高龄急性大血管闭塞性卒中患者血管内治疗的疗效及预后分析

Analysis of the efficacy and outcome of endovascular treatment in elderly patients with acute large vessel occlusion stroke

目的分析高龄(≥80岁)急性大血管闭塞性卒中(ALVOS)患者血管内治疗的安全性和有效性,并探讨影响其预后的相关因素.方法回顾性分析2017年6月至2021年12月郑州大学附属郑州中心医院神经介入科行血管内治疗的68例高龄ALVOS患者的临床资料,以术后3个月的改良Rankin量表评分(mRS)结果分为预后良好组(mRS<3分)和预后不良组(mRS≥3分),并对两组患者的基线资料、临床特征及治疗过程行单因素分析,并将结果中P<0.05的因素纳入多因素logistic回归分析模型中,选择向前进行逐步回归,获得影响高龄患者预后不良的独立预测因素.绘制受试者工作特征(ROC)曲线并计算曲线下面积(AUC),以确定预后的临界值及其预测效能.结果68例患者的血管内治疗均顺利完成.53例(77.9%)患者血管成功再通,术后41例(60.3%)发生肺部感染、4例(5.9%)血栓逃逸、17例(25.0%)症状性颅内出血(sICH)、19例(27.9%)死亡.预后良好组29例(42.6%),预后不良组39例(57.4%);两组患者单因素分析结果显示,心房颤动、术前美国国立卫生研究院卒中量表(NIHSS)评分、术前静脉溶栓、术中动脉溶栓、术中配合抽吸、术中支架取栓次数、治疗方式、超时间窗(发病至手术时间>6 h)、血管成功再通的差异均有统计学意义(均P<0.05).多因素logistic回归分析结果显示,术中支架取栓次数、术前NIHSS评分和血管成功再通是患者预后不良的独立影响因素(均P<0.05).多因素综合ROC曲线结果预测术后3个月预后不良的临界值为0.64,约登指数最大值为0.73,灵敏度为79.5%,特异度为93.1%,AUC值为0.92(95%CI:0.86~0.98,P<0.001);术前NIHSS评分预测术后3个月预后不良的临界值为14.50,约登指数最大值为0.48,灵敏度为82.1%,特异度为65.5%,AUC值为0.78(95%CI:0.67~0.90,P<0.001).结论高龄ALVOS患者接受血管内治疗后应警惕术后神经功能障碍、sICH、死亡等并发症的发生;通过术前NIHSS评分个体化选择患者进行血管内治疗,并在术中尽量减少支架取栓次数实现闭塞血管成功再通,可使患者从中获益.

Objective To analyze the safety and efficacy of endovascular treatment in elderly(≥80 years old)patients with acute large vessel occlusion stroke(ALVOS),and to explore the relevant factors affecting the outcome.Methods A retrospective analysis was conducted on the clinical data of 68 elderly patients with ALVOS who underwent endovascular treatment in the Department of Neurological Intervention,Zhengzhou Central Hospital of Zhengzhou University from June 2017 to December 2021.Based on the modified Rankin scale(mRS)scores at 3 months after surgery,all patients were divided into good outcome group(mRS<3 points)and poor outcome group(mRS≥3 points).The baseline data,clinical characteristics,and treatment of the two groups were analyzed using univariate analysis.Factors with P<0.05 were incorporated into a multivariate logistic regression analysis model.Forward stepwise regression was used to obtain independent predictors of poor outcome in elderly patients.We plotted the receiver operating characteristic(ROC)curve and calculated the area under the curve(AUC)to determine the critical value of prognosis and its predictive efficacy.Results The endovascular procedures of 68 patients were successfully completed.In this series,53 patients(77.9%)had successful revascularization,41 patients(60.3%)experienced pulmonary infection,4 patients(5.9%)experienced thrombus escape,17 patients(25.0%)had sICH,and 19 patients(27.9%)died after surgery.There were 29 cases(42.6%)in the group with good outcome and 39 cases(57.4%)reported poor outcome.The results of two sets of univariate analysis showed that there were statistically significant differences in atrial fibrillation,preoperative NIHSS score,preoperative intravenous thrombolysis,intraoperative arterial thrombolysis,intraoperative suction coordination,intraoperative stent thrombectomy frequency,treatment method,time window(onset to surgery time>6 hours),and successful vascular recanalization(all P<0.05).The results of multivariate logistic regression analysis showed that the frequency of intraoperative stent thrombectomy,preoperative NIHSS score,and vascular recanalization were independent influencing factors for poor outcomes of patients(all P<0.05).Multifactor ROC curve results for predicting poor prognosis at 3 months after surgery was 0.64,the maximum value of the Jordan index was 0.73,the sensitivity was 79.5%,the specificity was 93.1%,and the AUC value was 0.92(95%CI:0.86-0.98,P<0.001);The critical value of preoperative NIHSS score for predicting poor prognosis at 3 months after surgery was 14.50,the maximum value of the Jordan index was 0.48,the sensitivity was 82.1%,the specificity was 65.5%,and the AUC value was 0.78(95%CI:0.67-0.90,P<0.001).Conclusions For elderly patients with ALVOS after endovascular treatment,attention should be paid to the occurrence of complications such as postoperative neurological dysfunction,sICH,and death.Endovascular treatment should be individually selected based on the preoperative NIHSS score.The number of stent thrombectomy procedure should be minimized during surgery to achieve recanalization of occluded blood vessels,which can benefit patients.