不同病因急性脑梗死患者静脉溶栓治疗的疗效分析

Clinical Analysis of Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Different Causes

目的比较不同病因脑梗死患者静脉溶栓早期疗效及出血转化风险,为不同病因脑梗死静脉溶栓治疗提供参考和依据。方法回顾性纳入2015年9月-2019年9月在深圳市人民医院神经内科住院接受rt-PA静脉溶栓的连续性急性脑梗死患者,收集患者的基线资料,并根据中国缺血性卒中分型(Chinese Ischemic Stroke Subclassification,CISS)标准进行病因分组。临床有效定义为溶栓后较溶栓前NIHSS评分下降≥4分或NIHSS评分降至0分。分析不同病因患者静脉溶栓后24 h和7 d的有效率及24 h出血转化的风险。结果共纳入283例患者,静脉溶栓后24 h有效例数共129例(45.58%),其中穿支动脉疾病(penetrating artery disease,PAD)组35例(63.64%)、大动脉粥样硬化型(large-artery atherosclerosis,LAA)组70例(54.69%)、病因不确定(undetermine detiology,UE)组10例(45.45%)、其他病因(other etiology,OE)组3例(23.08%)、心源性(cardiogenic stroke,CS)组11例(16.92%)。组间比较,PAD组有效率明显高于UE组、OE组、CS组,P值分别为0.015、0.008、0.004;LAA组有效率明显高于UE组、OE组、CS组,P值分别为0.032、0.011、0.009;UE组有效率明显高于OE组、CS组,P值分别为0.031、0.019。溶栓7 d有效例数共193例(68.20%),其中PAD组有效率明显高于CS组(72.73%vs 58.46%,P=0.009)。溶栓7 d后≤55岁患者有效率明显高于≥80岁患者(76.11%vs 55.56%,P=0.013)。共有23例出现出血转化(8.13%),PAD组出血转化率(1.82%)明显低于LAA组、OE组、UE组、CS组,P值分别为0.025、0.018、0.004、0.001;CS组出血转化率(18.46%)明显高于LAA组、OE组、UE组,P值分别为0.005、0.012、0.021;≥80岁患者出血转化率明显高于≤55岁患者(14.81%vs 6.19%,P=0.002)和55~79岁患者(14.81%vs 8.39%,P=0.006)。结论不同病因脑梗死患者早期溶栓有效率和出血转化风险有差异,穿支动脉疾病组溶栓早期有效率较高,出血转化风险低;心源性组患者早期有效率较低,出血转化风险相对较高;患者越年轻,溶栓效果越好,出血转化风险越小。

Objective To evaluate the early effectiveness and risk of hemorrhagic transformation(HT) of intravenous thrombolysis(IVT) in patients with acute ischemic stroke(AIS) of different causes.Methods AIS patients treated with intravenous thrombolysis using rt-PA in Department of Neurology of Shenzhen People’s Hospital between September 2015 and September 2019 were retrospectively included in this analysis. All the patients were grouped according to the Chinese Ischemic Stroke Subclassification(CISS). Clinical effectiveness was defined as a decrease of NIHSS score ≥4 points or NIHSS score decreasing to 0 point. The outcome at 24 hours and 7 days after thrombolysis and risk of HT at 24 hours after thrombolysis in different groups were analyzed.Results A total of 283 patients were included. The overall effective rate was 45.58%(n=129) at 24 hours after IVT, of which penetrating artery disease(PAD) group was 63.64%(n=35), large-artery atherosclerosis(LAA) group was 54.69%(n=70), undetermined etiology(UE) group was 45.45%(n=10), other etiology(OE) group was 23.08%(n=3), cardiogenic stroke(CS) group was 16.92%(n=11). Comparison among groups showed that the effective rate of PAD group were better than that of UE, OE and CS groups, and the P value was 0.015, 0.008 and 0.004, respectively;LAA group was better than UE, OE and CS group, and the P value was 0.032, 0.011 and 0.009, respectively;UE group was better than OE and CS groups, and the P value was 0.031 and 0.019. The overall effective rate was 68.20%(n=193) at 7 days after IVT, and the effective rate of PAD group was better than that of CS group(72.73% vs 58.46%, P=0.009), the 7-day effective rate in patients under 55 years was better than that in patients over 80 years(76.11% vs 55.56%, P=0.013). HT occurred in 23 patients(8.13%), the HT rate of PAD group(1.82%) was lower than that of LAA, OE, UE and CS groups, the P value was 0.025, 0.018, 0.004 and 0.001, respectively;and the HT rate of CS group(18.46%) was higher than that of LAA, OE and UE groups, the P value was 0.005, 0.012 and 0.021, respectively. The HT rate of patients over 80 years was higher than that of patients under 55 years(14.81% vs 6.19%, P=0.002) and patients aged 55 to 79(14.81% vs 8.39%, P=0.006).Conclusions The early thrombolytic effect and HT risk were different in AIS patients with different causes. PAD group had higher effective rate of thrombolysis and lower HT risk, while CS group had lower effective rate and relatively higher HT risk. The younger the patient, the better the thrombolysis effect and the lower the risk of HT.