伴非瓣膜性心房颤动急性缺血性脑卒中合并脑微出血患者发生症状性脑出血危险因素分析

Analysis of risk factors for symptomatic cerebral hemorrhage in patients with acute ischemic stroke and cerebral microbleeds with non-valvular atrial fibrillation

目的探讨伴非瓣膜性心房颤动的急性缺血性卒中(AIS)患者合并脑微出血(CMBs)时,发生症状性脑出血(sICH)的危险因素。方法选取自2016年4月至2020年11月于辽宁省人民医院住院治疗的83例伴非瓣膜性心房颤动的AIS患者为研究对象,患者均行头部核磁共振常规序列扫描和头部磁敏感加权成像(SWI)序列检查。根据SWI检查结果,将患者分为无CMBs组(n=27)与CMBs组(n=56)。记录并比较两组患者年龄、性别、吸烟史、饮酒史、既往病史(高血压、糖尿病、卒中)、美国国立卫生院神经功能缺损(NIHSS)评分、非瓣膜性心房颤动患者脑卒中危险评分(CHA2DS2-VASc)、出血风险评分(HAS-BLEDS)等临床资料。记录CMBs的患者的严重程度分级、发生CMBs的部位以及抗凝药的种类、剂量、服用时间等,主要终点事件为口服抗凝药90 d内发生sICH,分析CMBs患者口服抗凝剂治疗的安全性。记录本研究纳入患者出血不良事件发生情况。结果本研究出血事件发生率为16.9%(14/83)。其中,小出血10例(12.1%),包括牙龈出血、皮肤瘀斑、痰中带血、便潜血、轻微眼底出血;临床相关非大出血2例(2.4%),包括便血、严重眼底出血;大出血2例(2.4%),为脑出血。2例患者分别于口服抗凝药物后第64天和第82天发生sICH。2例患者的出血部位均与原梗塞部位无关,但出血部位既往均存在CMBs病灶。CMBs组有高血压病病史患者比例高于无CMBs组,差异有统计学意义(P<0.05)。多因素分析结果显示,NIHSS评分是伴非瓣膜性心房颤动的AIS合并CMBs患者发生sICH的独立危险因素(OR=0.448,95%可信区间0.150~1.344,P=0.032)。结论伴非瓣膜性心房颤动的AIS患者有较高的CMBs的发生率,高血压病史与CMBs的发生相关。当伴非瓣膜性心房颤动的AIS患者合并CMBs时,NIHSS评分是sICH发生的独立危险因素。

Objective To investigate the risk factors of symptomatic intracerebral hemorrhage(sICH)in patients with acute ischemic stroke(AIS)and non-valvular atrial fibrillation complicated with cerebral microbleeds(CMBs).Methods A total of 83 patients with AIS and non-valvular atrial fibrillation hospitalized in Liaoning Provincial People′s Hospital from April 2016 to November 2020 were selected and all patients underwent routine head MRI sequence scan and head susceptibility-weighted imaging(SWI)sequence examination.According to the SWI examination,the patients were divided into the non-CMBs group(n=27)and the CMBs group(n=56).Age,gender,smoking habit,drinking habit,anamnesis(hypertension,diabetes,stroke),National Institutes of Health stroke scale(NIHSS)score,stroke risk score in patients with non-valvular atrial fibrillation(CHA2DS2-VASc),bleeding risk score(HAS-BLEDS)and etc were recorded and compared between the two groups.The severity classification of CMBs patients,the site of CMBs,and the type,dose,and duration of anticoagulant drugs were recorded.The primary endpoint was the occurrence of sICH within 90 days of oral anticoagulants,and the safety of oral anticoagulant therapy in patients with CMBs was analyzed.The incidence of bleeding adverse events in the patients included in this study was recorded.Results The incidence of bleeding events in this study was 16.9%(14/83).Among them,there were 10 cases(12.1%)of minor bleeding,including bleeding gums,skin ecchymosis,blood-stained sputum,fecal occult blood and minor fundus hemorrhage.There were 2 cases(2.4%)of clinically relevant non-major bleeding,including hematochezia,severe fundus hemorrhage.Two cases(2.4%)of major bleeding were cerebral hemorrhage,who occurred sICH on the 64th day and the 82th day after oral anticoagulation.The bleeding sites of the two patients were unrelated to the original infarct site,but the bleeding sites had previously existed in CMBs lesions.The proportion of patients with hypertension in the CMBs group was higher than that in the non-CMBs group,and the difference was statistically significant(P<0.05).Multivariate analysis showed that NIHSS score was an independent risk factor for sICH in patients with AIS and CMBs with non-valvular atrial fibrillation(OR=0.448,95%confidence interval 0.150-1.344,P=0.032).Conclusion AIS patients with non-valvular atrial fibrillation have a higher incidence of CMBs,and hypertension is associated with the occurrence of CMBs.NIHSS score is an independent risk factor for sICH in AIS patients with non-valvular atrial fibrillation complicated with CMBs.