系统性免疫炎症指数对急性前循环大血管闭塞机械取栓首次通过效应的预测价值

Predictive value of the systemic immuno-inflammatory index for the first pass effect of mechanical thrombectomy in acute anterior circulation large vessel occlusions

目的 研究系统性免疫炎症指数(SII)与急性前循环大血管闭塞机械取栓首次通过效应(FPE)的关系以及SII对FPE的预测价值。方法 回顾性连续纳入宝鸡市中心医院自2017年12月至2022年6月在神经内科住院并接受机械取栓治疗的急性前循环大血管闭塞患者219例,根据取栓装置首次通过闭塞血管后是否成功再通分为FPE组和非FPE组。比较两组患者的一般资料(性别、年龄及既往史如高血压病、糖尿病、高脂血症、冠心病、心房颤动、吸烟)、实验室指标(同型半胱氨酸、尿酸、白细胞计数、中性粒细胞计数、淋巴细胞计数、血小板计数及SII)、临床资料[入院时美国国立卫生研究院卒中量表(NIHSS)评分、入院时Albert卒中项目早期CT(ASPECT)评分、血栓负荷评分(CBS)、是否静脉溶栓、脑梗死类型及血管闭塞位置]、手术相关数据[发病至动脉穿刺时间、动脉穿刺至血管再通时间、血管再通技术、血管是否再通(以改良脑梗死溶栓分级评估)]和手术预后指标如症状性颅内出血、术后90 d改良Rankin量表(mRS)评分及患者死亡情况,将单因素分析中P<0.05的变量纳入多因素Logistic回归模型得出影响FPE的独立因素,构建列线图模型并分析其预测效能,绘制受试者工作特征(ROC)曲线并进行临床决策曲线分析(DAC),评估SII对FPE的预测作用及临床应用价值。结果 两组患者相比,年龄、高血压病、心房颤动、中性粒细胞计数、中性粒细胞与淋巴细胞计数比值、血小板与淋巴细胞计数比值、SII差异均有统计学意义(均P<0.05)。与非FPE组相比,FPE组入院时ASPECT评分高,CBS>6分比例高,差异均有统计学意义(均P<0.05);术后效果及预后指标方面,FPE组动脉穿刺至血管再通时间较非FPE组低[116(110,137) min比131(112,147) min],血管再通率高于非FPE组[100.0%(87/87)比79.5%(105/132)],术后90 d预后良好率高于非FPE组[49.4%(43/87)比29.5%(39/132)],症状性颅内出血发生率低于非FPE组[10.3%(9/87)比22.0%(29/132)],术后90 d内病死率低于非FPE组[4.6%(4/87)比12.1%(16/132)],差异均有统计学意义(均P<0.05)。Logistic回归分析结果显示,年龄(OR=0.962,95%CI:0.922~0.984)、高血压病(OR=0.774,95%CI:0.579~0.941)、入院时ASPECT评分(OR=2.587,95%CI:1.677~3.992)、动脉穿刺至血管再通时间(OR=0.913,95%CI:0.841~0.975)、CBS≥6分(OR=1.678,95%CI:1.142~6.961)、SII(OR=0.895,95%CI:0.801~0.971)是影响FPE的独立因素(均P<0.05)。根据Logistic回归分析结果构建列线图,此模型对FPE的预测效能较好,一致性指数(C-index)为0.848。ROC曲线提示SII联合基线模型预测FPE的曲线下面积为0.848(95%CI:0.792~0.904,P<0.05);DCA提示,SII联合基线模型风险阈值在0.01~0.87时有临床获益,单纯基线模型风险阈值在0.01~0.79、0.88~0.92时临床获益,但与单纯基线模型相比,SII联合基线模型临床净获益更高。结论 入院时SII减低是急性前循环大血管闭塞机械取栓获得FPE的预测因素,SII预测机械取栓FPE有潜在的临床应用价值。

Objective To investigate the relationship between systemic immune-inflammatory index(SII) and the first pass effect(FPE) of mechanical thrombectomy for acute anterior circulation large vessel occlusion and to identify the predictive value of SII on FPE. Methods A total of 219 patients with acute anterior circulation large vessel occlusion cerebral infarction who were hospitalized and treated with mechanical thrombectomy from December 2017 to June 2022 in the Department of Neurology, Baoji Municipal Central Hospital were included in the study. Patients were divided into FPE and non-FPE groups according to whether the occluded vessel was successfully recanalized after the first pass of thrombectomy device. Demographics(gender, age, and previous medical history such as hypertension, diabetes, hyperlipidemia, coronary heart disease, atrial fibrillation, smoking), laboratory indicators(high homocysteine, uric acid, white blood cell count, neutrophil, lymphocyte, platelet count and SII), baseline clinical data(the National Institutes of Health stroke scale[NIHSS] scores, Albert stroke program early CT score[ASPECTS], clot burden score [CBS], venous thrombolysis or not, classification of cerebral infarction and location of vascular occlusion), surgical data(time from onset to arterial puncture, time from arterial puncture to vascular recanalization, vascular recanalization technique, vascular recanalization status[modified thrombolysis in cerebral infarction])and prognostic indicators such as symptomatic intracranial hemorrhage, modified Rankin scale(mRS) score at 90 days, and death from both groups were recorded and compared. Variables with P <0.05 in univariate analysis were included in Logistic regression to identify independent factors influencing FPE. Nomogram was constructed, and its predictive efficacy was validated. Receiver operating characteristic(ROC) and decision curve analysis(DAC) were plotted to analyze the predictive effect of SII on FPE and the clinical value of SII on FPE. Results There were statistically significant differences in age, hypertension, atrial fibrillation, neutrophil counts, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and SII between the 2 groups(all P< 0.05). Compared with the non-FPE group, the FPE group had higher ASPECTS and a higher rate of CBS≥6. The differences were statistically significant(both P<0.05). In terms of postoperative effect and prognostic indicators, the time from arterial puncture to recanalization in FPE group was lower than that in non-FPE group(116 [110,137] min vs. 131 [112,147] min), and the vascular recanalization rate was higher than that in non-FPE group(100.0% [87/87] vs. 79.5% [105/132]). The rate of good prognosis 90 days after surgery was higher than that in the non-FPE group(49.4% [43/87] vs. 29.5% [39/132]), and the rate of symptomatic intracranial hemorrhage was lower than that in the non-FPE group(10.3% [9/87] vs. 22.0% [29/132]). The mortality rate within 90 days after surgery was lower than that in the non-FPE group(4.6% [4/87] vs. 12.1% [16/132]). The differences were statistically significant(all P< 0.05). Logistic regression analysis suggested that age(OR,0.962, 95%CI 0.922-0.984), hypertension(OR,0.774, 95%CI 0.579-0.941), admission ASPECTS(OR,2.587, 95%CI 1.677-3.992), arterial puncture to revascularization time(OR,0.913, 95%CI 0.841-0.975), CBS≥6(OR,1.678, 95%CI 1.142-6.961), and SII(OR,0.895, 95%CI 0.801-0.971) were independent factors affecting FPE(all P < 0.05). The nomogram was constructed based on the Logistic regression analysis results, and this model had a good predictive efficiency for EPF with a concordance index(C-index) of 0.848. The ROC curve showed that the area under the curve of the SII combined with the baseline model in predicting FPE was 0.848(95%CI 0.792-0.904, P<0.05). DCA indicated that if the threshold probability is between 0.01 and 0.87 in SII plus baseline model between 0.01 and 0.79 or 0.88 and 0.92 in the baseline model, the prediction models had a good performance. However, the performance of the SII plus baseline model was better than the baseline model. Conclusion Decreased admission SII is a predictor of FPE for mechanical thrombectomy in acute anterior circulation large vessel occlusion, and the prediction of SII on FPE has potential clinical application value.