急性缺血性卒中静脉溶栓患者侧支循环状态对神经功能及临床转归的影响

Effect of collateral circulation status on the neurological function and clinical outcome in acute ischemic stroke patients with intravenous thrombolysis

目的研究急性缺血性卒中静脉溶栓患者不同侧支循环与对早期神经功能及临床转归的影响,同时探讨美国国立卫生研究院卒中量表(NIHSS)子项目评分与侧支循环状态的关系。方法回顾性连续纳入2016年12月至2019年4月入诊于新乡医学院第一附属医院神经内科静脉溶栓的大脑中动脉M1段重度狭窄及闭塞的73例患者,根据头部CT血管成像(CTA)-CT灌注(CTP)成像检查选择目标患者,并评估静脉溶栓前的侧支循环状态,据此分为侧支循环良好组与侧支循环不良组。收集患者的临床资料,采用NIHSS评分进行神经功能缺损评分,发病后90 d采用改良Rankin量表(mRS)评估预后。比较两组患者的临床资料,采用单因素Logistic回归分析研究侧支循环状态与入院时NIHSS评分子项目的关系,同时探讨静脉溶栓前的侧支循环状态与溶栓后患者临床转归[主要结局:发病90 d时mRS评分0~1分;次要结局:早期神经功能显著改善(治疗后72 h NIHSS评分为0~1分,或较基线NIHSS评分降低8分)及发病后90 d时mRS评分为0~2分;安全性结局:脑出血转化及发病后90 d死亡]的关系。结果73例患者中,侧支循环良好组43例,侧支循环不良组30例。侧支循环良好组患者入院时NIHSS评分及治疗后72 h NIHSS评分均明显低于侧支循环不良组[分别为2.00(1.00,5.00)分比7.00(3.75,10.00)分,1.00(0.00,3.00)分比5.00(1.75,6.25)分;Z值分别为-3.793、3.447,均P<0.01]。单因素Logistic回归分析结果显示,侧支循环不良组面瘫、上肢运动、下肢运动、构音障碍评分均明显高于侧支循环良好组[OR值及95%CI分别为5.058(2.249~11.372)、1.465(1.024~2.094)、1.633(1.069~2.495)、2.669(1.072~6.647),均P<0.05]。在主要结局中,侧支循环良好组67.4%(29/43)患者和侧支循环不良组40.0%(12/30)患者mRS评分为0~1分(OR=1.686,95%CI:1.068~3.105,P=0.020)。对于次要结局,侧支循环良好组53.5%(23/43)患者和侧支循环不良组20.0%(6/30)患者获得早期神经功能改善(OR=2.672,95%CI:1.241~5.765,P=0.004);侧支循环良好组86.0%(37/43)患者和侧支循环不良组63.3%(19/30)患者mRS评分为0~2分(OR=1.359,95%CI:1.009~1.830,P=0.024)。在安全结局中,侧支循环良好组及侧支循环不良组的患者中分别有2例和7例出现了出血转化(OR=0.199,95%CI:0.044~0.894,P=0.043);死亡风险组间差异无统计学意义(OR=0.698,95%CI:0.104~4.682,P=1.000)。结论对于急性缺血性卒中大脑中动脉重度狭窄及闭塞患者,良好的侧支循环与较轻的临床症状有关,NIHSS评分子项目中的面瘫、上肢运动、下肢运动及构音障碍评分增加可反映侧支循环不良;良好的侧支循环有利于静脉溶栓患者获得早期神经功能改善及良好的预后,可能降低出血转化风险,但不降低患者死亡风险。

Objective To study the effect of different collateral circulation on the neurological function and clinical outcome in acute ischemic stroke patients with intravenous thrombolysis,and explore the relationship of the sub item of National Institute of Health stroke scale(NIHSS)with collateral circulation status.Methods From December 2016 to April 2019,73 consecutive patients with severe stenosis and occlusion of middle cerebral artery(M1 segment)who underwent intravenous thrombolysis at the Department of Neurology,The First Affiliated Hospital of Xinxiang Medical College were retrospectively recruited.The target patients were selected according to CT angiography(CTA)-CT perfusion(CTP)and the collateral circulation status was evaluated before intravenous thrombolysis.The patients were divided into the good collateral circulation group and the poor collateral circulation group.Clinical data were collected and the NIHSS score was used to assess the neurological deficit.The modified Ranking scale(mRS)was used to assess the prognosis of 90 days after onset.The clinical data of the two groups were compared to investigate the relationship between collateral circulation status and NIHSS score sub-items at admission by univariate and multivariate Logistic regression analysis.Also,the relationship between collateral circulation before thrombolysis and clinical outcome after thrombolysis was studied(The primary outcome:mRS score 0-1 at 90 d;the secondary outcomes:early neurological function significant improvement[NIHSS score 0-1 at 72 h after treatment,or 8 points lower than baseline NIHSS score]and mRS score 0-2 at 90 d after onset;the safety outcome:cerebral hemorrhagic transformation and death 90 days after onset).Results Among the 73 patients,43 patients were in the good collateral circulation group and 30 patients were in the poor collateral circulation group.The NIHSS scores at admission and 72 hours after treatment in the good collateral circulation group were lower than those in the poor collateral circulation group(2.00[1.00,5.00]score vs.7.00[3.75,10.00]score,1.00[0.00,3.00]score vs.5.00[1.75,6.25]score,respectively;all P<0.01).Single factor Logistic regression analysis showed that,the scores of facial paralysis,upper limb movement,lower limb movement,dysarthria in the poor collateral circulation group were more than those in the good collateral circulation group(OR and 95%CI,5.058[2.249-11.372],1.465[1.024-2.094],1.633[1.069-2.495],2.669[1.072-6.647],all P<0.05).For the primary outcome,67.4%(29/43)of patients with good collateral circulation and 40.0%(12/30)of patients with poor collateral circulation had a mRS score of 0-1(OR,1.686,95%CI 1.068-3.105,P=0.020).For the secondary outcomes,early neurological improvement was achieved in 53.5%(23/43)of patients with good collateral circulation and 20.0%(6/30)in patients with poor collateral circulation(OR,2.672,95%CI 1.241-5.765,P=0.004);the mRS score 0-2 was obtained in 86.0%(37/43)of patients with good collateral circulation and 63.3%(19/30)of patients with poor collateral circulation(OR,1.359,95%CI 1.009-1.830,P=0.024).For the safety outcome,2 patients in the good collateral circulation group and 7 patients in the poor collateral circulation group had hemorrhagic transformation(OR,0.199,95%CI 0.044-0.894,P=0.043);there was no significant difference in mortality risk between the two groups(OR,0.698,95%CI 0.104-4.682,P=1.000).Conclusions For acute ischemic stroke patients with middle cerebral artery severe stenosis and occlusion,good collateral circulation is associated with mild clinical symptoms.The increased scores of the facial paralysis,upper limb movement,lower limb movement,dysarthria in NIHSS score sub-item could reflect the poor collateral circulation.Good collateral circulation is conducive to early improvement of neurological function and favorable prognosis in patients with intravenous thrombolysis.It may reduce the risk of hemorrhagic transformation but not the risk of death.