脑白质高信号对急性前循环大血管闭塞机械取栓术后症状性颅内出血和功能转归的影响

Effect of white matter hyperintensities on symptomatic intracranial hemorrhage and functional outcome after mechanical thrombectomy in patients with acute anterior circulation large vessel occlusive stroke

目的探讨脑白质高信号(WMHs)与急性前循环大血管闭塞患者血管内机械取栓术后症状性颅内出血和功能转归的关系。方法回顾性连续纳入2018年3月至2021年12月经广州中医药大学附属中山中医院急诊卒中绿色通道就诊的急性前循环大血管闭塞并接受机械取栓术的患者。收集患者的基线资料[年龄、性别、既往史(卒中史、糖尿病史、高血压病史、心房颤动史、高脂血症史)、吸烟、饮酒、基线实验室检查、入院时美国国立卫生研究院卒中量表(NIHSS)评分]及临床资料如闭塞部位、静脉溶栓、手术时间、WMHs评分,以及症状性颅内出血、发病90 d改良Rankin量表(mRS)评分等。根据MRI图像,采用Fazekas量表对WMHs负荷程度进行评估(脑室旁和深部WMHs评分相加,0分为无病变,1~2分为轻度,3~4分为中度,5~6分为重度),并将所有纳入患者分为无WMHs组(Fazekas量表评分0分)、轻中度WMHs组(Fazekas量表评分1~4分)、重度WMHs组(Fazekas量表评分5~6分)。运用多因素Logistic回归分析法分析WMHs严重程度与急性前循环大血管闭塞患者机械取栓术后症状性颅内出血及功能转归的关系。采用发病90 d(±3 d)mRS评估患者功能转归(mRS 0~2分为功能转归良好,3~6分为转归不良)。结果共纳入224例患者,146例(65.2%)合并WMHs,其中39例(17.4%)为重度WMHs。20例(8.9%)发生症状性颅内出血,117例(52.2%)发病90 d后功能转归不良。无WMHs组(78例)、轻中度WMHs组(107例)和重度WMHs组(39例)患者术后90 d功能转归差异有统计学意义(χ^(2)=15.671,P<0.01),重度WMHs组发病90 d功能转归不良的比例明显高于无WMHs组或轻中度WMHs组。多因素Logistic回归分析结果显示,重度WMHs是发病90 d后功能转归不良的独立危险因素(OR=3.220,95%CI:1.102~9.406,P=0.033),但与症状性颅内出血无明显相关(OR=3.220,95%CI:0.720~14.395,P=0.126)。结论重度WMHs与急性前循环大血管机械取栓术后功能转归不良相关,而与症状性颅内出血无关。本研究结果有待于进一步验证。

Objective To investigate the association of white matter hyperintensities(WMHs)with symptomatic intracranial hemorrhage(sICH)and functional outcome after mechanical thrombectomy(MT)in patients with acute large vessel occlusion(LVO)of the anterior circulation.Methods Consecutive patients with acute LVO of the anterior circulation and received MT in Stroke Center of Zhongshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Chinese Medicine were retrospectively recruited from March 2018 to December 2021.Baseline data(including age,gender,previous medical history[history of stroke,diabetes,hypertension,hyperlipidemia,atrial fibrillation],smoking,drinking,laboratory examination,the National Institute of Health Stroke Scale[NIHSS]score on admission),clinical data such as location of occlusion,intravenous thrombolysis,operation time,WMHs score,symptomatic intracranial hemorrhage(sICH),modified Rankin scale(mRS)score at 90-day after onset,etc.The degree of WMHs was evaluated based on MRI using the Fazekas scale(paraventricular and deep WMHs scores were added,0 was no lesion,1-2 was mild,3-4 was moderate,and 5-6 was severe).All enrolled patients were divided into non-WMHs group(Fazekas scale score 0),mild-moderate WMHs group(Fazekas scale score 1-4),and severe WMHs group(Fazekas scale score 5-6).Multivariable Logistic regression was used to analyze the association of severity of WMHs with sICH and functional outcome after MT in patients with acute anterior circulation LVO.The mRS at 90(±3)days after onset was used to evaluate the functional outcome of the patients(mRS 0-2 was classified as good functional outcome,and mRS 3-6 was classified as poor functional outcome).Results A total of 224 patients were included.There were 146(65.2%)patents with WMHs and 39(17.4%)with severe WMHs.20(8.9%)patients had sICH and 117(52.2%)with poor functional outcome 90 days after onset.There were statistically significant differences in functional outcome 90 days after operation among patients without WMHs(78 cases),mild-moderate WMHs(107 cases)and severe WMHs(39 cases)(χ2=15.671,P<0.01).The proportion of poor functional outcome 90 days after onset in severe WMHs group was significantly higher than that in non-WMHs group or mild-moderate WMHs group.Multivariable Logistic regression showed that severe WMHs was an independent risk factor of poor functional outcome 90 days after stroke onset(OR,3.220,95%Cl 1.102-9.406,P=0.033),but not sICH(OR,3.220,95%Cl 0.720-14.395,P=0.126).Conclusions Severe WMHs is associated with poor functional outcome after MT for acute LVO in the anterior circulation,but not with sICH.The results of this study need to be further verified.