入院血压对行血管内治疗的急性缺血性卒中患者神经功能预后的影响研究

Effect of admission blood pressure on prognosis of neurological function in patients with acute ischemic stroke undergoing endovascular treatment

目的探讨血管内治疗的急性大血管闭塞性缺血性卒中患者入院血压与术后90 d神经功能预后之间的关系。方法回顾性分析2018年1月至2019年12月于首都医科大学宣武医院神经内科接受血管内治疗的急性大血管闭塞性卒中患者的基线资料[包括年龄、性别、体质量指数、血管危险因素、入院时即刻血压情况、卒中前改良Rankin量表(mRS)评分、美国国立卫生研究院卒中量表(NIHSS)评分、Alberta卒中项目早期CT评分、实验室检查结果及梗死部位(前循环、后循环)]以及血管内治疗相关信息(发病至治疗时间和闭塞血管再通程度)以及术后90 d神经功能预后、术后症状性颅内出血等。入院时记录基线收缩压和舒张压。闭塞血管再通评估采用改良脑梗死溶栓(mTICI)分级,术后90 d神经功能预后以mRS评估(mRS评分0~2分为预后良好,>2分为预后不良,其中6分为死亡),将所有患者依据术后90 d预后情况分为预后良好组与预后不良组。采用Spearman相关性分析方法评价入院血压与术后90 d mRS评分的关系,采用Logistic回归分析方法分析术后90 d时预后不良的影响因素。采用受试者工作特征(ROC)曲线评价入院血压对术后90 d预后不良的预测价值,依据截断值,将所有患者分成较高血压组(入院收缩压高于截断值)与较低血压组(入院收缩压低于截断值),分析不同收缩压患者的术后90 d mRS评分、良好预后比例及死亡情况。结果共入组369例患者,血管内治疗后血管再通322例(87.3%);术后症状性颅内出血62例(16.8%);术后90 d,137例(37.1%)患者预后良好,232例(62.9%)患者预后不良。入院收缩压与术后90 d神经功能预后相关(r=0.212,P<0.01)。预后不良组患者入院收缩压高于预后良好组[155(139,170)mmHg比142(130,162)mmHg,Z=-3.559,P<0.01]。Logistic回归分析结果显示,入院收缩压(OR=1.016,95%CI:1.005~1.028,P=0.004)、高脂血症病史(OR=0.550,95%CI:0.310~0.977,P=0.042)、卒中病史(OR=2.016,95%CI:1.125~3.613,P=0.019)、入院NIHSS评分(OR=1.063,95%CI:1.026~1.101,P=0.001)、血管再通(OR=0.387,95%CI:0.168~0.892,P=0.026)、术后症状性颅内出血(OR=11.690,95%CI:3.890~35.131,P<0.01)为急性大血管闭塞性卒中患者血管内治疗后90 d神经功能预后的独立影响因素。入院收缩压作为神经功能预后预测因子的曲线下面积为0.611(95%CI:0.552~0.669,P<0.01),入院收缩压149.5 mmHg是预测预后的最佳截断值。与入院收缩压≥149.5 mmHg(较高血压组,206例)患者比较,入院收缩压<149.5 mmHg(较低血压组,163例)患者的术后90 d mRS评分较低[中位数评分:3(1,5)分比4(2,6)分,Z=-4.022,P<0.01],术后90 d预后良好比例较高[47.9%(78/163)比28.6%(59/206),χ^(2)=14.389,P<0.01],术后90 d病死率较低[23.3%(38/163)比35.9%(74/206),χ^(2)=6.844,P=0.009]。结论对于接受血管内治疗的急性大血管闭塞性卒中患者,较高的入院收缩压是术后90 d不良神经功能预后的独立预测因子。

Objective To investigate the relationship between admission blood pressure and 90 d neurological functional prognosis in patients with acute large-vessel occlusive ischemic stroke undergoing endovascular therapy.Methods From January 2018 to December 2019,acute large-vessel occlusive ischemic stroke patients who received endovascular therapy in the Department of Neurology of Xuanwu Hospital,Capital Medical University were recruited.Baseline data including age,gender,body mass index,vascular risk factors,blood pressure on admission,pre-morbid modified Rankin scale(mRS)score,the National Institutes of Health Stroke scale(NIHSS)score,the Alberta stroke project early CT score(ASPECTS),laboratory test results,infarction site(anterior circulation and posterior circulation),information related to endovascular therapy(time from onset to treatment and recanalization status),prognosis of neurological function at 90 days after surgery and postoperative symptomatic intracranial hemorrhage were retrospectively analyzed.Baseline systolic and diastolic blood pressure was recorded on admission.The modified thrombolysis in cerebral infarction(mTICI)was used to evaluate the recanalization status.The neurological outcome at 90 days after surgery was evaluated using the mRS(mRS score 0-2 was classified as good prognosis,>2 as poor prognosis,and 6 as death).All patients were divided into good prognosis group and poor prognosis group according to the prognosis at 90 days after operation.Spearman correlation analysis was used to evaluate the relationship between admission blood pressure and mRS score at 90 days after surgery,and Logistic regression analysis was used to analyze the influencing factors of poor prognosis at 90 days after surgery.Receiver operating characteristic(ROC)curve was used to evaluate the predictive value of admission blood pressure for poor prognosis at 90 days after surgery.According to the cut-off value,all patients were divided into high blood pressure group(admission systolic blood pressure higher than the cut-off value)and low blood pressure group(admission systolic blood pressure lower than the cut-off value).The mRS scores at 90 days after operation,proportion of good prognosis and death in patients with different systolic blood pressure were analyzed.Results A total of 369 patients were enrolled,322 cases(87.3%)of which were recanalized after endovascular therapy.Postoperative symptomatic intracranial hemorrhage occurred in 62 cases(16.8%).At 90 days after surgery,137 patients(37.1%)had a good prognosis and 232 patients(62.9%)had a poor prognosis.Admission systolic blood pressure was significantly correlated with neurological function outcome 90 days after surgery(r=0.212,P<0.01).Admission systolic blood pressure in the poor prognosis group was higher than that in the good prognosis group(155[139,170]mmHg vs.142[130,162]mmHg,Z=-3.559,P<0.01).Logistic regression analysis showed that the admission systolic blood pressure(OR,1.016,95%CI 1.005-1.028,P=0.004),history of hyperlipidemia(OR,0.550,95%CI 0.310-0.977,P=0.042),history of stroke(OR,2.016,95%CI 1.125-3.613,P=0.019),and NIHSS score on admission(OR,1.063,95%CI 1.026-1.101,P=0.001),recanalization of the artery(OR,0.387,95%CI 0.168~0.892,P=0.026),symptomatic intracerebral hemorrhage postoperation(OR,11.690,95%CI 3.890-35.131,P<0.01)were independent factors influencing the prognosis of neurological function 90 days after endovascular therapy in patients with acute large-vessel occlusive stroke.The area under the curve of admission systolic blood pressure as a predictor of neurological function prognosis was 0.611(95%CI 0.552-0.669,P<0.01),and admission systolic blood pressure 149.5 mmHg was the best cut-off value for predicting prognosis.Compared with patients with systolic blood pressure≥149.5 mmHg(high blood pressure group,206 cases),patients admitted to hospital with systolic blood pressure<149.5 mmHg(low blood pressure group,163 cases)had lower mRS scores at 90 days after surgery(median score:3[1,5]vs.4[2,6],Z=-4.022,P<0.01),higher proportion of 90 d good prognosis after surgery(47.85%[78/163]vs.28.64%[59/206],χ^(2)=14.389,P<0.01)and lower 90 d mortality rate(23.31%[38/163]vs.35.92%[74/206],χ^(2)=6.844,P=0.009).Conclusion For patients with acute large-vessel occlusive stroke and receiving endovascular treatment,higher systolic blood pressure on admission is an independent predictor of poor neurological function prognosis at 90 days after surgery.