重组组织型纤溶酶原激活剂静脉溶栓治疗急性脑梗死伴应激性高血糖的临床研究

Intravenous thrombolysis with recombinant tissue plasminogen activator in acute ischemic stroke with high stress hyperglycemia

目的:探讨糖化血红蛋白(GHbA1c)指导重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗急性脑梗死伴应激性高血糖的有效性和安全性。方法:连续收集2018年1月至2021年6月于南开大学附属第四中心医院卒中中心就诊的195例入院血糖超过22.2 mmol/L和GHbA1c检测值小于15.59%的急性脑梗死患者的临床资料并将其纳入研究。将入组的患者分为对照组(60例)、rt-PA小剂量组(0.6 mg/kg,70例)和rt-PA标准剂量组(0.9 mg/kg,65例),评价rt-PA治疗的有效性和安全性。结果:rt-PA小剂量组治疗24 h的有效率和7 d良好率分别为61.4%(43/70)和72.9%(51/70),rt-PA标准剂量组分别为64.6%(42/65)和69.2%(45/65),均优于对照组的30.0%(18/60;χ^(2) =18.25, P<0.001)和46.7%(28/60;χ^(2) =13.65, P=0.001)。rt-PA小剂量组90 d的预后良好率为82.8%(58/70),优于对照组的63.3%(38/60;χ^(2) =6.38, P=0.016),但与rt-PA标准剂量组的72.3%(47/65)相比,差异无统计学意义(χ^(2) =2.17, P=0.153)。rt-PA小剂量组的90 d病死率为7.1%(5/70),低于rt-PA标准剂量组的20.0%(13/65;χ^(2) =4.82, P=0.041)和对照组的18.3%(11/60;χ^(2) =5.04, P=0.030)。rt-PA小剂量组的颅内出血率及症状性颅内出血发生率分别为8.5%(6/70)和2.9%(2/70),均低于rt-PA标准剂量组的20.0%(13/65;P=0.048)和13.8%(9/65;P=0.020)。rt-PA小剂量组颅外出血发生率为7.1%(5/70),低于rt-PA标准剂量组的18.9%(12/65;P=0.042)。 结论:急性脑梗死伴入院血糖大于22.2 mmol/L的患者,当GHbA1c检测值小于15.59%时可以接受rt-PA静脉溶栓治疗,推荐0.6 mg/kg小剂量方案。

Objective To investigate the efficacy and safety of intravenous thrombolysis with recombinant tissue plasminogen activator(rt-PA)for acute ischemic stroke with stress hyperglycemia under the guidance of glycosylated hemoglobin A1c(GHbA1c).Methods The clinical data of 195 patients of acute cerebral infarction with admission blood glucose over 22.2 mmol/L and GHbA1c less than 15.59%were collected in Nankai University Affiliated Tianjin Fourth Central Hospital from January 2018 to June 2021 and analyzed retrospectively.Patients were divided into control group(60 cases),rt-PA low-dose group(0.6 mg/kg,70 cases)and rt-PA standard-dose group(0.9 mg/kg,65 cases)to evaluate the guiding effect of GHbA1c and the efficacy and safety of rt-PA.Results The effective rate at 24 hours and good rate at 7 days were 61.4%(43/70)and 72.9%(51/70)in the rt-PA low-dose group,64.6%(42/65)and 69.2%(45/65)in the rt-PA standard-dose group,respectively,both better than the control group[30.0%(18/60);χ²=18.25,P<0.001 and 46.7%(28/60);χ²=13.65,P=0.001].The good outcome rate at 90 days was 82.8%(58/70)in the rt-PA low-dose group,which was better than 63.3%(38/60)in the control group(χ²=6.38,P=0.016),but without statistically significant difference compared with the rt-PA standard-dose group[72.3%(47/65);χ²=2.17,P=0.153].The case fatality rate at 90 days of the rt-PA low-dose group was 7.1%(5/70),which was lower than 20.0%(13/65)in the rt-PA standard-dose group(χ²=4.82,P=0.041)and 18.3%(11/60)in the control group(χ²=5.04,P=0.030).The incidence of intracranial hemorrhage and symptomatic intracranial hemorrhage was 8.5%(6/70)and 2.9%(2/70)in the rt-PA low-dose group,lower than 20.0%(13/65;P=0.048)and 13.8%(9/65;P=0.020)in the rt-PA standard-dose group.The incidence of extracranial hemorrhage was 7.1%(5/70)in the rt-PA low-dose group,lower than 18.9%(12/65)in the rt-PA standard-dose group(P=0.042).Conclusion Acute cerebral infarction patients with admission blood glucose over 22.2 mmol/L can receive rt-PA treatment when GHbA1c is less than 15.59%,and 0.6 mg/kg dosage is recommended.