重组组织型纤溶酶原激活剂静脉溶栓后症状性颅内出血风险评估量表的对比研究

Comparison of predicting scales for symptomatic intracranial hemorrhage after stroke thrombolysis with recombinant tissue plasminogen activator

目的比较目前临床常用溶栓后出血转化风险量表的预测价值.方法回顾性连续纳入2016年8月至2018年4月苏州大学附属第一医院神经内科在4.5 h时间窗内接受重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓的脑卒中患者.使用了以下7个症状性颅内出血(sICH)预测量表:HAT(Hemorrhage After Thrombolysis)、SEDAN[blood Sugar,Early infarct signs,(hyper)Dense cerebral artery sign,Age,National Institutes of Health Stroke Scale]、SPAN(Stroke Prognostication using Age and National Institutes of Health Stroke Scale)-100、SITS(Safe Implementation of Thrombolysis in Stroke)、THRIVE(Total Health Risks In Vascular Events)、GRASPS[Glucose at presentation,Race(Asia),Age,Sex(male),systolic blood Pressure at presentation,and Severity of stroke at presentation(National Institutes of Health Stroke Scale)]和MSS(Multicenter Stroke Survey).利用回归分析判断量表评分与sICH的相关性,用受试者操作特征曲线下面积(AUROC)评价各量表的判别能力.使用Hosmer-Lemeshow拟合优度检验对回归模型进行质量控制评估校准.结果共入组293例急性脑梗死患者.24-36 h的sICH发生率按照定义不同,分别为sICHNINDS 7.85%(23/293)、sICHECASSⅡ5.46%(16/293)、sICHSITS-MOST 4.44%(13/293).SEDAN量表对于预测3种定义的sICH均有最高的AUROC值,其中sICHNINDS:AUROC=0.843,OR=3.167,95%CI 2.106-4.762,P<0.01;sICHECASSII:AUROC=0.797,OR=2.509,95%CI 1.652-3.812,P<0.01;sICHSITS:AUROC=0.784,OR=2.172,95%CI 1.405-3.357,P<0.01.SPAN-100量表的AUROC值在所有比较中均最低,且仅与sICHNINDS风险有关.进一步将293例患者按照前后循环梗死进行分组,回归分析结果提示对于后循环梗死,本研究纳入的7个量表与sICH风险均无相关性.结论SEDAN量表对于rt-PA静脉溶栓sICH预测价值最高,SPAN-100量表最低.但本研究纳入的预测量表仅能预测前循环梗死后的sICH,与后循环梗死的sICH无显著相关.

Objective Symptomatic intracranial hemorrhage(sICH)is one of the severe complications of ischemic stroke thrombolysis.Several prognostic scales have been developed to predict the risk of sICH.The performance of seven scales was compared in a single center cohort.Methods Data of patients with consecutive ischemic stroke who received 0.9 mg/kg intravenous recombinant tissue plasminogen activator(rt-PA)thrombolysis within 4.5 h time window from stroke onset were collected.Seven scales that can provide an estimate of risk of sICH were identified and evaluated:Hemorrhage After Thrombolysis(HAT),blood Sugar,Early infarct signs,(hyper)Dense cerebral artery sign,Age,National Institutes of Health(NIH)Stroke Scale(SEDAN),Stroke Prognostication using Age and NIH Stroke Scale(SPAN)-100,Safe Implementation of Thrombolysis in Stroke(SITS),Total Health Risks In Vascular Events(THRIVE),Glucose at presentation,Race(Asia),Age,Sex(male),systolic blood Pressure at presentation,and Severity of stroke at presentation(NIH Stroke Scale;GRASPS)and Multicenter Stroke Survey(MSS).The area under the receiver operating characteristic curve(AUROC)was calculated and Logistic regression and the Hosmer-Lemeshow test were also performed.Results The current study included 293 patients,of whom 7.85%(23/293)had sICH by National Institute of Neurological Disorders and Stroke(SICHNINDS),5.46%(16/293)by Europe Cooperative Acute Stroke StudyⅡ(SICHECASSⅡ)and 4.44%(13/293)by Safe Implementation of Thrombolysis in Stroke(SICHSITS)criteria.SEDAN had the highest AUROC for predicting sICH:sICHNINDS:AUROC=0.843,OR=3.167,95%CI 2.106-4.762,P<0.01;sICHECASSⅡ:AUROC=0.797,OR=2.509,95%CI 1.652-3.812,P<0.01;sICHSITS:AUROC=0.784,OR=2.172,95%CI 1.405-3.357,P<0.01.And SPAN-100 had the lowest AUROC among all the seven scales and was only associated with risk of SICHNINDS in regression analysis.Furthermore,when sub-grouped the cohort into anterior circulation infarction and posterior circulation infarction,regression analysis suggested that all the seven scales were however not associated with sICH risk in patients with posterior circulation infarction.Conclusions SEDAN constantly had the highest predictive power,SPAN-100 had the worst.The seven scales studied could not predict sICH in posterior circulation infarction.