脑梗死后非症状性出血转化的危险因素及预后

发布时间：2018-01-25 11:39

本文关键词： 非症状性出血转化独立危险因素预后　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：研究背景及目的:脑血管病是引起人类残疾的主要原因之一,其中脑梗死占80%。卒中后发生一系列并发症常常使患者病情加重,其中最常见的是梗死后出血性转化[1]。急性脑梗死发生后血液通过损伤的血管内皮溢出即出血转化(hemorrhagic transformation,HT),其可以通过影像学手段(如MRI、CT)明确诊断。目前,根据是否出现临床症状加重,可将HT分为非症状性出血转化及症状性出血转化[2]。前者是指临床上没有明显症状,仅在影像上提示出血灶,而后者则定义较多,其中欧洲急性卒中协作研究(ECASS)将症状性出血转化定义为CT发现的可以解释临床症状恶化的病灶,且NIHSS评分提高≥4分。目前已经有很多危险因素被证实与脑梗死后HT有关,比如梗死部位、梗死面积、循环再通时间、梗死严重程度、血压、血糖、血小板数量,抗凝、抗血小板、溶栓治疗等[3]。溶栓治疗是目前有效的治疗脑梗死的方法,但其可使HT发生率显著增高,且很多研究证实HT可以显著促进大脑进一步损伤,并且与不良预后有关,因此限制了溶栓治疗的使用[4]。非症状性出血转化(asymptomatic hemorrhagic transformation,aSHT)与急性脑卒中患者的功能恶化无关,然而,其是否会影响患者远期预后,至今仍不清楚。因此,了解HT相关危险因素,在溶栓及抗栓治疗前发现出血转化高危人群,对于减少HT的发生及改善急性缺血性卒中预后至关重要。本文的目的就是研究非症状性出血性转化对急性脑梗死后3个月的功能是否有影响及与其相关独立危险因素。方法:搜集2015年8月至2016年8月在我院住院的急性缺血性卒中患者448名,均符合中华医学会第四次全国脑血管病会议制定的关于缺血性脑血管病诊断标准,并经头颅MRI+DWI证实为急性脑梗死,其中符合入组标准非症状性出血转化患者44例,无出血转化患者404例。详细记录患者性别、年龄、既往史(吸烟、饮酒、既往卒中相关病史、高血脂、高血压、高血糖、房颤、肿瘤、家族史等)、入院时基线血脂(甘油三酯、总胆固醇、低密度脂蛋白、高密度脂蛋白)、脑梗死部位(前循环、后循环)、脑梗死面积、脑梗死后出血转化情况、入院初始NIHSS评分等,并对上述指标进行单因素分析,对单因素分析存在统计学意义的影响因素进行Logistic回归分析,以阐明影响非症状性HT的独立危险因素;并于患者出院3个月时进行电话随访,详细询问并记录mRS评分,通过比较HT与非HT两组间mRS的差异评估HT是否影响脑梗死患者的远期预后。结果:448急性缺血性脑卒中患者中发生非症状性出血性转化的共44例,发生率约为9.82%,其中死亡2例(0.45%),占脑梗死总死亡数的2/9;脑梗死后非症状性出血转化使90天神经功能恶化(OR=5.86,P0.001);单因素分析表明高血压、高血脂、房颤、大面积脑梗死和基线NIHSS高5组变量在两组之间有统计学意义(P分别0.05),另外,本研究发现后循环卒中是非症状性HT发生率低的预测因素(P0.05);而年龄、性别、吸烟、高血糖、既往卒中史、肿瘤史与非症状性出血转化无统计学相关性。以是否存在非症状性出血转化为因变量(HT=1,非HT=0),对高血压、高血脂、房颤、大面积脑梗死及基线NIHSS评分进行Logistic回归分析表明房颤(OR=2.096,P=0.047,95%CI 1.923-4.757)、大面积脑梗死(OR=10.455,P0.001,95%CI 4.765-22.940)、初始NIHSS评分(OR=1.123,P=0.015,95%CI 1.023-1.232)为脑梗死后非症状性出血转化的独立危险因素。结论:(1)脑梗死后非症状性出血转化影响患者的远期预后(OR=5.86,p0.001)。(2)asHT相关独立危险因素有房颤、大面积脑梗死、初始高NIHSS评分。(3)后循环脑梗死为非症状性出血转化发生率低的预测因素。
[Abstract]:Background and purpose: cerebrovascular disease is the main cause of the disabled people, which accounted for 80%. of cerebral infarction after stroke occurred in a series of complications often increase the patient's condition, is one of the most common hemorrhagic transformation after cerebral infarction [1]. after the onset of acute cerebral infarction by blood vascular endothelial injury is overflow (hemorrhagic transformation, HT hemorrhagic transformation), can learn by means of the image (such as MRI, CT) to confirm the diagnosis. At present, according to the appearance of clinical symptoms, the HT can be divided into non symptomatic hemorrhagic transformation and symptomatic hemorrhagic transformation [2]. the former refers to no obvious clinical symptoms, suggesting hemorrhage only in the image, the latter is more defined among them, the European Cooperative Acute Stroke Study (ECASS) symptomatic hemorrhagic transformation is defined as CT that can explain the clinical symptoms of the deterioration of the lesions, and the NIHSS score increased more than 4. At present there have been Many risk factors were confirmed after cerebral infarction and HT related, such as myocardial infarction, infarct size, circulating recanalization time, infarction severity, blood pressure, blood glucose, platelet count, anticoagulation, antiplatelet, thrombolytic therapy of [3]. thrombolytic therapy is an effective method for the treatment of cerebral infarction, but the incidence rate of HT was significantly increased, and the many studies have confirmed that HT can significantly promote the further brain damage, and associated with poor prognosis, thus limiting the use of thrombolytic therapy for asymptomatic hemorrhagic transformation ([4]. asymptomatic hemorrhagic transformation, aSHT) and the function of patients with acute stroke progression free, however, whether it will affect the long-term prognosis of patients, is still unclear. Therefore, understand the HT risk factors in thrombolytic and antithrombotic therapy before the discovery of hemorrhagic transformation in high risk population, to reduce the incidence of HT and improve the prognosis of acute ischemic stroke. Important. The purpose of this paper is to study the non symptomatic hemorrhagic transformation of acute cerebral infarction after 3 months if there is an effect function and related independent risk factors. Methods: collected from August 2015 to August 2016 in our hospital in patients with acute ischemic stroke in 448, are in line with the Huayi Institute of the fourth national cerebrovascular disease conference set about the diagnosis of ischemic cerebrovascular disease, and confirmed by brain MRI+DWI for acute cerebral infarction, which met the inclusion criteria for non symptomatic hemorrhagic transformation in patients with 44 cases, 404 cases without conversion. Detailed records of patients with hemorrhage in patients with sex, age, smoking, alcohol drinking, past medical history (related to a history of previous stroke, hyperlipidemia, hypertension, high blood glucose, atrial fibrillation, cancer, family history), admission baseline lipids (triglycerides, total cholesterol, low density lipoprotein, high density lipoprotein), cerebral infarction area (anterior circulation, posterior circulation cerebral infarction). The area, the transformation of hemorrhage after cerebral infarction, initial admission NIHSS score, and the above indexes were analyzed by single factor analysis, single factor analysis of the factors influencing the statistical significance of Logistic regression analysis, to clarify the influence of non independent risk factors of symptomatic HT; telephone follow-up and 3 months after discharge in patients when asked in detail and record the mRS score, by assessing whether the difference between the HT and non HT mRS between the two groups of HT affect the long-term prognosis of patients with cerebral infarction. Results: asymptomatic hemorrhagic transformation of a total of 44 cases occurred in 448 patients with acute ischemic stroke, the incidence rate is about 9.82%, of which 2 cases died (0.45%), accounting for cerebral infarction the total number of deaths of 2/9; symptoms of hemorrhagic transformation of the 90 day non neurological deterioration after cerebral infarction (OR=5.86, P0.001); single factor analysis showed that hypertension, hyperlipidemia, atrial fibrillation, large area cerebral infarction and 5 groups of variables in the baseline NIHSS Between the two groups was statistically significant (P = 0.05), in addition, the study found that the posterior circulation stroke is a predictor of low rate of occurrence of asymptomatic HT (P0.05); age, gender, smoking, high blood glucose, stroke history, history of tumor and non symptomatic hemorrhagic transformation had no correlation to the existence. Non symptomatic hemorrhagic transformation as the dependent variable (HT=1, non HT=0), hypertension, hyperlipidemia, atrial fibrillation, large area cerebral infarction and baseline NIHSS scores of Logistic regression analysis showed that atrial fibrillation (OR=2.096 P=0.047,95%CI 1.923-4.757), large area cerebral infarction (OR=10.455, P0.001,95%CI, 4.765-22.940), the initial NIHSS score (OR=1.123, P=0.015,95%CI 1.023-1.232) were the independent risk factors of non symptomatic hemorrhagic transformation after cerebral infarction. Conclusion: (1) symptomatic hemorrhagic transformation affect the long-term prognosis of patients with non cerebral infarction (OR=5.86, p0.001). (2) the risk factors of asHT are real Tremor, large area cerebral infarction, initial high NIHSS score. (3) posterior circulation cerebral infarction was a predictor of low incidence of non symptomatic hemorrhage.

【学位授予单位】：大连医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3

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