炎性反应相关指标对急性缺血性卒中患者血管内治疗临床预后的影响

Influence of inflammatory markers on predicting clinical prognosis in patients with acute ischemic stroke after endovascular treatment

目的探讨术前炎性反应相关指标对急性大血管闭塞性卒中患者血管内治疗(EVT)术后90 d临床预后的影响。方法回顾性连续纳入2019年1月至2021年1月在首都医科大学宣武医院急诊科和神经内科接受EVT的急性大血管闭塞性卒中患者,根据术后90 d改良Rankin量表(mRS)评分结果,将其分为预后良好组与预后不良组。以mRS评分0~2分为预后良好,3~6分为预后不良,其中6分为死亡。收集并分析两组患者的基线资料、血管危险因素、术前实验室检测指标、术前炎性反应相关指标[中性粒细胞与淋巴细胞比值(NLR)、血小板与淋巴细胞比值(PLR)、全身炎症反应指数(SIRI)和系统性免疫炎症指数(SII)]、就诊流程时间、脑梗死分型及血管病变部位等临床资料。将单因素分析中P<0.05且临床意义较大的项目为自变量纳入多因素Logistic回归分析,探讨EVT术后90 d预后不良的独立影响因素。结果共纳入426例患者,其中预后良好组152例(35.7%),预后不良组274例(64.3%)。(1)与预后良好组相比,预后不良组患者年龄、入院收缩压、入院美国国立卫生研究院卒中量表(NIHSS)评分、术后NIHSS评分均较高[67(58,76)岁比62(54,70)岁,Z=-4.293;153(138,170)mmHg比143(130,160)mmHg,Z=-3.559;17(13,21)分比14(11,18)分,Z=-4.550;17(11,21)分比9(5,14)分,Z=-7.558],男性、饮酒比例均较低[60.2%(165/274)比77.0%(117/152),χ^(2)=12.265;23.4%(64/274)比37.5%(57/152),χ^(2)=9.615],糖尿病、卒中、冠心病比例均较高[33.6%(92/274)比19.7%(30/152),χ^(2)=9.163;34.3%(94/274)比20.4%(31/152),χ^(2)=9.126;28.1%(77/274)比17.1%(26/152),χ^(2)=6.449],入院Alberta卒中项目早期CT评分(ASPECTS)较低[8(7,9)分比9(8,10)分,Z=-9.134],组间差异均有统计学意义(均P<0.05)。两组体质量指数、高血压病、高脂血症、心房颤动、吸烟、入院舒张压的差异均无统计学意义(均P>0.05)。(2)与预后良好组相比,预后不良组患者急诊快测血糖、空腹血糖、中性粒细胞计数、C反应蛋白、D-二聚体、NLR、PLR、SIRI及SII水平均较高,淋巴细胞计数和单核细胞计数均较低,组间差异均有统计学意义[7.5(6.3,9.8)mmol/L比6.9(6.0,8.4)mmol/L,Z=-2.904;7.5(6.2,10.6)mmol/L比6.5(5.3,8.3)mmol/L,Z=-5.177;7.4(5.1,9.7)×10^(9)/L比6.5(5.0,8.6)×10^(9)/L,Z=-2.012;29.2(13.0,78.1)mg/L比12.6(7.1,17.7)mg/L,Z=-3.370;1.1(0.5,2.7)mg/L比0.6(0.3,1.7)mg/L,Z=-3.582;6.5(4.0,10.5)比5.1(2.9,7.7),Z=-3.614;185.2(123.1,281.6)比153.8(103.8,217.6),Z=-3.229;2.2(1.3,3.6)比1.7(1.1,3.0),Z=-2.222;1361(758,2401)比1019(535,1746),Z=-3.265;1.1(0.8,1.6)×10^(9)/L比1.4(1.1,1.9)×10^(9)/L,Z=-3.513;0.38(0.28,0.48)×10^(9)/L比0.41(0.32,0.52)×10^(9)/L,Z=-2.334;均P<0.05];白细胞计数的组间差异无统计学意义(P>0.05)。(3)与预后良好组相比,预后不良组患者血管再通达改良脑梗死溶栓(mTICI)分级2b~3级的比例较低,发生症状性颅内出血(sICH)及肺炎比例均较高,组间差异均有统计学意义[85.8%(235/274)比93.4%(142/152),χ^(2)=5.627;22.6%(62/274)比2.6%(4/152),χ^(2)=29.857;54.4%(149/274)比28.3%(43/152),χ^(2)=26.881;均P<0.05];两组急性卒中Org 10172治疗试验(TOAST)分型、流程时间及闭塞血管部位的差异均无统计学意义(均P>0.05)。(4)多因素Logistic回归分析显示,既往卒中(OR=2.302,95%CI:1.350~3.926,P=0.002)、冠心病史(OR=1.902,95%CI:1.072~3.372,P=0.028)、入院收缩压升高(OR=1.016,95%CI:1.006~1.026,P=0.002)、入院NIHSS评分高(OR=1.048,95%CI:1.014~1.083,P=0.006)、术后并发肺炎(OR=2.330,95%CI:3.657~31.741,P<0.01)、术后并发sICH(OR=10.774,95%CI:1.141~5.897,P<0.01)、mTICI分级<2b级(OR=2.594,95%CI:1.014~1.083,P=0.023)、高NLR(OR=1.135,95%CI:1.056~1.219,P=0.001)是急性大血管闭塞性卒中患者EVT后90 d预后的独立危险因素,高SIRI是EVT后90 d预后的保护因素(OR=0.898,95%CI:0.809~0.997,P=0.045)。结论术前高NLR可能增加急性大血管闭塞卒中患者EVT后90 d预后不良的风险,术前SIRI水平尚不能用于对EVT后90 d预后的评价。本研究结果有待于未来扩大样本量以及行多中心前瞻性EVT的炎性反应指标研究进一步证实。

Objective To investigate the influence of inflammatory markers on the 90 d clinical prognosis of acute large vessel occlusive stroke(ALVOS)patients after endovascular treatment(EVT).Methods Patients with ALVOS who underwent EVT in the Emergency Department or Neurology Department of Xuanwu Hospital,Capital Medical University from January 2019 to January 2021 were retrospectively and consecutively included.The patients were divided into good prognosis and poor prognosis groups according to the results of modified Rankin scale(mRS)scores 90 d after EVT.The mRS score of 0 to 2 was used as good prognosis,3 to 6 as poor prognosis,and 6 as death.Baseline data,vascular risk factors,laboratory test,inflammatory markers neutrophil-to-lymphocyte ratio[NLR],platelet-to-lymphocyte ratio[PLR],systemic inflammatory response index[SIRI]and systemic immune-inflammatory index[SII],time of consultation process,cerebral infarction classification and vascular lesion site were collected and analyzed for both groups.Univariate analysis and multivariate Logistic regression were performed to analyze the independent factors influencing the poor prognosis of patients 90 days after EVT.Results A total of 426 patients were included,including 152(35.7%)cases in the good prognosis group and 274(64.3%)cases in the poor prognosis group.(1)Compared with the good prognosis group,patients in the poor prognosis group had higher age,admission systolic blood pressure,admission National Institutes of Health Stroke scale(NIHSS)score,and postoperative NIHSS score(67[58,76]years old vs.62[54,70]years old,Z=-4.293;153[138,170]mmHg vs.143[130,160]mmHg,Z=-3.559;17[13,21]points vs.14[11,18]points,Z=-4.550;17[11,21]points vs.9[5,14]points,Z=-7.558),with lower proportions of male and drinking(60.2%[165/274]vs.77.0%[117/152],χ^(2)=12.265;23.4%[64/274]vs.37.5%[57/152],χ^(2)=9.615),and higher proportions of diabetes,stroke,and coronary heart disease(33.6%[92/274]vs.19.7%[30/152],χ^(2)=9.163;34.3%[94/274]vs.20.4%[31/152],χ^(2)=9.126;28.1%[77/274]vs.17.1%[26/152],χ^(2)=6.449),and lower admission Alberta stroke program early CT score(ASPECTS;8[7,9]vs.9[8,10],Z=-9.134),and all differences between groups were statistically significant(all P<0.05).The differences between two groups in body mass index,hypertension,hyperlipidemia,atrial fibrillation,smoking,and admission diastolic blood pressure were not statistically significant(all P>0.05).(2)Compared with the good prognosis group,patients in the poor prognosis group had higher levels of emergency fast glucose,fasting glucose,neutrophil count,C-reactive protein,D-dimer,NLR,PLR,SIRI and SII,and lower lymphocyte count and monocyte count,all with statistically significant differences between two groups(7.5[6.3,9.8]mmol/L vs.6.9[6.0,8.4]mmol/L,Z=-2.904;7.5[6.2,10.6]mmol/L vs.6.5[5.3,8.3]mmol/L,Z=-5.177;7.4[5.1,9.7]×10^(9)/L vs.6.5[5.0,8.6]×10^(9)/L,Z=-2.012;29.2[13.0,78.1]mg/L vs.12.6[7.1,17.7]mg/L,Z=-3.370;1.1[0.5,2.7]mg/L vs.0.6[0.3,1.7]mg/L,Z=-3.582;6.5[4.0,10.5]vs.5.1[2.9,7.7],Z=-3.614;185.2[123.1,281.6]vs.153.8[103.8,217.6],Z=-3.229;2.2[1.3,3.6]vs.1.7[1.1,3.0],Z=-2.222;1361[758,2401]vs.1019[535,1746],Z=-3.265;1.1[0.8,1.6]×10^(9)/L vs.1.4[1.1,1.9]×10^(9)/L,Z=-3.513;0.38[0.28,0.48]×10^(9)/L vs.0.41[0.32,0.52]×10^(9)/L,Z=-2.334;all P<0.05);there was no statistically significant difference between groups in the white blood cell count(P>0.05).(3)Compared with the good prognosis group,patients in the poor prognosis group had a lower proportion of revascularization of modified thrombolysis in cerebral infarction(mTICI)2b to 3 and a higher proportion of both symptomatic intracranial hemorrhage(sICH)and pneumonia,with statistically significant differences between two groups(85.8%[235/274]vs.93.4%[142/152],χ^(2)=5.627;22.6%[62/274]vs.2.6%[4/152],χ^(2)=29.857;54.4%[149/274]vs.28.3%[43/152],χ^(2)=26.881;all P<0.05);no statistically significant differences in trial of Org10172 in acute stroke treatment(TOAST)typing,process time and occluded vessel site were found between two groups(all P>0.05).(4)Multivariate Logistic regression analysis showed that previous stroke(OR,2.302,95%CI 1.350-3.926,P=0.002),previous coronary artery disease(OR,1.902,95%CI 1.072-3.372,P=0.028),high systolic blood pressure on admission(OR,1.016,95%CI 1.006-1.026,P=0.002),high admission NIHSS score(OR,1.048,95%CI 1.014-1.083,P=0.006),pneumonia(OR,2.330,95%CI 3.657-31.741,P<0.01),sICH(OR,10.774,95%CI 1.141-5.897,P<0.01),mTICI<2b(OR,2.594,95%CI 1.014-1.083,P=0.023),high NLR(OR,1.135,95%CI 1.056-1.219,P=0.001)were independent risk factor on the prognosis of 90 d after EVT in ALVOS,high SIRI was a protective factor for the 90 d prognosis after EVT(OR,0.898,95%CI 0.809-0.997,P=0.045).Conclusions High preoperative NLR may increase the risk of poor prognosis 90 d after EVT in patients with ALVOS.Preoperative SIRI levels cannot be used to evaluate the 90 d prognosis after EVT.The results of this study need to be further confirmed by expanding the sample size and performing a multicenter prospective EVT study of inflammatory markers in the future.