急性缺血性脑卒中血栓负荷的影响因素及其与临床转归的相关性

Factors of clot burden and its correlation with clinical outcome in acute ischemic stroke

目的回顾性分析急性缺血性脑卒中(AIS)患者血栓负荷的影响因素,并评价血栓负荷与临床转归的关系。方法收集2019年1月至2020年6月收住于苏州市立医院北区神经内科的88例AIS患者的基线临床资料,根据血栓负荷评分(CBS)将患者分为高血栓负荷组(0~6分)和低血栓负荷组(7~10分),通过单因素分析和多变量Logistic回归模型分析CBS的影响因素,记录患者的区域软脑膜侧支评分(rLMC)、影像学特征、临床结局,通过χ^(2)检验和受试者工作特征(ROC)曲线评估血栓负荷和临床转归的关系及其预测价值。结果88例患者中高血栓负荷组36例(40.9%),低血栓负荷组52例(59.1%),单因素分析显示心房颤动史(33.3%vs 13.5%)、基线美国国立卫生研究院卒中量表(NIHSS)评分[11.0(6.5,17.5)分vs 9.5(5.5,14.0)分]、发病至CT血管造影和CT灌注成像检查时间[380(190,525)min vs 408(180,610)min]、核心梗死区体积[21.62(15.71,42.26)ml vs 11.18(6.18,14.30)ml]、rLMC[(8.36±2.90)分vs(16.85±1.46)分]在2组间差异均具有统计学意义(χ^(2)=4.926,P=0.026;Z=3.682,P=0.031;Z=3.508,P=0.044;Z=3.115,P=0.039;t=-16.192,P<0.001),多变量Logistic回归模型分析显示心房颤动史[优势比(OR)=1.944,95%可信区间(CI):1.101~2.431;P=0.022]、基线NIHSS评分高(OR=1.326,95%CI:1.036~1.696;P=0.025)、核心梗死区体积大(OR=1.120,95%CI:1.011~1.367;P=0.034)是高血栓负荷的独立危险因素,而rLMC高(OR=0.571,95%CI:0.372~0.801;P=0.016)是高血栓负荷的抑制性因素。低血栓负荷组的90 d恢复良好率明显高于高血栓负荷组(42.3%vs 16.7%,χ^(2)=4.947,P=0.026),脑出血转化率明显低于高血栓负荷组(1.9%vs 13.9%,χ^(2)=4.794,P=0.029),但2组的全因死亡率差异并无统计学意义(P>0.05)。CBS预测临床转归的曲线下面积为0.784(95%CI:0.606~0.862;P<0.001),最佳截断值为6.5分,敏感度和特异度分别为78.1%和69.4%。结论心房颤动史、基线NIHSS评分高、核心梗死区体积大是AIS高血栓负荷的独立危险因素,rLMC高是高血栓负荷的抑制性因素,低血栓负荷组患者转归良好率更高,CBS对AIS临床转归具有良好的预测价值。

Objective To retrospectively analyze the factors influencing clot burden in patients with acute ischemic stroke(AIS)and evaluate the correlation between clot burden and outcome.Methods The baseline clinical dates of 88 patients with AIS admitted to North district of Suzhou Municipal Hospital from January 2019 to June 2020 were collected.According to the clot burden score(CBS),the patients were divided into high clot burden group(CBS 0-6)and low clot burden group(CBS 7-10),and the factors influencing CBS were analyzed by univariate analysis and multivariate Logistic regression model.Regional leptomeningeal score(rLMC),imaging characteristics and clinical outcomes were collected,then the correlation between clot burden and clinical outcomes were evaluated byχ^(2) test and the predictive value of CBS to outcome were calculated by receiver operating characteristic(ROC)curve.Results Among the 88 patients,36 cases(40.9%)were in the high clot burden group and 52 cases(59.1%)were in the low clot burden group.Univariate analysis showed significant differences in history of atrial fibrillation(33.3%vs 13.5%),baseline National Institutes of Health stroke scale(NIHSS)score[11.0(6.5,17.5)points vs 9.5(5.5,14.0)points],time from onset to CT angiography and CT perfusion imaging[380(190,525)min vs 408(180,610)min],core infarction area[21.62(15.71,42.26)ml vs 11.18(6.18,14.30)ml]and rLMC[(8.36±2.90)points vs(16.85±1.46)points]between the two groups(χ^(2)=4.926,P=0.026;Z=3.682,P=0.031;Z=3.508,P=0.044;Z=3.115,P=0.039;t=-16.192,P<0.001).Multivariate Logistic regression model analysis showed a history of atrial fibrillation[odds ratio(OR)=1.944,95%confidence interval(CI):1.101-2.431;P=0.022],a high baseline NIHSS score(OR=1.326,95%CI:1.036-1.696;P=0.025)and larger core infarction area(OR=1.120,95%CI:1.011-1.367;P=0.034)were independent risk factors for high clot burden.A high rLMC was inhibitory factor for high clot burden(OR=0.571,95%CI:0.372-0.801;P=0.016).The 90-day good outcome in the low clot burden group was significantly more frequent than that in the high clot burden group(42.3%vs 16.7%;χ^(2)=4.947,P=0.026),while the conversion rate of intracerebral hemorrhage in the former group was significantly lower than that in the latter group(1.9%vs 13.9%;χ^(2)=4.794,P=0.029).However,there was no significant difference in all-cause mortality between the two groups(P>0.05).The area under the curve for CBS prediction of clinical outcome was 0.784(95%CI:0.606-0.862;P<0.001)with the best cutoff value of 6.5,the sensitivity of 78.1%,and the specificity of 69.4%.Conclusion A history of atrial fibrillation,high baseline NIHSS score and large core infarction area volume were independent risk factors,while high rLMC was inhibitory factor for high clot burden in AIS.Patients with low clot burden are more likely to have good outcome,and CBS had a good predictive value for clinical outcome of AIS.