急性多血管闭塞的危险因素分析及其对血管内治疗后良好再通前循环急性大血管闭塞性卒中患者预后的影响

Influencing factor of acute multivessel occlusion and its impact on prognosis of acute large vessel occlusion stroke patients after successful recanalization of endovascular treatment

目的探讨发生急性多血管闭塞(MVO)的危险因素及其对血管内治疗(EVT)后良好再通的前循环急性大血管闭塞性卒中(ALVOS)患者预后的影响。方法回顾性连续纳入皖南医学院弋矶山医院神经内科自2015年7月至2023年4月收治的急诊行EVT后良好再通的前循环ALVOS患者的临床资料。收集患者的基线及随访资料,包括年龄、性别、发病至穿刺时间(OTP)、发病至血流恢复时间(OTR)、既往史(包括心房颤动、糖尿病、高血压病)、饮酒史、吸烟史及入院时血压(收缩压、舒张压)、Alberta卒中项目早期CT评分(ASPECTS)、美国国立卫生研究院卒中量表(NIHSS)评分、急性卒中Org 10172治疗试验(TOAST)分型(大动脉粥样硬化型、心源性栓塞型、其他原因型)及术后90 d改良Rankin量表(mRS)评分等。根据术中延迟DSA时闭塞动脉供血区域内对比剂逆流使血管显影的程度,对软脑膜侧支情况进行评估,并分为侧支循环不良与侧支循环良好。恶性脑水肿定义为术后3 d复查CT时提示中线移位≥5 mm。主要终点事件(有效性指标)为术后90 d mRS评分,以mRS评分≤2分为预后良好,mRS评分>2分为预后不良。次要终点事件(安全性指标)为术后90 d病死率。根据多个还是单个颅内血管闭塞将所有患者分为MVO组(非单个颅内血管闭塞)和非MVO组(单个颅内血管闭塞)。将急性MVO定义为在患者的CT血管成像和(或)MR血管成像或DSA检查中,除了主要血管[颈内动脉、大脑中动脉(MCA)的M1段或M2段]闭塞外,还检测到其他的大或中等血管发生急性闭塞,导致不同于主要闭塞血管供血区域的脑组织遭受缺血。将单因素分析,差异有统计学意义的因素进一步纳入多因素Logistic回归分析以明确急性MVO发生的危险因素和影响ALVOS患者预后的因素。结果共纳入846例ALVOS患者,年龄26~94岁,平均(69±11)岁,男性患者占比57.2%(484/846);中位入院ASPECTS为8(7,9)分,中位入院NIHSS评分为14(12,18)分;术后3 d恶性脑水肿发生率13.4%(112/835),术后90 d病死率19.1%(162/846)。(1)846例ALVOS患者中,非MVO组810例(95.7%),MVO组36例(4.3%)。单因素分析结果显示,MVO组与非MVO组的患者在心房颤动、恶性脑水肿、入院ASPECTS、入院NIHSS评分、TOAST分型、侧支循环、术后血管完全再通比例及术后90 d预后不良率上的差异均有统计学意义(均P<0.05),而两组术后90 d病死率差异无统计学意义(P=0.193)。多因素Logistic回归分析结果显示,TOAST分型为心源栓塞型(OR=16.089,95%CI:1.835~141.061,P=0.012)和其他原因型(OR=9.768,95%CI:1.078~88.540,P=0.043)与MVO的发生有关。(2)846例ALVOS患者中,术后90 d预后良好组445例,预后不良组401例。单因素分析结果显示,与预后良好组相比,预后不良组男性、吸烟比例更低,平均年龄、基线收缩压及高血压病、糖尿病、心房颤动患者比例更高(均P<0.01)。此外,预后不良组患者的入院NIHSS评分更高(P<0.01),入院ASPECTS及侧支循环良好、血管完全再通比例更低,恶性脑水肿、MVO患者比例更高,且两组TOAST分型分布差异有统计学意义(均P<0.01)。多因素Logistic分析结果显示,MVO与ALVOS患者行EVT术后90 d预后不良有关(OR=3.368,95%CI:1.149~9.878,P=0.027)。此外,年龄增加(OR=1.045,95%CI:1.025~1.066)、糖尿病(OR=1.719,95%CI:1.080~2.734)、高基线收缩压(OR=1.012,95%CI:1.004~1.019)、低入院ASPECTS(OR=0.746,95%CI:0.674~0.826)、高入院NIHSS评分(OR=1.115,95%CI:1.070~1.162)、术后即刻血管未完全再通(OR=0.413,95%CI:0.290~0.592)、侧支循环不良(OR=0.594,95%CI:0.415~0.851)、恶性脑水肿(OR=6.191,95%CI:3.026~12.670)均与ALVOS患者行EVT术后90 d不良预后有关(均P<0.05)。结论TOAST分型为心源性栓塞型和其他原因型是导致MVO的高风险因素。MVO是影响ALVOS患者行EVT治疗良好再通后预后的危险因素。

Objective To investigate the influencing factors for acute multiple vessels occlusion(MVO)and its impact on the prognosis of patients with anterior circulation acute large vessel occlusion stroke(ALVOS)who achieved successful recanalization after endovascular treatment(EVT).Methods Patients with anterior circulation ALVOS who received successful EVT at the Yijishan Hospital of Wannan Medical College between July 2015 and April 2023 were retrospectively analyzed.Baseline data,including age,sex,onset-to-puncture time(OTP),onset-to-recanalization time(OTR),medical history(including atrial fibrillation,diabetes,hypertension),alcohol and smoking history,admission blood pressure(systolic and diastolic),Alberta stroke program early CT score(ASPECTS),National Institutes of Health stroke scale(NIHSS)score,trial of Org 10172 in acute stroke treatment(TOAST)classification(atherosclerotic type,cardioembolic type,and other etiology types),and 90-day modified Rankin scale(mRS)score were collected.Collateral circulation was assessed based on the degree of contrast agent reflux observed in the occluded arterial supply area during delayed DSA,and patients were classified into poor and good collateral circulation groups.Malignant cerebral edema was defined as a midline shift of≥5 mm on the follow-up CT scan performed on day 3 post-surgery.The primary endpoint(efficacy indicator)was the 90-day mRS score,with mRS score≤2 considered as a good prognosis and mRS score>2 considered as a poor prognosis.The secondary endpoint(safety indicator)was the 90-day mortality rate.All patients were divided into MVO and non-MVO groups based on whether they had single or multiple intracranial vessel occlusions.Acute MVO was defined as the detection of acute occlusion of other large or medium vessels,in addition to the main vessels(internal carotid artery or M1/M2 segments of the middle crebral artery[MCA]),in CT angiography,MR angiography,or DSA,resulting in ischemia in brain regions distinct from the main occlusion area.Factors that showed statistically significant differences in univariate analysis were further analyzed using multivariate Logistic regression to identify the risk factors for the occurrence of acute MVO and the factors associated with the prognosis of ALVOS patients.Results A total of 846 patients with ALVOS were included,with ages ranging from 26 to 94 years(mean age[69±11]years).The proportion of male patients was 57.2%(484/846).The median admission ASPECTS was 8(7,9)and the median admission NIHSS score was 14(12,18).The incidence of malignant cerebral edema at 3 days post-surgery was 13.4%(112/835),and the 90-day mortality rate was 19.1%(162/846).(1)Among the 846 ALVOS patients,810(95.7%)were in the non-MVO group and 36(4.3%)were in the MVO group.Univariate analysis showed significant differences between the MVO and non-MVO groups in terms of atrial fibrillation,malignant cerebral edema,admission ASPECTS,admission NIHSS scores,TOAST classification,collateral circulation,rate of complete recanalization,and 90-day poor prognosis rate(all P<0.05).However,there was no statistically significant difference in 90-day mortality between the two groups(P=0.193).Multivariate Logistic regression analysis showed that TOAST classification of cardioembolic type(OR,16.089,95%CI 1.835-141.061,P=0.012)and other etiology types(OR,9.768,95%CI 1.078-88.540,P=0.043)were associated with the occurrence of MVO.(2)Among the 846 ALVOS patients,445 had a good prognosis at 90 days,and 401 had a poor prognosis.Univariate analysis showed that,compared to the good prognosis group,the poor prognosis group had a lower proportion of males and smokers,and a higher proportion of patients with older age,higher baseline systolic blood pressure,hypertension,diabetes,and atrial fibrillation(all P<0.01).Additionally,the poor prognosis group had higher admission NIHSS scores(P<0.01),lower admission ASPECTS,lower rates of good collateral circulation and complete recanalization,higher rates of malignant cerebral edema and MVO,and statistically significant differences in TOAST classification distribution(all P<0.01).Multivariate Logistic regression analysis showed that MVO was associated with poor 90-day prognosis in ALVOS patients after EVT(OR,3.368,95%CI 1.149-9.878,P=0.027).Furthermore,older age(OR,1.045,95%CI 1.025-1.066),diabetes(OR,1.719,95%CI 1.080-2.734),higher baseline systolic blood pressure(OR,1.012,95%CI 1.004-1.019),lower admission ASPECTS(OR,0.746,95%CI 0.674-0.826),higher admission NIHSS score(OR,1.115,95%CI 1.070-1.162),without immediate postoperative complete recanalization(OR,0.413,95%CI 0.290-0.592),poor collateral circulation(OR,0.594,95%CI 0.415-0.851),and malignant cerebral edema(OR,6.191,95%CI 3.026-12.670)were all associated with poor 90-day prognosis after EVT in ALVOS patients(all P<0.05).Conclusions The TOAST classification of cardioembolic type and other etiology types is associated with MVO.MVO is a risk factor for poor outcomes after successful EVT in ALVOS patients.