急性脑梗死患者静脉溶栓后早期神经功能恶化的影响因素分析

Influencing factors of early neurological deterioration after intravenous thrombolysis in acute cerebral infarction

目的分析急性脑梗死静脉溶栓后发生早期神经功能恶化(END)的影响因素。方法回顾性连续纳入2018年3—8月首都医科大学宣武医院神经内科发病4.5 h内接受阿替普酶静脉溶栓治疗的急性脑梗死患者139例,其中男116例,女23例。根据静脉溶栓后是否出现END,将139例患者分为END组(25例)和无END组(114例)。收集两组患者的基线及临床资料,基线资料包括年龄、性别、既往史[高血压病、糖尿病、冠心病、先天性心脏病、心房颤动、高脂血症、缺血性卒中(脑梗死、短暂性脑缺血发作)]、吸烟史,临床资料包括入院时美国国立卫生研究院卒中量表(NIHSS)评分、低密度脂蛋白胆固醇、血糖、血压、前循环梗死比例、急性卒中Org 10172治疗试验(TOAST)分型情况,并进行组间比较。将单因素分析中P<0.1的参数作为自变量,进一步对急性脑梗死患者静脉溶栓后发生END的影响因素行多因素Logistic回归分析。END定义为静脉溶栓后24 h内,NIHSS评分较入院时增加≥4分或死亡。结果(1)139例急性脑梗死静脉溶栓患者中,END发生率为18.0%(25例)。(2)两组患者年龄、性别及高血压病、糖尿病、高脂血症、吸烟、心房颤动、冠心病、先天性心脏病、缺血性卒中史的差异均无统计学意义(均P>0.05)。(3)两组患者入院时血压、血糖、低密度脂蛋白胆固醇、NIHSS评分值以及前循环梗死比例的差异均无统计学意义(均P>0.05)。(4)END组TOAST分型大动脉粥样硬化比例高于无END组,组间差异有统计学意义[76.0%(19/25)比45.6%(52/114),χ2=7.576,P<0.01]。(5)以急性脑梗死静脉溶栓患者发生END为因变量,以缺血性卒中史、TOAST分型(大动脉粥样硬化与非大动脉粥样硬化)为自变量进一步行多因素Logistic回归分析,结果显示,大动脉粥样硬化是急性脑梗死静脉溶栓患者发生END的危险因素(OR=3.517,95%CI:1.296~9.547,P=0.014),缺血性卒中史不是急性脑梗死静脉溶栓患者发生END的影响因素(P>0.05)。结论TOAST病因分型大动脉粥样硬化可增加急性脑梗死患者静脉溶栓后发生END的风险。

Objective To investigate influencing factors of early neurological deterioration(END)in acute cerebral infarction patients after intravenous thrombolysis.Methods From March to August in 2018,a total of 139 consecutive acute cerebral infarction patients receiving intravenous thrombolysis within 4.5 h after onset in Department of Neurology of Xuanwu Hospital,Capital Medical University were recruited.These patients included 116 males and 23 females.According to the presence of END after intravenous thrombolysis,the patients were divided into the END group(n=25)and the non-END group(n=114).Baseline and clinical data were collected and compared between the two groups,including age,sex,past medical history(hypertension,diabetes,coronary heart disease,congenital heart disease,atrial fibrillation,hyperlipidemia,ischemic stroke[cerebral infarction,transient ischemic attack]),smoking,the National Institute of Health Stroke Scale(NIHSS),low-density lipoprotein cholesterol,blood glucose,blood pressure,proportion of anterior circulation infarction and the Trial of Org 10172 in Acute Stroke Treatment(TOAST)classification.Multivariate logistic regression analysis was performed for END incidence of these patients with the parameters of P<0.1 in the univariate analysis as independent variables.END was defined as the increase of NIHSS score≥4 points or death within 24 hours after intravenous thrombolysis.Results(1)In 139 patients with acute cerebral infarction,the incidence of END was 18.0%(25 cases).(2)There was no significant difference in age,sex,hypertension,diabetes,hyperlipidemia,smoking,atrial fibrillation,coronary heart disease,congenital heart disease and ischemic stroke between the two groups(all P>0.05).(3)There was no significant difference in blood pressure at admission,blood glucose,low-density lipoprotein cholesterol,NIHSS score and the proportion of anterior circulation infarction between the two groups(all P>0.05).(4)The large-artery atherosclerosis rate of the END group was significantly higher than that of the non-END group(76.0%[19/25]vs.45.6%[52/114],χ2=7.576,P<0.01).(5)Multivariate logistic regression analysis was further performed,taking END incidence in acute cerebral infarction patients with cerebral thrombolysis as the dependent variable,and ischemic stroke history and TOAST classification(large-artery atherosclerosis and non-large artery atherosclerosis)as independent variables.The results showed large-artery atherosclerosis was a risk factor for END in acute cerebral infarction patients with cerebral thrombolysis(OR=3.517,95%CI 1.296-9.547,P=0.014)but not ischemic stroke history(P>0.05).Conclusion Large-artery atherosclerosis in TOAST classification can increase the risk of END after intravenous thrombolysis in patients with acute cerebral infarction.