大脑中动脉磁敏感血栓征对急性缺血性脑卒中静脉溶栓影响的研究

发布时间：2018-06-24 03:01

  本文选题：再通 + 出血转化　； 参考：《浙江大学》2014年博士论文

【摘要】：研究背景 脑血管病是威胁人类生命最常见的神经系统疾病,根据最新的流行病学调查结果,卒中已攀升为我国成人中第一位致残和死亡原因,且发病有逐年增多的趋势。随着动脉内机械取栓技术的发展,分析急性缺血性卒中颅内动脉新鲜血栓的组织病理学变成可能。在一项大脑中动脉取栓的组织病理学研究发现,所有的血栓都包含纤维蛋白、血小板、有核细胞(中性粒细胞／单核细胞)以及红细胞等成分,但不同血栓内各种成分比例不同。在股动脉血栓形成模型中,富含血小板的白色血栓对静脉rt-PA溶栓显示出一定的阻抗,而富含红细胞的红色血栓则表现出更快速的药物反应。血栓的特性决定了血管再通治疗的疗效。 大脑中动脉(middle cerebral artery, MCA)是临床上最为常见的颅内大血管闭塞部位。梯度回波序列(gradient-recalled echo, GRE)提供了一个特异性和敏感性高的显示血栓的方法。GRE序列对脱氧血红蛋白非常敏感,大脑中动脉的磁敏感血栓征,可能提示血栓成分中含有较多的红细胞。此外,最近的一项影像学及病理学关联性研究表明,GRE上的磁敏感血栓征与CT上的大脑中动脉高密度征都提示血栓成分中包含了更多的红细胞。所以磁敏感血栓征可能存在预测血管再通及临床预后的潜在价值。 在动脉纤溶治疗或者静脉重组组织型纤溶酶原激活剂(rt-PA)治疗中,责任血管内血栓的体积或长度是血管是否再通和预后的重要影响因素。一项最新的机械取栓研究表明,不规则形状的血栓提示影响了大脑中动脉主干的Merci取栓后再通成功率。静脉rt-PA溶栓治疗与动脉取栓不同rt-PA需将纤溶酶原激活成纤溶酶,通过渗透进入目标血栓,溶解纤维蛋白丝起到溶解血栓的作用。目前大脑中动脉磁敏感血栓征与急性缺血性卒中静脉rt-PA治疗后血管再通缺乏相关研究。 研究目的 观察影响大脑中动脉磁敏感血栓征出现的因素,明确大脑中动脉磁敏感血栓征对于急性缺血性卒中患者静脉重组组织型纤溶酶原激活剂(rt-PA)溶栓后大脑中动脉的再通、出血转化以及3个月后神经功能结局的影响。 研究方法 连续收集就诊于我科并接受静脉rt-PA溶栓治疗的急性缺血性卒中患者,入组行溶栓前后磁共振检查的大脑中动脉闭塞患者,分析其临床资料,在磁敏感序列上评价血栓征体积、长度及形态,利用动脉闭塞病灶(Arterial Occlusive Lesion,AOL)量表评估治疗后血管再通情况,出血转化根据欧洲协作性急性卒中研究Ⅱ(ECASS II)标准评定,改良Rankin评分≥3分定义为不良神经功能结局。 研究结果 72例患者符合入组条件,平均年龄为(66.14±13.19)岁,女性22例(30.6%),发病至溶栓时间为(229.10±67.77)分,溶栓前NIHSS为(12.90±5.92)分。共27例(37.5%)影像学表现为溶栓后出血转化,18例(25.0%)为出血性梗死(HI)型,9例(12.5%)为脑实质出血(PH)型,其中3例(4.2%)为症状性脑出血(sICH).其中50例(69.4%)患者存在磁敏感血栓征,33例(45.8%)复查磁共振血管检查提示再通。经二元Logistic回归分析提示,合并糖尿病(OR=0.157,95%CI0.031～0.784,P=0.024)与低国际标准化比值(INR)(OR=0.215per0.1,95%CI0.080～0.577,P=0.002)是磁敏感血栓征存在的独立影响因素,使用基线血糖水平替代糖尿病病史进入模型,仍有统计学差异(OR=0.741,95%CI0.562-0.977,P=0.033)。相对于初次诊断的房颤来说,慢性房颤有更容易出现磁敏感血栓征的趋势(OR=4.424,95%CI0.913-21.439,P=0.065).单纯磁敏感血栓征的存在与否无法预测溶栓后无再通(OR=2.333,95%CI0.760-7.161,P=0.139),出血转化(OR=0.635,95%CI0.189.2.136,P=0463)以及3月不良神经功能结局(OR=2.003,95%CI0.507-7.915,P=0.322)。 在50例存在磁敏感血栓征的患者中,平均长度为14.744±7.971mm(范围为3.98-38.31mm),平均体积为0.377±0.255ml(范围为0.02-1.22m1)。M1闭塞的患者中存在更多的不规则磁敏感血栓征。不规则磁敏感血栓征的长度要大于规则的血栓征(18.134±8.787mm VS11.072±4.936mm, P=0.001),并且体积也更大(0.490±0.270ml VS0.256±0.172ml,P=0.001).而且存在规则磁敏感血栓的患者,其溶栓后24小时大脑中动脉再通的比例更高(62.5%VS23.1%,P=0.009)。不规则形状的磁敏感血栓征能独立预测溶栓后24小时大脑中动脉无再通(OR=6.153,95%CI1.515-24.993,P=0.011),优于血栓征长度(OR=1.095,95%CI0.970-1.236,P=0.142),但不能预测溶栓后出血转化(OR=0.762,95%CI0.177～3.280,P=0.715)与3月不良神经功能结局(OR=1.570,95%CI0.377～6.529,P=0.535). 研究结论 血糖与INR水平影响了急性缺血性卒中患者大脑中动脉磁敏感血栓征的形成。单纯磁敏感血栓征无法预测溶栓后大脑中动脉再通情况、溶栓后出血转化及3月神经功能结局。不规则形状的磁敏感血栓征能独立预测溶栓后24小时大脑中动脉再通情况,但不能预测溶栓后出血转化及3月神经功能结局。
[Abstract]:Background of the study

Cerebral vascular disease is one of the most common neurological diseases threatening the life of human life . According to the latest epidemiological investigation , the cause of death and death of cerebral artery in the adult of our country has been rising . With the development of internal mechanical thrombectomy , it is found that all the thrombus contains fibrin , platelets , nucleated cells ( neutrophils / monocytes ) and red blood cells , but the proportion of various components in different thrombosis is different . In the model of femoral artery thrombosis , the white thrombus rich in platelets shows a certain impedance to the intravenous rt - PA thrombolytic therapy , while red blood cells rich in red blood cells show a more rapid drug reaction .

The middle cerebral artery ( MCA ) is one of the most common intracranial vascular occlusion sites in the clinic . gradient echo sequence ( GRE ) provides a specific and sensitive method for displaying thrombus . GRE sequences are very sensitive to deoxyhemoglobin , and the magnetic susceptibility of the middle cerebral artery may indicate that there are more red blood cells in the thrombus .

In the treatment of thrombolytic therapy or intravenous recombinant tissue type plasminogen activator ( rt - PA ) , the volume or length of thrombus in a responsible vessel is an important factor influencing the re - opening and prognosis of blood vessels .

Purpose of study

To investigate the factors affecting the occurrence of magnetic susceptibility in the middle cerebral artery , and to clarify the effect of magnetic susceptibility of middle cerebral artery on the re - opening , bleeding and neurological outcome of the middle cerebral artery after thrombolytic therapy in patients with acute ischemic stroke .

Research Methods

The clinical data of patients with acute ischemic stroke treated with intravenous rt - PA thrombolytic therapy were collected , and the clinical data were analyzed . The volume , length and morphology of thrombus were assessed on the magnetic sensitive sequences .

Results of the study

Of the 72 patients , the mean age was ( 66.14 卤 13.19 ) years old , and 22 cases ( 36.6 % ) of female were divided into two groups ( OR = 0.157 , 95 % CI 0.031 锝，

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