应激性高血糖与前循环取栓再通后早期预后的相关性研究

The Association between Stress Hyperglycemia and Early Prognosis after Successful Recanalization with Thrombectomy in Acute Anterior Circulation Large Artery Occlusion

目的探讨应激性高血糖与急性前循环大血管闭塞取栓再通后早期预后的相关性。方法本回顾性研究纳入于丽水市中心医院接受急诊取栓并成功再通的急性前循环大血管闭塞性缺血性卒中患者,成功再通定义为mTICI分级为2b~3级。依据应激性高血糖比值(stress hyperglycemia ratio,SHR)中位数将患者分为低SHR组和高SHR组,主要结局为出院功能预后不良(mRS评分4~6分),次要结局为术后72 h内恶性脑水肿(malignant cerebral edema,MCE)。采用有序logistic回归分析SHR与出院mRS评分增加的关系,多因素logistic回归探究SHR与出院功能预后不良、MCE的相关性。结果研究最终纳入312例患者,低SHR组与高SHR组各156(50%)例,SHR为0.953(0.817~1.100),静脉溶栓率为48.1%,NIHSS评分为14(11~18)分,72 h内发生MCE的有74例,出院功能预后不良的有196例。与低SHR组相比,高SHR组入院NIHSS评分更高(16分vs.14分,P=0.031),72 h内MCE发生率更高(33.3%vs.14.1%,P<0.001),出院功能预后不良比例更高(72.4%vs.53.2%,P<0.001)。多因素logistic回归显示,高SHR是脑梗死取栓再通后出院mRS评分增加(OR 1.910,95%CI 1.257~2.904,P=0.002)、出院功能预后不良(OR 2.064,95%CI 1.223~3.482,P=0.007)、72 h内发生M CE(OR 2.746,95%CI 1.532~4.922,P=0.001)的独立预测因素。依据有无基础糖尿病及长期血糖控制水平进行亚组分析显示,高SHR与非糖尿病患者出院功能预后不良(OR 2.132,95%CI 1.175~3.868,P=0.013)、72 h内发生MCE(OR 3.079,95%CI 1.540~6.155,P=0.001)显著相关,高SHR与糖化血红蛋白(glycosylated hemoglobin,HbA1c)≤6.5%、患者出院功能预后不良(OR 1.925,95%CI 1.082~3.424,P=0.026)、72 h内发生MCE(OR 2.869,95%CI 1.459~5.642,P=0.002)显著相关。交互作用检验及亚组分析显示,年龄≤80岁(OR 2.074,95%CI 1.165~3.690,P=0.013)、TC>3.81 mmol/L(OR 2.763,95%CI 1.267~6.026,P=0.011)、ASPECTS评分8~10分(OR 1.865,95%CI 1.023~3.401,P=0.042)、入院NIHSS评分≤14分(OR 2.926,95%CI 1.400~6.115,P=0.004)、发病至再通时间6~12 h(OR 2.088,95%CI 1.062~4.103,P=0.033)的大动脉粥样硬化性脑梗死(OR 4.151,95%CI 1.880~9.169,P<0.001)患者中,高SHR与出院不良功能预后风险增加相关。结论高SHR与急性前循环大血管闭塞取栓再通后72 h内发生MCE、出院功能预后不良显著相关。

Objective To investigate the association between stress hyperglycemia and early neurological prognosis after successful recanalization with thrombectomy in acute anterior circulation large artery occlusion.Methods Patients with acute anterior circulation large artery occlusion after successful recanalization with thrombectomy in Lishui Municipal Central Hospital were enrolled in this retrospective analysis.Patients were divided into low stress hyperglycemia ratio(SHR)group and high SHR group according to median of SHR.Successful recanalization was defined as modified thrombolysis in cerebral infarction(mTICI)2b to 3.Primary outcome was poor functional outcome at discharge(defined as a mRS score of 4-6)and secondary outcome was malignant cerebral edema(MCE)within 72 hours after thrombectomy.The association between SHR and mRS increase at discharge was analyzed by ordinal logistic regression,and the association of SHR with poor functional outcome and MCE was analyzed by multivariate logistic regression.Results A total of 312 patients were enrolled in the final analysis,with 156 patients in each group.The median SHR was 0.953(0.817-1.100),intravenous thrombolysis accounted for 48.1%,median admission NIHSS score was 14(11-18),74 patients developed MCE within 72 hours,and 196 patients had poor functional outcome at discharge.Compared to the low SHR group,the high SHR group had higher admission NIHSS score(16 vs.14,P=0.031),higher proportion of MCE within 72 hours(33.3%vs.14.1%,P<0.001)and poor functional outcome at discharge(72.4%vs.53.2%,P<0.001).The multivariate logistic regression showed that high SHR was an independent predictive factor for mRS increase(OR 1.910,95%CI 1.257-2.904,P=0.002),poor functional outcome at discharge(OR 2.064,95%CI 1.223-3.482,P=0.007)and MCE within 72 hours(OR 2.746,95%CI 1.532-4.922,P=0.001).Subgroup analysis based on basal diabetes and long-term glucose control level showed that high SHR was associated with poor functional outcome at discharge(OR 2.132,95%CI 1.175-3.868,P=0.013)and MCE within 72 hours(OR 3.079,95%CI 1.540-6.155,P=0.001)in non-diabetes patients,and high SHR was associated with poor functional outcome at discharge(OR 1.925,95%CI 1.082-3.424,P=0.026)and MCE within 72 hours(OR 2.869,95%CI 1.459-5.642,P=0.002)in patients with glycosylated hemoglobin(HbA1c)≤6.5%.Interaction test and subgroup analysis showed that high SHR was strongly associated with poor functional outcome at discharge in patients with age≤80 years old(OR 2.074,95%CI 1.165-3.690,P=0.013),TC>3.81 mmol/L(OR 2.763,95%CI 1.267-6.026,P=0.011),admission ASPECTS score of 8-10(OR 1.865,95%CI 1.023-3.401,P=0.042),admission NIHSS score≤14(OR 2.926,95%CI 1.400-6.115,P=0.004),time from stroke onset to recanalization of 6-12 h(OR 2.088,95%CI 1.062-4.103,P=0.033)and large artery atherosclerotic stroke subtype(OR 4.151,95%CI 1.880-9.169,P<0.001).Conclusions High stress hyperglycemia ratio was associated with MCE within 72 hours and poor functional outcome at discharge in patients with acute anterior circulation large artery occlusion after successful recanalization with thrombectomy.