儿童重症监护病房缺血性脑卒中的临床特征及其预后的回顾性队列研究

Clinical characteristic and prognosis of ischemic stroke in pediatric intensive care unit:A retrospective cohort study

目的分析PICU缺血性脑卒中(IS)近期预后不良的关联因素,构建多因素预后预测模型。方法纳入复旦大学附属儿科医院PICU 2013年1月至2018年12月收治的IS连续病例,以出院时脑功能分类量表评分(PCPC)≥4分为预后不良,<4分为预后良好,采集患儿的基本信息、临床、影像及脑电图特征等信息,行单因素分析及二分类Logistic逐步回归分析,并基于预测指标构建预后预测模型,评价内部有效性。结果114例IS进入本文分析,男64例,女50例,中位年龄30.0(9.0,102.8)个月,有局灶性表现78例(68.4%),有全身性表现101例(88.6%),同时有局灶和全身性表现65例(57.0%),IS后症状性癫癎发作61例(53.5%),收住PICU时改良GCS 3~15(10.5±3.2)分,动脉IS 98.2%(112例),梗死灶横向性同时累及双侧脑部36.8%(42例),仅累及左侧脑部32.5%(37例),仅累及右侧脑部30.7%(35例)。Synek脑电分级≥3分61.4%(70例)。IS复发8例(7.0%),男7例,复发距离首次起病间隔时长中位数4.5(1.3,14.0)个月;预后良好81例(71.1%),预后不良33例。7例死亡(出院病死率6.1%)。107例存活者中,95例遗留有程度不等和形式不一的机体功能障碍,依次为运动障碍,认知障碍、语言障碍和症状性癫癎等。7例死亡患儿均非复发IS病例且均有全身性表现,4例存在IS后急性症状性癫癎发作。改良GCS评分(OR=0.601,95%CI:0.460~0.784)及VEEG的Synek分级评分(OR=4.518,95%CI:1.682~12.137)是儿童IS预后不良的独立预测因子,以此构建的多因素预后预测模型,内部验证预测正确率89.5%,预测概率的ROC曲线下面积(AUC)0.946(95%CI:0.906~0.986)。结论PICU儿童IS发生率低(1.38%),总体近期预后良好,出院病死率低,但致残率高。改良GCS评分联合VEEG的Synek分级评分构建预后预测模型的预测效能高,具有潜在临床应用价值。

Objective To investigate the related indicators associated with poor short-term prognosis of ischemic stroke(IS)in PICU,and to establish a multivariate prognostic prediction model for IS in PICU.Methods The consecutive hospitalized patients with acute IS who were admitted to PICU in Children's Hospital of Fudan University from January 2013 to December 2018 were included.Short-term prognosis was evaluated according to Pediatric Cerebral Performance Category score(PCPC)at hospital discharge.The poor prognosis was defined as PCPC≥4 at hospital discharge,and the good prognosis was PCPC<4.Univariate analysis and binary logistic stepwise regression analysis were performed to screen the related indicators associated with poor prognosis including patients'basic information,clinical situation,imaging and VEEG characteristic.A multivariate prognostic prediction model was established based on the above predictive indicators,and its internal effectiveness was evaluated.Results A total of 114 patients with IS who met the inclusion and exclusion criteria of this study were included in the analysis with 64 males(56.1%)and 50 females.The median age was 30.0(9.0-102.8)months.There were 78 cases(68.4%)with focal manifestations,101 cases(88.6%)with systemic manifestations and 65 cases(57.0%)with both focal and systemic manifestations.Sixty-one cases(53.5%)had symptomatic ictus epilepticus after IS.The modified GCS was evaluated when IS patients were admitted to PICU,ranging from 3 to 15(10.5±3.2).Arterial IS(112 cases)accounted for 98.2%of all IS.The infarctus laterally involved 42 cases(36.8%)of bilateral brain simultaneously,37 cases(32.5%)of left brain and 35 cases(30.7%)of right brain respectively.There were 70 patients(61.4%)with Synek classification score of VEEG≥3.Recurrent IS occurred in 8 cases(7%),7 of which were males.The median interval between recurrence and the first onset was 4.5(1.3-14.0)months.There were 81(71.1%)cases with good prognosis and 33 cases with poor prognosis.Seven patients died(mortality rate 6.1%at discharge).Among the rest 107 survivors,95 cases(88.8%)had different degree and varied forms of dysfunction including dyskinesia,cognitive impairment,speech disorder and symptomatic epilepsy in a descending order of frequency.None of the dead patients were recurrent cases and all of the dead patients had systemic manifestations,4 of which had acute symptomatic ictus epilepticus after IS.The modified GCS(OR=0.601,95%CI:0.460-0.784)and Synek classification score of VEEG(OR=4.518,95%CI:1.682-12.137)were independent predictors of poor prognosis of pediatric IS in PICU.The internal validation of the multivariate prognostic prediction model which was established based on the above predictors showed that the prediction accuracy was 89.5%and the area under ROC curve of the prediction probability was 0.946(95%CI:0.906-0.986).Conclusion The incidence of pediatric IS in PICU was low(1.38%),the overall short-term prognosis was good,the mortality rate at discharge was low,but the disability rate was high.The combination of modified GCS and Synek classification score of VEEG got high prediction efficiency which had potential clinical application value.