Analysis of the effect of reperfusion after intravenous thrombolysis in different time windows of acute ischemic stroke on clinical outcome and 90-day prognosis
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摘要:
目的 分析急性缺血性脑卒中(AIS)不同时间窗静脉溶栓后再灌注对临床转归及90 d预后的影响。 方法 选取2020年10月—2022年10月在郑州市第三人民医院北部院区神经内科接受静脉溶栓治疗的AIS患者158例，根据溶栓时间窗分为A(42例)、B(53例)、C(63例)3组，溶栓时间窗分别为＜3.0 h、3.0~4.5 h及＞4.5~＜6.0 h，对比3组的临床转归。随访90 d，根据改良Rankin量表(mRS)将患者分为预后良好组(89例)与预后不良组(69例)，分析患者90 d预后的影响因素。 结果 A组与B组溶栓后的美国国立卫生院神经功能缺损评分(NIHSS)均低于C组，近期预后良好率均高于C组(P＜0.05)，A组与B组溶栓后NIHSS评分及近期预后良好率差异均无统计学意义(P＞0.05)。3组出血事件发生率分别为9.52%(4例)、13.21%(7例)、15.87%(10例)，差异无统计学意义(χ2=0.882，P＞0.05)。预后不良组年龄[(67.20±10.33)岁vs. (60.69±10.41岁)]、入院时NIHSS评分[(12.35±3.50)分vs.(7.91±2.12)分]、心房颤动占比(17.39% vs. 3.37%)、发病后＞4.5~ < 6.0 h溶栓占比(53.62% vs. 29.21%)均高于预后良好组(P＜0.05)。Logistic回归分析显示，高龄、入院高NIHSS评分、心房颤动、溶栓时间窗＞4.5~＜6.0 h均是AIS患者预后不良的独立危险因素(P＜0.05)。 结论 AIS患者发病后4.5 h内溶栓治疗获益较好，年龄、入院时NIHSS评分、心房颤动、溶栓时间窗均可影响AIS患者90 d预后。 -
关键词:
- 急性缺血性脑卒中 /
- 溶栓 /
- 重组组织型纤溶酶原激活剂 /
- 预后
Abstract:Objective To analyze the effect of reperfusion after thrombolysis in different time windows on clinical outcome and 90-day prognosis of acute ischemic stroke (AIS). Methods A total of 158 AIS patients who received intravenous thrombolytic therapy in the Department of Neurology of the Northern Ward of the Third People's Hospital of Zhengzhou from October 2020 to October 2022 were selected. The patients were divided into three groups according to the thrombolytic time window: A(42 cases), B (53 cases) and C (63 cases). The thrombolytic time windows were < 3.0 h, 3.0-4.5 h, and >4.5- < 6.0 h, respectively. The clinical results of the three groups were compared. After 90 days of follow-up, the patients were divided into a good prognosis group (89 cases) and a poor prognosis group (69 cases) according to the modified Rankin scale (mRS), and the factors influencing the prognosis of the patients at 90 days were analyzed. Results The National Institutes of health stroke scale (NIHSS) score after thrombolysis in group A and group B was lower than that in group C, and the rate of short-term good prognosis was higher than that in group C (P < 0.05). There was no statistical significance in NIHSS score and short-term good prognosis between group A and group B (P>0.05). The incidence of bleeding events in the three groups was 4 (9.52%), 7 (13.21%), and 10 (15.87%), respectively, with no significant difference (χ2=0.882, P>0.05). In the poor prognosis group, age [(67.20±10.33) vs. (60.69±10.41) years], NIHSS score at admission [(12.35±3.50) points vs. (7.91±2.12) points], proportion of atrial fibrillation (17.39% vs. 3.37%) and proportion of thrombolysis >4.5- < 6.0 h after onset (53.62% vs. 29.21%) were higher than in the good prognosis group (P < 0.05). Logistic regression showed that older age, high admission NIHSS score, atrial fibrillation, and thrombolysis time window >4.5- < 6.0 h were independent risk factors for poor prognosis in AIS patients (P < 0.05). Conclusion Thrombolysis is beneficial within 4.5 hours of AIS onset. Age, NIHSS score on admission, atrial fibrillation, and time window of thrombolysis may influence the 90-day prognosis of AIS patients. -
表 1 3组AIS患者基线资料比较
Table 1. Comparison of baseline data among three groups of AIS patients
项目 A组(42例) B组(53例) C组(63例) 统计量 P值 性别(男性/女性，例) 24/18 30/23 34/28 0.064a 0.969 年龄(x±s, 岁) 63.35±9.25 64.58±7.85 62.78±10.01 0.571b 0.566 BMI(x±s) 23.86±1.58 23.41±1.32 24.01±1.70 2.257b 0.108 既往史[例(%)] 高血压 20(47.62) 23(43.40) 32(50.79) 0.632a 0.729 冠心病 8(19.05) 15(28.30) 20(31.75) 2.099a 0.350 糖尿病 10(23.81) 12(22.64) 18(28.57) 0.424a 0.809 高脂血症 28(66.67) 35(66.04) 41(65.08) 0.030a 0.985 心房颤动 4(9.52) 6(11.32) 5(7.94) 0.384a 0.825 吸烟 18(42.86) 20(37.74) 25(39.68) 0.258a 0.879 饮酒 12(28.57) 15(28.30) 18(28.57) 0.001a 0.999 入院时指标 收缩压(x±s，mmHg) 158.63±15.63 160.32±14.89 159.67±16.98 0.132b 0.876 舒张压(x±s，mmHg) 92.36±10.33 93.74±11.54 92.87±10.87 0.196b 0.822 空腹血糖(x±s，mmol/L) 4.89±1.02 5.01±1.12 4.78±1.11 0.641b 0.528 NIHSS评分(x±s，分) 10.33±2.01 9.27±1.85 10.01±2.03 1.655b 0.194 血小板计数(x±s, ×109/L) 175.52±50.32 180.32±52.36 178.95±56.32 0.098b 0.907 APTT(x±s，s) 44.25±7.33 45.32±6.52 46.01±5.87 0.924b 0.399 INR(x±s) 1.02±0.12 1.03±0.10 1.04±0.12 0.395b 0.674 梗死部位[例(%)] 0.067a 0.967 前循环 29(69.0) 36(67.9) 42(66.7) 后循环 13(31.0) 17(32.1) 21(33.7) 注：a为χ2值，b为F值。1 mmHg=0.133 kPa。 
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表 2 3组AIS患者溶栓前后NIHSS评分比较(x±s，分)
Table 2. Comparison of NIHSS scores before and after thrombolysis in three groups of AIS patients (x±s, score)
组别 例数 溶栓前 溶栓后24 h 溶栓后7 d F值 P值 A组 42 10.33±2.01 8.04±1.45a 6.55±1.01ad 63.775 ＜0.001 B组 53 9.87±2.85 8.25±1.55a 6.75±1.20ad 32.355 ＜0.001 C组 63 10.01±2.03 9.01±1.62abc 7.33±1.35abcd 40.460 ＜0.001 F值 0.471 5.926 6.026 P值 0.626 0.003 0.003 注：与溶栓前比较，aP＜0.05；与溶栓后24 h比较，dP＜0.05；与A组比较，bP＜0.05；与B组比较，cP＜0.05。
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表 3 3组AIS患者出血事件发生率比较[例(%)]
Table 3. Comparison of bleeding events among three groups of AIS patients[cases (%)]
组别 例数 症状性脑出血 牙龈出血 消化道出血 出血事件总发生 A组 42 2(4.76) 2(4.76) 0(0.00) 4(9.52) B组 53 4(7.55) 2(3.77) 1(1.89) 7(13.21) C组 63 6(9.52) 2(3.17) 2(3.17) 10(15.87) 注：3组出血事件发生率比较，χ2=0.882, P=0.643。
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表 4 影响AIS患者预后不良相关因素的单因素分析
Table 4. Univariate analysis of associated factors affecting poor prognosis in AIS patients
项目 预后不良组(n=69) 预后良好组(n=89) 统计量 P值 性别(男性/女性，例) 40/22 48/40 0.257a 0.612 年龄(x±s，岁) 67.20±10.33 60.69±10.41 3.912b ＜0.001 BMI(x±s) 24.11±2.12 23.50±1.85 1.928b 0.056 既往史[例(%)] 高血压 30(43.48) 45(50.56) 0.782a 0.377 冠心病 16(23.19) 27(30.34) 1.003a 0.317 糖尿病 20(28.99) 20(22.47) 0.872a 0.350 高脂血症 50(72.46) 54(60.67) 2.401a 0.121 心房颤动 12(17.39) 3(3.37) 8.892a 0.003 吸烟 29(42.03) 34(38.20) 0.237a 0.626 饮酒 22(31.88) 23(25.84) 0.696a 0.404 入院时指标 收缩压(x±s, mmHg) 160.33±17.98 159.05±17.50 0.451b 0.653 舒张压(x±s，mmHg) 93.50±13.01 92.66±11.25 0.435b 0.664 空腹血糖(x±s, mmol/L) 4.90±0.95 4.88±1.01 0.127b 0.899 NIHSS评分(x±s，分) 12.35±3.50 7.91±2.12 9.864b ＜0.001 血小板计数(x±s，×109/L) 180.11±50.01 177.25±53.41 0.343b 0.732 APTT(x±s，s) 45.52±7.01 45.92±8.55 1.103b 0.272 INR(x±s) 1.04±0.10 1.02±0.12 1.081b 0.281 溶栓时间窗[例(%)] ＜3.0 h 14(20.29) 28(31.46) 9.663a 0.008 3.0~4.5 h 18(26.09) 35(39.33) ＞4.5~＜6.0 h 37(53.62) 26(29.21) 注：a为χ2值，b为t值。
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表 5 变量赋值情况
Table 5. Variable assignment
变量 赋值方法 年龄 连续性变量(以实际值赋值) 入院时NIHSS评分 连续性变量(以实际值赋值) 心房颤动 0=无，1=有 溶栓时间窗 0=＜3.0 h，1=3.0~4.5 h，2=＞4.5~＜6.0 h 预后不良 0=否，1=是
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表 6 AIS患者预后不良影响因素的多因素logsitic回归分析
Table 6. Multivariate logsitic regression analysis of influencing factors of poor prognosis in AIS patients
变量 B SE Waldχ2 P值 OR值 95% CI 年龄 0.665 0.235 8.008 0.010 1.944 0.901~3.584 入院时NIHSS评分 1.058 0.295 13.648 ＜0.001 3.040 1.525~5.056 心房颤动 0.774 0.2401 10.475 ＜0.001 2.181 1.154~4.009 溶栓时间窗＞4.5~＜6.0 h 0.958 0.252 16.386 ＜0.001 2.751 1.341~4.784
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