急性缺血性卒中静脉溶栓后远隔部位脑出血的临床特征和预后分析

Clinical Features and Prognosis of Remote Parenchymal Hemorrhage after Intravenous Thrombolysis in Acute Ischemic Stroke

目的探讨急性缺血性卒中静脉溶栓后发生远隔部位脑出血(remoteparenchymalhemorrhage,rPH)的临床特征和预后。方法回顾性分析2016年1月-2020年4月在长沙市中心医院静脉溶栓后发生rPH患者的资料,探讨r PH的临床及影像学特征以及90 d时功能预后(良好预后定义为mRS<2分)。结果共纳入静脉溶栓患者376例,发生出血转化的患者共31例(8.2%),其中发生rPH患者10例,r PH在所有静脉溶栓患者中的发生率为2.7%,占全部出血转化的32.3%。在10例rPH患者,男性9例(90.0%),平均年龄69.5±8.6岁,溶栓前NIHSS评分为4.5(3~9)分;6例患者溶栓前CT平扫上有陈旧性梗死病灶,5例患者磁共振FLAIR序列提示有中重度脑白质疏松;2例患者伴有出血灶对侧颈内动脉起始部重度狭窄,2例患者溶栓后纤维蛋白原浓度明显下降;8例患者为脑叶r PH,2例为深部rPH;出血量<5 mL者6例,6~10 mL者2例,>10 mL者2例。8例rPH-1型患者中6例(60.0%)90 d功能预后良好,另外2例(20.0%)预后不良(mRS分别为3分和4分);2例(20.0%)rPH-2型患者均死亡。结论rPH是急性缺血性卒中静脉溶栓后一种少见的并发症,发病机制可能与梗死灶内出血不同,多位于脑叶,r PH-2型患者预后差,病死率高。

Objective To investigate the clinical features and prognosis of remote parenchymal hemorrhage(rPH)after intravenous thrombolysis in acute ischemic stroke.Methods A retrospective analysis of patients with rPH after intravenous thrombolysis from Changsha Central Hospital between January 2016 and April 2020 was performed.The clinical features,imaging characteristics and 90-day functional outcome(a favorable outcome was defined as mRS score<2 at 90 days)of patients with rPH were analyzed.Results A total of 376 patients received intravenous thrombolysis,and hemorrhagic transformation(HT)occurred in 31 patients(8.2%),including 10 patients with rPH.The incidence of rPH in all thrombolysis patients was 2.7%,and 32.3%in all HT patients.For 10 rPH patients,9 cases(90.0%)were men,the mean age was 69.5±8.6 years,the baseline NIHSS score before thrombolysis was 4.5(3~9).6 rPH patients had old ischemic lesions on CT scan before thrombolysis;5 rPH patients had moderate to severe leukoaraiosis on MR FLAIR imaging;severe stenosis at the initial segment of internal carotid artery contralateral to the bleeding lesions were observed in 2 rPH patients;the fibrinogen concentration after thrombolysis reduced significantly in 2 rPH patients.8 patients had lobar rPH,and 2 patients had deep rPH.There were 6 rPH cases with bleeding<5 mL,2 rPH cases with 6-10 mL and 2 rPH cases with bleeding>10 mL.For 8 patients with rPH-1 type,6(60.0%)had a favorable outcome at 90 days,and the other two(20.0%)had a poor outcome(mRS:3 and 4);for 2 patients with rPH-2 type,they both(20.0%)died.Conclusions rPH is an uncommon complication after intravenous thrombolysis in acute ischemic stroke.The pathogenesis of rPH may be different from hemorrhagic transformation within infarct lesions.Most of rPH were lobar rPH.Patients with rPH-2 type usually had poor prognosis and high mortality.