静脉溶栓在急性大血管闭塞性脑卒患者中的疗效及预后影响因素

Efficacy of mechanical thrombectomy in acute ischemic stroke with large vessel occlusion and analysis of related factors affecting its prognosis

目的比较单独静脉溶栓(IVT)与机械取栓术(MT)对急性大血管闭塞性脑卒中(AIS-LVO)的疗效,分析影响MT预后的相关因素。方法回顾性分析2016年4月至2021年7月在大连医科大学附属第二医院卒中中心收治的接受IVT和(或)MT治疗的197例AIS-LVO患者。收集入组患者的基线资料、临床资料及90 d预后等数据。通过单因素分析和多因素回归分析比较单独IVT和MT(伴或不伴IVT)的疗效和风险,筛查影响MT预后的相关因素。结果纳入符合入组标准患者共197例,分为单独IVT组62例和MT组135例。单因素分析显示,相比单独IVT组,MT组的入院收缩压更低[(147±23)mmHg比(158±27)mmHg,P=0.003],基线美国国立卫生研究院卒中量表(NIHSS)评分更高[15(12,19)比12(8,16),P=0.003],两组闭塞血管差异有统计学意义(χ^(2)=15.504,P=0.004),MT组大脑中动脉M1段和基底动脉闭塞占比较高;在结局上MT组获得90 d预后良好比例更高[53(39%)比13(21%),χ^(2)=6.381,P=0.012],但在症状性颅内出血(sICH)及90 d内死亡等因素上差异无统计学意义。在135例行MT的患者中,预后良好组53例,预后不良组82例。多因素分析显示:年龄(OR=1.078,95%CI:1.025~1.133,P=0.003)、中性粒细胞与淋巴细胞的比值(NLR)(OR=1.164,95%CI:1.013~1.338,P=0.032)、发病到再通时间(OR=1.004,95%CI:1.000~1.007,P=0.049)、症状性颅内出血(sICH)(OR=15.585,95%CI:1.397~173.865,P=0.026)、Alberta卒中项目早期CT评分(ASPECTS)/后循环(pc)-ASPECTS评分(OR=0.524,95%CI:0.017~0.582,P=0.024)和再通良好(OR=0.099,95%CI:1.718~59.046,P=0.010)是患者预后的独立影响因素。提前IVT、使用补救措施以及静点替罗非班及丁苯酞药物对MT组预后均无显著性影响。结论AIS-LVO患者MT治疗效果优于单独IVT治疗且同样安全;年龄大、NLR高、发病到再通时间长及术后sICH是MT治疗预后不良的独立预测因素,而ASPECTS/pc-ASPECTS评分和良好再通是MT治疗预后良好的保护因素。

Objective To compare the effectiveness of intravenous thrombolysis(IVT)alone versus mechanical thrombectomy(MT)in treating acute large vessel occlusive stroke(AIS-LVO).Amd to analyze the factors that are associated with the prognosis of MT.Methods A total of 197 patients with acute ischemic stroke with large vessel occlusion(AIS-LVO)who received intravenous thrombolysis(IVT)and/or mechanical thrombectomy(MT)at the Stroke Center of the Second Hospital of Dalian Medical University from April 2016 to July 2021 were included in this retrospective analysis.Baseline data,clinical data,and 90-day Modified Rankin Scale(mRS)scores were collected for each group.The efficacy and risk of IVT alone and MT were compared using univariate and multivariate logistic regression analysis.Additionally,factors influencing the prognosis of MT were identified.Results A total of 197 patients who met the inclusion criteria were included in this study.Out of these,62 patients were in the IVT alone group and 135 patients were in the MT group.The results of the univariate analysis showed that the MT group had lower admission systolic blood pressure(147±23 vs.158±27 mmHg,P=0.003),higher baseline NIHSS score[15(12,19)vs.12(8,16),P=0.003],and there were also differences in vascular occlusion between the two groups(χ^(2)=15.504,P=0.004).Specifically,the middle cerebral artery and basilar artery occlusion were higher in the MT group.In terms of outcome,the MT group had a higher percentage of good outcomes at 90 days[53(39%)vs.13(21%),χ^(2)=6.381,P=0.012],and there was no significant difference in symptomatic intracranial hemorrhage(sICH)and mortality within 90 days.Among the 135 patients who underwent MT,53 patients were classified as having a good prognosis,while 82 patients were classified as having a poor prognosis.Multivariate analysis revealed that age(OR=1.078,95%CI:1.025-1.133,P=0.003),neutrophil to lymphocyte ratio(NLR)(OR=1.164,95%CI:1.013-1.338,P=0.032),time from onset to recanalization(OR=1.004,95%CI:1.000-1.007,P=0.049),sICH(OR=15.585,95%CI:1.397-173.865,P=0.026),ASPECTS/pc-ASPECTS score(OR=0.524,95%CI:0.017-0.582,P=0.024),and good recanalization(OR=0.099,95%CI:1.718-59.046,P=0.010)were identified as independent prognostic factors.The results indicate that percutaneous transluminal angioplasty,stent implantation,and the use of tirofiban and butylphthalide did not significantly affect the prognosis of the MT group.Conclusions The use of mechanical thrombectomy(MT)in patients with acute ischemic stroke due to large vessel occlusion(AIS-LVO)is more effective than intravenous thrombolysis(IVT)alone and has a similar safety profile.However,there are certain factors that can influence the prognosis of MT treatment.Older age,higher neutrophil-to-lymphocyte ratio(NLR),longer time from symptom onset to recanalization,and the occurrence of postoperative symptomatic intracranial hemorrhage(sICH)were identified as independent predictors of poor prognosis in MT treatment.On the other hand,a higher ASPECTS/pc-ASPECTS score and successful recanalization were found to be protective factors associated with a favorable prognosis in MT treatment.