不同部位脑白质病变对急性缺血性脑卒中rt-PA静脉溶栓患者临床预后的影响

Influence of Different White Matter Lesions Sites on Clinical Prognosis of Acute Ischemic Stroke Patients Treated with rt-PA Intravenous Thrombolysis

目的探讨不同部位脑白质病变(white matter lesions,WMLs)对急性缺血性脑卒中(acute ischemic stroke,AIS)静脉溶栓患者临床预后的影响。方法收集笔者医院2014年7月~2021年2月发病4.5h以内接受rt-PA静脉溶栓治疗的合并有脑室旁白质病变(periventricular white matter lesions,PWMLs)或深部白质病变(deep white matter lesions,DWMLs)的前循环AIS患者129例。根据Fazekas评分量表评分分为PWMLs组(2~3分)和DWMLs组(2~3分)。根据90天改良Rankin量表(mRS)评分分为预后良好组(0~2分)和预后不良组(3~6分)。收集患者的基线资料和临床资料,分析不同部位WMLs对临床预后的影响。结果PWMLs组与DWMLs组在年龄、总胆固醇、甘油三酯、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、高血压病方面比较,差异均有统计学意义(P均<0.05);PWMLs组脑卒中复发比例、预后不良发生比例均明显高于DWMLs组(P均<0.05)。预后良好组与预后不良组溶栓前血糖(P=0.028),血同型半胱氨酸(P=0.001)、溶栓前NIHSS评分(P<0.001)、TOAST分型(P=0.038)、WMLs部位(P=0.025)、脑卒中复发比例(P<0.001)方面比较,差异有统计学意义。多因素回归分析后发现,PWMLs较DWMLs(OR=8.92,P=0.037)溶栓前NIHSS评分(OR=1.67,P<0.001)、脑卒中复发(OR=19.97,P=0.003)是前循环AIS静脉溶栓90天预后不良的危险因素。结论合并有PWMLs的前循环AIS静脉溶栓患者脑卒中复发率更高,发病后90天神经功能恢复更差。与DWMLs比较,PWMLs能够更好地预测前循环AIS静脉溶栓患者的临床预后。

Objective To investigate the influence of different white matter lesions sites on clinical prognosis of acute ischemic stroke(AIS)patients treated with intravenous thrombolysis.Methods A total of 129 patients who combined with periventricular white matter lesions(PWMLs)or deep white matter lesions(DWMLs)with AIS on anterior circulation treated with intravenous thrombolysis within the 4.5 hour time window in our hospital were collected between July 2014 to February 2021.According to Fazekas scale score,the patients were divided into PWMLs group(2-3 points)and DWMLs group(2-3 points).According to the 90 days modified Rankin Scale score,the patients were divided into good prognosis group(0-2 points)and poor prognosis group(3-6 points).The baseline data and clinical data of the AIS patients with intravenous thrombolysis were collected,and were used to analyze the influence of WMLs sites on the clinical prognosis of patients.Results There was significant difference between PWMLs group and DWMLs group in age,total cholesterol,triglyceride,high-density lipoprotein cholesterol,low-density lipoprotein cholesterol and hypertension(all P<0.05);The proportion of stroke recurrence and poor prognosis in the PWMLs group was significantly higher than that in the DWMLs group(all P<0.05).There was no statistically significant difference in the remaining baseline data and clinical data between the two groups(all P>0.05).There was significant difference in pre-thrombolytic blood glucose(P=0.028),homocysteine(P=0.001),baseline NHISS score(P<0.001),TOAST classification distribution(P=0.038),area of WMLs(P=0.025),proportion of early neurological deterioration(P=0.001)and proportion of stroke recurrence(P<0.001)between the good prognosis group and the poor prognosis group.Multivariate regression analysis revealed that PWMLs compared with DWMLs(OR=8.92,P=0.037),baseline NHISS score(OR=1.67,P<0.001),and stroke recurrence(OR=19.97,P=0.003)were independent risk factors for poor prognosis in patients with anterior circulation acute ischemic stroke patients after intravenous thrombolysis at 90 days.Conclusion The recurrence rate of stroke in patients with anterior circulation acute ischemic stroke combined with PWMLs undergoing intravenous thrombolysis is higher,and the clinical prognosis is poorer at 90 days after onset.Compared with DWMLs,PWMLs can better predict the clinical prognosis of patients undergoing intravenous thrombolysis in anterior circulation acute ischemic stroke.