基于弥散加权成像与液体衰减反转恢复序列不匹配的静脉溶栓在醒后卒中患者中的有效性和安全性

Efficacy and safety of intravenous thrombolysis based on diffusion-weighted imaging and fluid-attenuated inversion recovery mismatch in patients with wake-up stroke

目的探讨基于弥散加权成像(diffusion-weighted imaging,DWI)与液体衰减反转恢复序列(fluid-attenuated inversion recovery,FLAIR)不匹配的静脉溶栓在醒后卒中患者中的有效性和安全性。方法回顾性纳入2019年7月至2021年6月在合肥市第二人民医院卒中中心接受阿替普酶静脉溶栓治疗的急性缺血性卒中患者,根据发现症状的时间分为醒后卒中组与非醒后卒中组,记录并比较两组人口统计学和基线临床资料。有效性终点为发病后90 d时应用改良Rankin量表(modified Rankin Scale,mRS)评估的临床转归,0~2分定义为转归良好,>2分定义为转归不良。主要安全性终点为有症状颅内出血(symptomatic intracranial hemorrhage,sICH);次要安全性终点为发病后90 d内死亡。应用多变量logistic回归分析确定转归不良的独立危险因素。结果共纳入256例急性缺血性卒中患者,男性155例(60.5%),年龄(63.0±8.53)岁,发现症状至静脉溶栓的中位时间为130.5 min,中位基线美国国立卫生研究院卒中量表(National Institutes of Health Stroke Scale,NIHSS)评分为7分。48例(18.7%)为WUS,208例(81.3%)为非WUS;186例(72.7%)转归良好,70例(27.3%)转归不良。醒后卒中组与非醒后卒中组90 d转归良好率(79.2%对71.2%;χ^(2)=1.260,P=0.262)、sICH发生率(4.2%对5.3%;χ^(2)=0.102,P=0.750)以及90 d病死率(2.1%对3.4%;χ^(2)=0.000,P=1.000)差异均无统计学意义。转归不良组基线NIHSS评分、发现症状至静脉溶栓时间以及心源性栓塞的患者构成比均显著高于转归良好组(P均<0.05)。多变量logistic回归分析显示,基线NIHSS评分(优势比1.670,95%置信区间1.453~1.919;P<0.001)以及发现症状到静脉溶栓时间(优势比1.007,95%置信区间1.000~1.015;P=0.043)是患者转归不良的独立危险因素。结论DWI-FLAIR不匹配的醒后卒中患者接受静脉溶栓的有效性及安全性与时间窗内急性缺血性卒中患者相当。

Objective To investigate the efficacy and safety of intravenous thrombolysis based on diffusion-weighted imaging(DWI)and fluid-attenuated inversion recovery(FLAIR)mismatch in patients with wake-up stroke(WUS).Methods Patients with acute ischemic stroke received alteplase intravenous thrombolysis in the Stroke Center,the Second People's Hospital of Hefei from July 2019 to June 2021 were enrolled retrospectively.According to the time of finding the symptoms,they were divided into WUS group and non-WUS group.The demographic and baseline clinical data were documented and compared between the two groups.The efficacy endpoint was the clinical outcome assessed by the modified Rankin Scale(MRS)score at 90 d after onset.0-2 was defined as a good outcome,and>2 were defined as a poor outcome.The primary safety endpoint was symptomatic intracranial hemorrhage(sICH);the secondary safety endpoint was death within 90 d after onset.Multivariate logistic regression analysis was used to determine the independent risk factors for poor outcome.Results A total of 256 patients with acute ischemic stroke were enrolled,including 155 males(60.5%),aged 63.0±8.53 years.The median time from symptom onset to intravenous thrombolysis was 130.5 min,and the median baseline National Institutes of Health Stroke Scale(NIHSS)score was 7.Forty-eight patients(18.7%)were WUS and 208(81.3%)were non-WUS;186(72.7%)had a good outcome and 70(27.3%)had a poor outcome.There were no significant differences in 90 d good outcome rate(79.2%vs.71.2%;χ^(2)=1.260,P=0.262),sICH incidence(4.2%vs.5.3%;χ^(2)=0.102,P=0.750)and 90 d mortality(2.1%vs.3.4%;χ^(2)=0.000,P=1.000)between the WUS group and the non-WUS group.The baseline NIHSS score,the time from symptom onset to intravenous thrombolysis and the proportion of patients with cardiogenic embolism in the poor outcome group were significantly higher than those in the good outcome group(all P<0.05).Multivariate logistic regression analysis showed that the baseline NIHSS score(odds ratio 1.670,95%confidence interval 1.453-1.919;P<0.001)and the time from symptom onset to intravenous thrombolysis(odds ratio 1.007,95%confidence interval 1.000-1.015;P=0.043)were the independent risk factors for the poor outcome.Conclusion The efficacy and safety of intravenous thrombolysis in DWI-FLAIR-mismatched wake-up stroke patients are comparable to those of acute ischemic stroke within the time window.