急性颅内外大动脉粥样硬化性脑梗死抗栓治疗后的侧支循环建立及预后评估

Prognosis evaluation and establishment of collateral circulation after antithrombotic therapy for acute intracranial and extracranial atherosclerotic cerebral infarction

目的 评估不同发病机制的急性颅内外大动脉粥样硬化性脑梗死抗栓治疗后侧支循环建立及预后情况。方法选取2018年1月至2020年1月在绍兴市人民医院住院治疗的108例急性颅内外大动脉粥样硬化性脑梗死患者为研究对象,按照发病机制不同分为4种大动脉粥样硬化(LAA)亚型(载体动脉堵塞穿支24例,动脉到动脉栓塞30例,分水岭/栓子清除下降33例,混合机制21例)。所有患者入院1周内完善头颈部CT血管和侧支循环评估,抗栓治疗3个月后采用改良Ranking量表评估预后。比较不同预后患者临床资料,采用多因素logistic回归分析影响患者预后的因素;比较4种LAA亚型患者的临床特征。结果 预后良好71例,预后不良37例。不同预后患者在基线美国国立卫生研究院卒中量表(NIHSS)评分、急诊开始抗栓治疗、LAA亚型、侧支循环良好、病情加重、卒中再发、颅内出血等方面比较,差异均有统计学意义(均P<0.05);进一步作多因素分析显示,基线NIHSS评分(OR=0.479)、病情加重(OR=0.018)、侧支循环良好(OR=33.711)是患者预后的独立影响因素(均P<0.05)。4种LAA亚型患者在侧支循环良好、病情加重、颅内出血、预后良好等方面比较,差异均有统计学意义(均P<0.05),其中分水岭/栓子清除下降亚型患者病情加重的比例最高,侧支循环良好及预后良好的比例均最低。结论 基线NIHSS评分、病情加重、侧支循环良好是急性颅内外动脉粥样硬化性脑梗死预后的独立影响因素,不同发病机制的脑梗死患者抗栓治疗后侧支循环建立及预后存在差异。

Objective To evaluate the establishment of collateral circulation and prognosis after antithrombotic therapy for acute intracranial and extracranial atherosclerotic cerebral infarction with different pathogenesis. Methods A total of 108 patients with acute intracranial and extracranial atherosclerotic infarction who were hospitalized in Shaoxing People’s Hospital from January 2018 to January 2020 were selected. There were 4 subtypes of large atherosclerosis(LAA)according to different pathogenesis, 24 patients of parent artery(plaque or thrombus) occluding penetrating artery, 30patients of artery-to-artery embolism, 33 patients of watershed hypoperfusion/impaired embolectomy, 21 patients of multiple mechanisms. CT angiography(CTA) of head and neck was performed in all patients within 1 week of admission,and collateral circulation was evaluated. The modified Rankin scale(mRS) was used to evaluate the prognosis after 3months of antithrombotic therapy. The clinical data of patients with different prognosis were compared, and the factors affecting the prognosis were analyzed by multivariate logistic regression. The clinical characteristics of 4 subtypes of LAA patients were compared. Results The prognosis was good in 71 cases and poor in 37 cases. The baseline National Institutes of Health stroke scale(NIHSS) score, antithrombotic therapy in emergency, LAA subtypes, good collateral circulation, disease aggravation, stroke recurrence, intracranial hemorrhage and other aspects of patients with different prognosis were compared, and the differences were statistically significant(all P<0.05). Further multivariate analysis showed that baseline NIHSS score(OR=0.479), disease aggravation(OR=0.018) and good collateral circulation(OR=33.711)were independent prognostic factors(all P<0.05). There were statistically significant differences among the four LAA subtypes in terms of good collateral circulation, disease aggravation, intracranial hemorrhage and good prognosis(P<0.05).Among them, the subtype of watershed hypoperfusion/impaired embolectomy had the highest proportion of disease exacerbation and the lowest proportion of good collateral circulation and worst prognosis. Conclusion Baseline NIHSS score, disease aggravation and good collateral circulation were independent prognostic factors for acute intracranial and extracranial atherosclerotic cerebral infarction. There were differences in the establishment of collateral circulation and prognosis in patients with cerebral infarction with different pathogenesis after antithrombotic therapy.