binary Logistic regression analysis,risk factors for poor prognosis of rt-PA intravenous thrombolysis in patients with acute cerebral infarction were identified.Results There was significant difference in age ([65±12] years old vs.[70±12] years old,t=-2.984,P =0.003),history of atrial fibrillation (10.1%[25/247] vs.21.5%[17/79],χ^2=6.928,P =0.008),history of coronary atherosclerotic disease (8.1%[20/247] vs.21.5%[17/79],χ^2=10.717,P =0.001),pre-thrombolytic NIHSS score (median score 6 [4,10] vs.12 [8,19],Z =-7.183,P <0.01) and WMH (no WMH,mild WMH,moderate WMH,severe WMH:5.3%[13/247],55.9%[138/247],24.3%[60/247],14.6%[36/247] vs.0,36.7%[29/79],34.2%[27/79],29.1%[23/79],χ^2=17.631,P< 0.01).The binary Logistic regression analysis showed that moderate and severe WMH ( OR,2.145,95% CI 1.17 - 3.49,P =0.014) and pre-thrombolytic NIHSS score≥9 ( OR,1.131,95%CI 1.08 - 1.18,P <0.01) were the independent risk factors for poor prognosis in patients with acute cerebral infarction with alteplase intravenous thrombolysis.Conclusion Moderate and severe WMH and pre-thrombolytic NIHSS score were independent risk factors for poor prognosis in acute cerebral infarction patients treated with intravenous alteplase.