急性前循环大血管闭塞脑梗死血管内治疗后颅内出血的预测因素及其对预后的影响

发布时间：2018-08-08 21:16

【摘要】：研究背景和目的:颅内出血是急性脑梗死血管内治疗的主要并发症,目前各临床研究报道的再通治疗后出血发生率各不相同。其中,症状性颅内出血尤为重要,早期识别其危险因素对治疗决策及改善临床预后有重要意义。目前急性前循环大血管闭塞脑梗死血管内治疗后无症状性颅内出血对预后的影响尚需进一步研究。另外,成功再通后尽管未继发症状性颅内出血患者死亡的危险因素尚不清楚。本研究旨在:1)通过meta分析综合评价急性脑梗死血管内治疗与标准药物治疗相比出血风险是否增加;2)评估中国人急性前循环大血管闭塞脑梗死血管内治疗后症状性颅内出血的发生率及危险因素;3)评估中国人急性前循环大血管闭塞脑梗死血管内治疗后无症状颅内出血对90天神经功能预后的影响;4)评估中国人急性前循环大血管闭塞脑梗死血管内治疗成功再通后,尽管未继发症状性颅内出血但患者死亡的危险因素。方法收集2014年1月至2016年6月ACTUAL数据库病人资料。ACTUAL是一项真实世界急性脑梗死血管内治疗注册登记研究,本研究被各中心伦理委员会批准进行研究。根据现行急性缺血性脑卒中相关指南,行血管内治疗及其他药物治疗。每例患者治疗前均行非增强头颅CT检查,以排除脑出血,CTA、MRA、及DSA等,确定大动脉急性闭塞。通常治疗后24和72小时分别行头颅CT检查。颅内出血的诊断和分类根据海德堡出血分类标准确定。连续性变量根据是否符合正态分布采用Student's t-test或Mann-Whitney U test,分类变量采用卡方检验或Fisher exact test。使用logistic回顾分析评估症状性颅内出血及死亡的独立危险因素。通过meta分析综合评价急性脑梗死血管内治疗与标准药物治疗相比出血风险是否增加。结果总的颅内出血风险血管内治疗组高于药物治疗组(35.0%vs 19.0%,OR=2.55,95%CI:1.64-3.97,P0.0001);症状性颅内出血血管内治疗组与药物治疗组相似,无统计学差异(5.6%vs 5.2%,OR=1.09,95%CI:0.79-1.50,P=0.61);无症状颅内出血血管内治疗高于药物治疗(28%vs 12%,OR=3.16,95%CI:1.62-6.16;P0.001)。基线中性粒细胞比例0.83(OR=2.07,95%CI,1.24-3.46),治疗前ASPECTS6(OR=2.27,95%CI,1.24-4.14),心源性卒中(OR=1.91,95%CI,1.13-3.25),侧支循环不良(OR=1.97,95%CI,1.16-3.36),症状开始到股动脉穿刺时间延迟270 minutes(OR=1.70,95%CI,1.03-2.80),取栓次数超过3次(OR=2.55,95%CI,1.40-4.65)是急性前循环大血管闭塞脑梗死血管内治疗后症状性颅内出血的独立危险因素。急性前循环大血管闭塞脑梗死血管内治疗后无症状性颅内出血降低获得90天良好功能预后(excellent outcome,mRS 评分0-1)的机率,(OR=0.46,95%CI,0.28-0.77,P=0.003),同时降低获得功能独立的机率(functional independence,mRS 评分 0-2)(OR=0.61,95%CI,0.39-0.96,P=0.032)。但对90天死亡率无影响(OR=0.62,95%CI,0.33-1.14,P=0.125)。Age75(OR=2.68,95%CI,1.34-5.34),基线中性粒细胞比率0.83(OR=2.38,95%CI,1.23-4.59),治疗前ASPECTS6(vs ≥8,OR=4.76,95%CI,1.84-12.33),基线NIHSS评分 ≥21(vs≤10,OR=18.93,95%CI,2.34-153.42),基线血糖11.1mmol/L(vs≤7.0,OR=2.86,95%CI,1.19-6.88),ICA 闭塞(vs M1闭塞,OR=2.26,95%CI,1.15-4.44)可能增加成功再通且未继发症状性颅内出血患者90天死亡风险。结论1.尽管急性脑梗死血管内治疗后总的颅内出血风险增高,但与标准药物治疗相比,症状性颅内出血风险并未增加;2.心源性卒中,侧枝循环不良,治疗延迟,反复取栓,治疗前ASPECTS评分低及基线中性粒细胞比率增高,增加急性前循环大血管闭塞脑梗死患者机械取栓后继发症状性颅内出血的风险。3.中国人急性前循环大血管闭塞脑梗死,机械取栓后无症状性颅内出血降低获得90天良好功能预后的机率。临床医生需采取适当的措施,降低机械取栓后并发颅内出血(无论是症状性颅内出血还是无症状性颅内出血)的风险。4.成功再通后尽管未继发症状性颅内出血,仍有部分患者90天内死亡。高龄、基线中性粒细胞比率升高、高血糖、低ASPECTS、高NIHSS评分及ICA闭塞是90天死亡的独立危险因素。
[Abstract]:Background and objective: intracranial hemorrhage is the main complication of intravascular therapy for acute cerebral infarction. The incidence of hemorrhage after recanalization in various clinical studies is different. Among them, symptomatic intracranial hemorrhage is particularly important. Early identification of the risk factors is of great significance for treatment decision and improvement of clinical prognosis. Further study on the prognosis of asymptomatic intracranial hemorrhage after intravascular treatment of intracerebral hemorrhagic cerebral infarction is still needed. Furthermore, the risk factors for death in patients with no secondary intracranial hemorrhage are not clear after successful recanalization. The purpose of this study is to evaluate the comprehensive evaluation of intravascular therapy and standard drugs for acute cerebral infarction by meta analysis. Whether the risk of bleeding increased in comparison with the risk of bleeding; 2) the incidence and risk factors of symptomatic intracranial hemorrhage after endovascular treatment in Chinese patients with acute anterior circulation macrovascular occlusion, and 3) to assess the effect of asymptomatic intracerebral hemorrhage on the prognosis of 90 days after endovascular treatment in Chinese patients with acute anterior circulation large vascular occlusion; 4) assessment Methods collected from January 2014 to June 2016, ACTUAL database patient data.ACTUAL is a real world acute cerebral infarction intravascular treatment registration study. This study was studied. The center ethics committee approved the study. According to the current guidelines for acute ischemic stroke, intravascular therapy and other drug treatment were performed. Non enhanced cranial CT examinations were performed in each case before treatment to exclude cerebral hemorrhage, CTA, MRA, and DSA, and to determine acute occlusion of the large arteries. 24 and 72 hours after treatment, the head CT examination was performed respectively. The diagnosis and classification of intracranial hemorrhage are determined according to the criteria for the classification of Heidelberg bleeding. Student's t-test or Mann-Whitney U test is used depending on whether the continuous variables are in accordance with normal distribution. The independent risk factors for symptomatic intracranial hemorrhage and death are evaluated by chi square test or Fisher exact test. using a logistic retrospective analysis. Meta analysis synthetically evaluated the increase of bleeding risk compared with the standard drug treatment in acute cerebral infarction. Results the total intracerebral hemorrhage risk in the intravascular treatment group was higher than that of the drug treatment group (35.0%vs 19%, OR=2.55,95%CI:1.64-3.97, P0.0001); the intravascular treatment group of symptomatic intracranial hemorrhage was similar to the drug treatment group and had no statistics. Differences (5.6%vs 5.2%, OR=1.09,95%CI:0.79-1.50, P=0.61); intravascular therapy for asymptomatic intracranial hemorrhage (28%vs 12%, OR=3.16,95%CI:1.62-6.16; P0.001). Baseline neutrophils ratio 0.83 (OR=2.07,95%CI, 1.24-3.46), preoperative ASPECTS6 (OR=2.27,95%CI, 1.24-4.14), cardiac apoplexy, lateral branch OR=1.97,95%CI (1.16-3.36), the onset of symptoms began to delay 270 minutes of femoral artery puncture time (OR=1.70,95%CI, 1.03-2.80), and the number of embolus more than 3 times (OR=2.55,95%CI, 1.40-4.65) was an independent risk factor for symptomatic intracranial hemorrhage after intravascular treatment of acute anterior circulatory cerebral infarction. Acute anterior circulation large vascular occlusion Asymptomatic intracranial hemorrhage after cerebral infarction was reduced to 90 days of good functional prognosis (excellent outcome, mRS score 0-1), (OR=0.46,95%CI, 0.28-0.77, P=0.003), and decreased the probability of obtaining functional independence (functional independence, mRS score 0-2) (OR=0.61,95%CI, 0.39-0.96, P=0.032). But there was no death rate for 90 days. OR=0.62,95%CI, 0.33-1.14, P=0.125).Age75 (OR=2.68,95%CI, 1.34-5.34), baseline neutrophils ratio 0.83 (OR=2.38,95%CI, 1.23-4.59), before treatment ASPECTS6 (vs > 8, OR=4.76,95%CI, 1.84-12.33). A occlusion (vs M1 occlusion, OR=2.26,95%CI, 1.15-4.44) may increase the 90 day risk of death in patients with successful recurrent and asymptomatic intracranial hemorrhage. Conclusion 1. although the risk of intracranial hemorrhage is higher after intravascular treatment in acute cerebral infarction, the risk of symptomatic intracranial hemorrhage is not increased compared with standard drug treatment; 2. cardiogenic stroke, collateral branch Poor circulation, delayed treatment, repeated thrombectomy, low ASPECTS score before treatment and increased baseline neutrophils ratio, increased risk of symptomatic intracranial hemorrhage secondary to acute anterior circulation cerebral infarction patients after mechanical thrombectomy,.3. Chinese patients with acute anterior circulation large vascular occlusion, and asymptomatic intracranial hemorrhage after mechanical thrombectomy. The risk of good functional prognosis for 90 days is low. Clinicians need to take appropriate measures to reduce the risk of intracranial hemorrhage (either symptomatic intracranial hemorrhage or asymptomatic intracranial hemorrhage) after mechanical thrombectomy. After successful repassage, there are still some patients who died within 90 days despite no secondary intracranial hemorrhage. Age, baseline neutrophils,.4. Elevated cell ratio, hyperglycemia, low ASPECTS, high NIHSS score and ICA occlusion were independent risk factors for 90 day mortality.
【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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