早期神经功能改变与介入治疗急性缺血性脑卒中患者预后的关系研究及其相关预测因素

发布时间：2018-06-20 10:50

本文选题：急性缺血性脑卒中 + 血管内治疗　；参考：《南方医科大学》2017年博士论文

【摘要】：背景:既往研究表明,对颈内动脉供血区域内的颅内大血管闭塞性急性缺血性脑卒中患者而言,血管内治疗要优于最佳药物治疗(包括静脉溶栓治疗)。如今,血管内支架样取栓术已成为急性颅内大血管闭塞性缺血性脑卒中治疗的新标准。对急性缺血性脑卒中患者而言,在治疗后24小时就能对长期结局进行预测的可靠的替代指标是非常有价值的。因此本课题的目的是为了观察经血管内治疗的急性缺血性脑卒中患者早期神经功能改变与临床结局的关系及其预测因素。方法:我们首先回顾性分析经血管内治疗(动脉溶栓+机械取栓)的98例急性缺血性脑卒中患者。接着我们分析了 97例进行机械取栓的急性缺血性脑卒中患者。收集的资料包括人口统计学、血管危险因素、入院时及治疗24小时的NIHSS评分以及治疗前后的再灌注评分和侧支循环评分。临床结局使用3个月时mRS评分。神经功能无改善(LOI)定义为入院时NIHSS评分与血管内治疗后24小时NIHSS评分的差值小于或等于3分。NIHSS评分百分比改善定义为[(基线NIHSS评分-24小时NIHSS评分)/基线NIHSS评分]×100%,而NIHSS评分绝对值改善则定义为基线NIHSS评分-24小时NIHSS评分。使用AUC来比较两者对结局的预测价值。根据ROC曲线的最大约登指数来确定截断值。快速神经功能改善(RNI)定义为神经功能改善大于或等于截断值。使用Logistic回归模型分析LOI、RNI以及24小时NIHSS与3个月时结局的关系以及预测因素。结果:(1)差的侧支循环(p=0.012)、发病到再灌注大于6小时(p=0.002)是LOI的独立预测因素。入院时高NIHSS评分(p=0.002)、LOI(p0.001)以及差的侧支循环(p=0.048)是不良结局的独立预测因素。(2)AUC曲线显示NIHSS评分百分比改善的曲线下面积要显著大于绝对值改善(p=0.004)。好的侧支循环(p=0.03)和发病到再灌注小于6小时(p=0.022)是RNI的独立预测因素。RNI(p0.001)以及好的侧支循环(p=0.006)是良好结局的独立预测因素,而入院时高NIHSS评分(p=0.002)是不良结局的独立预测因素。(3)24小时NIHSS评分对3个月时的良好结局的预测作用相当好(AUC = 0.882)。与24小时NIHSS评分相比,NIHSS评分百分比改善(AUC=0.859)和NIHSS评分绝对值改善(AUC =0.800)对3个月时的良好结局的预测作用相对较低。24小时高NIHSS评分(p0.001)是不良结局的独立预测因素,好的侧支循环(p=0.038)是良好结局的独立预测因素。结论:(1)在进行血管内治疗的急性缺血性脑卒中患者中,LOI与3个月时不良结局独立相关,差的侧支循环和发病到再灌注大于6小时是LOI的独立预测因素。(2)对进行支架取栓治疗急性缺血性卒中的患者而言,NIHSS评分百分比改善对3个月时结局的预测价值要优于NIHSS评分绝对值改善。好的侧支循环和发病到再灌注小于6小时是RNI的独立预测因素。(3)治疗后24小时NIHSS评分能够准确的预测进行支架样取栓治疗的急性缺血性脑卒中的患者90天时结局。
[Abstract]:Background: previous studies have shown that endovascular therapy is superior to the best drug therapy (including intravenous thrombolytic therapy) in patients with acute ischemic stroke with intracranial macrovascular occlusion in the area of internal carotid artery supply. Today, stent-like thrombolysis has become a new standard for the treatment of acute large-vessel occlusion ischemic stroke. For patients with acute ischemic stroke, reliable alternative indicators that predict long-term outcomes 24 hours after treatment are of great value. The purpose of this study was to investigate the relationship between early neurological function and clinical outcome in patients with acute ischemic stroke treated by intravascular therapy. Methods: first, we retrospectively analyzed 98 patients with acute ischemic stroke treated by endovascular therapy (thrombolytic mechanical thrombolysis). Then we analyzed 97 patients with acute ischemic stroke who underwent mechanical thrombus removal. Data collected included demographics, vascular risk factors, NIHSS scores on admission and 24 hours of treatment, reperfusion scores and collateral circulation scores before and after treatment. The clinical outcome was evaluated with Mrs at 3 months. The difference between NIHSS score on admission and NIHSS score at 24 hours after intravascular therapy was defined as [(baseline NIHSS score -24 hour NIHSS score / baseline NIHSS score] 脳 100). The percentage improvement of NIHSS score was defined as [(baseline NIHSS score -24 hour NIHSS score / baseline NIHSS score] 脳 100). The absolute improvement of NIHSS score is defined as the baseline NIHSS score-24 hours NIHSS score. AUC was used to compare the predictive value of the two for the outcome. The truncation value is determined by the maximum Jordan exponent of the ROC curve. Rapid neurological improvement (RNI) is defined as a neurological improvement greater than or equal to a truncated value. Logistic regression model was used to analyze the relationship between LOI RNI and 24 hour NIHSS and the outcome at 3 months and the predictive factors. Results the poor collateral circulation (p0.012), which occurred more than 6 hours after reperfusion, was an independent predictor of loi. High NIHSS score (P 0.002) and poor collateral circulation (P 0.048) were independent predictors of adverse outcome. The AUC curve showed that the area under the curve of percentage improvement of NIHSS score was significantly larger than that of absolute value improvement. Good collateral circulation p0.03) and less than 6 hours of reperfusion were independent predictors of RNI. RNIP 0.001) and good collateral circulation p0.006) were independent predictors of good outcome. The high NIHSS score on admission was an independent predictor of adverse outcome. The 24 hour NIHSS score had a good predictive effect on the good outcome at 3 months (AUC = 0.882). Compared with the 24 hour NIHSS score, the percentage improvement of NIHSS score (AUC0.859) and the absolute value improvement of NIHSS score (AUC 0.800) were independent predictors of adverse outcome. Good collateral circulation was an independent predictor of good outcome. Conclusion (1) loi in patients with acute ischemic stroke undergoing endovascular therapy is independently associated with adverse outcomes at 3 months. Poor collateral circulation and more than 6 hours from onset to reperfusion are independent predictors of loi.) for patients with acute ischemic stroke treated with stent thrombectomy, the improved percentage of NIHSS score should be used to predict the outcome at 3 months. Better than NIHSS score absolute value improvement. Good collateral circulation and onset to reperfusion less than 6 hours were independent predictors of RNI. The NIHSS score at 24 hours after treatment could accurately predict the 90-day outcome of patients with acute ischemic stroke treated with stent-like thrombolysis.
【学位授予单位】：南方医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R743.3

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